Lorenzini M., Cristofoli C., Governa M., Rigotti G., Barisoni D.

Divisione di Chirurgia Plastica e Centro Ustioni, Verona, Italia

SUMMARY. The development of microsurgery techniques over the past years has enabled us to obtain striking results in difficult cases which were not easily treated years ago. In burns therapy microsurgery has introduced a new philosophy of therapeutical approach, both in the acute phase and in the treatment of sequelae. The Authors present the experience of the Verona Burns Centre, Italy, with these innovative techniques, showing possible applications and describing cases. The results are excellent, but it is stressed that the patients have to be carefully selected. An analysis is made of the advantages that these methods can ofFer in comparison to traditional techniques.

Microsurgery in burns therapy has certainly offered surgeons a new and effective way of solving several critical problems. It has precise indications both in the acute phase and in the treatment of sequelac, according to the conditions and limitations of this kind of surgery.
First of all we have to consider:

1. the general conditions of the patient, who will be subjected to a long general anaesthesia, and the viability of his local and general vascular situation;
2. the real advantages we may gain with these particular techniques, without disregarding the traditional methods which are always to be considered as the first choice;
3. the availability of well-trained and experienced medical staff in order to minimize the risk of failures.

In acute burns, microsurgery finds a well-defined indication in the treatment of localized full-thickness lesions with exposure of important structures, such as tendons, bone and nerves. It allows us to cover these tissues with viable and well-vascularized flaps that offer immediate protection from the risk of infection and further necrosis; the forearm, hand, ankle and foot are the most common recipient areas.
When choosing the flaps, we have to estimate the size of the lesion and the functional and aesthetic characteristic of the area, dissecting a flap of suitable size and thickness.

In burns sequelae, microsurgery offers interesting solutions for the treatment of scar contractures and disfiguring scars in all those areas like limbs and face, where customary techiques seem to give insufficient results. Free flaps allow us to replace the damaged surfaces with soft, viable tissue which, in addition to a satisfactory cosmetic result, often gives functional recovery too.
For these reasons, particular attention has to be made when choosing the flap, assessing its matching with the recipient area, size and thickness, and considering the residual damage in the donor site.

Material and method

In Verona, we have treated 16 cases using microsurgical reconstruction: 9 in the acute phase and 7 for improvement of severe burns sequelae. Electrical and contact burns were the most common acute lesions in our series (Tab. 1).

Microvascular sutures were performed with nylon 9/0 or 10/0, arteries were usually connected by end-to-side suture and veins end-to-end.
The flaps used in our 16 patients and the recipient sites are reported in Tab. 2.

Results and discussion

We had only one failure, in a patient with a deep electrical injury in the left wrist, due to a venous thrombosis correlated to the local vascular condition.

Case 1: A) Severe burn sequelae of the left hand B) Dorsal pedis free laps C) Satisfactory functional result

In all the other cases we obtained satisfactory results with sufficient cosmetic and good functional recovery.
Different flaps were performed according to the needs of the various recipient areas and the characteristic of the different donor sites (Tab. 2).
Dorsalis pedis flaps were preferred in the treatment of lesions of the hands and face (cases 1 and 2), while larger and thicker flaps such as scapular and parascapular find their best utilization in the forearm, wrist and ankle (case 3).
With the progress and refinement of microvascular techniques, it has become possible to solve several critical problems in the surgical treatment of burned patients. Both in the acute phase and in burns sequelae this treatment seems to be the best remedy in more severe injuries.
Nevertheless traditional techniques remain the first choice in most cases, offering easier and equally effective solutions. Furthermore, thanks to the utilization of skin expanders, it is possible to obtain wide and movable local flaps which now appear to be the best solution in the treatment of scar contractures in particular areas like the neck and armpit. For these reasons, an accurate evaluation of all available surgical techniques and of the patients' general and local conditions is the first step in any logical microsurgery programme.

Case 2: A) Disfiguring scars of the face B) C) The result after partial reconstruction with dorsalis pedis free flap

Case 3: A) Deep bum of the ankle with tendon exposure B) Coverage with scapular free flap

RESUME. Le développement des techniques de la microchirurgie dans ces dernières années nous a permis d'obtenir des résultats exceptionnels chez certains patients que nous pouvions soigner seulement avec grande difficulté il y a très peu. Dans la thérapie des brûlures la microchirurgie a introduit une,nouvelle philosophie d'approche thérapeutique, pour ce qui concerne soit la phase aiguë soit le traitement des séquelles. Les Auteurs présentent l'expérience du Centre des Brûlés de Vérone, Italie, avec l'emploi des techniques innovatrices. Les résultats ont été excellents, mais il faut toujours sélectionner les patients avec grande attention. Les Auteurs analysent les avantages de ces méthodes par rapport aux techniques traditionelles.

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