PLASTIC SURGERY RE-EDUCATION IN SEVERELY BURNED PATIENTS: FROM SURVIVAL TO QUALITY OF LIFE

Caleffl E., Bocchi A., Toschi S., Papadia F.

Cattedra di Chirurgia Plastica dell'Universita di Parma, Italia

SUMMARY. In major burns, surgical procedures have a rehabilitative perspective in each therapeutic step: first, early debridenient and coverage of the burned areas are necessary for a quicker recovery and to reduce complications; improper early management ol'burned areas is still the main cause of scar contractures and disability. Subsequently, an appropriate surgical approach is often necessary to improve the functional outcome and social reintegration. In a complete therapeutic approach to the burned patient, each surgical operation must be associated with conservative treatment, i.e. nutritional, immunological support in the early phases, and physiatric devices in the post-acute phases. In this way surgical steps can be reduced and complete rehabilitation be more effective.

Plastic surgery re-education in the severely burned patient includes different surgical steps aimed at ensuring the patient's survival and permitting further surgical approaches for a better quality of life. We divide surgical re-education into three phases: 1. Early surgical re-education: this takes place when the patient is admitted to a Burn Centre and aims at his life support. It begins with escharectomy to prepare the burned surfaces for skin autografts. These, both direct autograft and autograft of previously cultured skin, have a quoad vitam purpose (to repair the skin covering) and also a quoad veletudinem purpose (to facilitate non-surgical re-education, avoiding subsequent incorrect postures), even though they sometimes give unsatisfactory aesthetic and functional results. Cultured skin autograft is an important new re-educative life support, especially in very severely burned patients, because it allows quite early intervention without creating donor sites. Allografts, heterografts, and amniotic and collagen membranes, used as biological dressing, have a minor re-educative meaning as life support because of their temporariness and the high risk of phlogosis and infection.

Elective surgical re-education: this concerns grafted or secondary closure healed areas. The re-educative purpose is to obtain the best individual and social integration of severely burned patients, the ideal result being to restore, as far as possible, the pre-existing local, functional and aesthetic conditions. We use:

a) Plastic for elongation and debridement of scars (Z-plasty, V-Y plasty,, W-plasty) and local flaps, to transfer the same kind of skin existing before the trauma to the burned area with minirriurn discomfort for the patient.

b) Expanded skin flaps, to repair extensive burned areas: two interventions and an expansion tinic are required, but they allow reintegration of damaged tissues whose reconstruct ion was impossible, or at least very difficult, in the past~ Cross-abdominal flaps: these still have an important re-educative role even though the long time required before pedicle separation proves to be very psychological patients, patients usually are.

Microsurgical flaps: these may give sensitivity, but have few strict indications and often post-operative complications. In phase 2 non-surgical re-education is mainly based on dynamic splints, to restore reconstruct& tissne function.

3. Sequelae surgical re-education.. this concei-ns surgically treated burned areas and donor sites, developing through "complementary" or "p rfective" surgical techniques, such as dertnoabrasion, peeling and punching, which represent a further surgical step.

Another important concept is re-educativc priority: since severely burned patients have extensively damaged tissue, a carefully selected re-educative programme is needed: surfaces covcring meta-epiphyscal zones in children, to prevent growth defects; in adults priority is given to body surfaces useful to working, then to the treatment of arthral surfaces and finally exposed areas, for aesthetic reasons,

In the last 10 years 938 burned patients have been admitted to our Burn Centre: in severely burned patients (50%) with over 15% BSA the complete three-phase treatment was applied in 215 cases.
We report five cases to illustrate our protocol and to show our results.

25-year-old woman with 2nd- and 3rd-degree burns, caused by hot water, in 40% BSA, 25% of which were classified as deep (sternal and mammary region, upper limbs); early escharectomy and tangential excision wefe performed and the wounds were covered with skin autografts.
4 years later pre-sternal hypertrophic scars were treated with Z-plasty. 8 years later 2 skin expanders (455 cc each) were introduced into the mammary region. After expansion and complete scar excision, the expanded skin flaps were used for coverage.

42-year-old male with 3rd-degree flame bums (extremities, face, neck, chest, upper and lower extremities) caused while attempting suicide, affecting 50% BSA.
In the early phase meshed and cultured skin grafts were used to accomplish a quick and complete coverage. 1 year later a tissue expansion was performed in the cervical region to correct a severe neck contracture.
A Z-plasty of the commissure was carried out 6 months later to enable the patient to play the trumpet again.

33-year-old woman with considerable burns of face, arms and hand which occurred at the age of 6 months.
Facial burned areas were repaired with splitthickness skin grafts. 14 years later the patient was admitted to our hospital for the first time: a tissue expander was introduced into the right cervical region. The expander skin flap was used to correct the severe contracture of the lower lip. 1 year later a left cervical expander (730 cc) was introduced to correct remaining scars of the cheek.
A few months later a chin augmentation was carried out, using osteocairtilaginous tissue obtained from septorhinoplasty.
A bilateral upper lip flap was also performed to recontruct the commissura labialis. Finally, reconstruction of the auricular lobe was performed.

Fig. la Extensive scars of sternal and mammary region treated with two tissue expanders Fig. lb Post-operative view after complete removal of sternal and mammary scars and correction with a Z-plasty of an axillary scar. A correction of ptosis has also been obtained

17-year-old woman with 3rd-degree burns of chest, BSA. Early escharectomy was carried out and coverage was perforned with skin autografts. After sexual development, debridement of thoracic scars and remodelling of left breast with a silicon prothesis were performed. One year later, reduction mammoplasty on the opposite side was performed. lower extremities and left arm, affecting 40%

Fig. 2a Severe scar contracture of the neck: pre-operative view Fig. 2b Expansion of cervical region previously treated with mesh grafts Fig. 2c Intra-operative view: large expanded flaps were raised and placed in Z-plasty manner to increase neck surface Fig. 2d Side post-operative view with elongation of neck skin Fig. 2e Front post-operative view: a Z-plasty of the commissure has also been performed

27-year-old woman with 2nd- and 3rd-degree burns of upper extremities and back.
During the post-acute phase in the hand and wrist the patient developed hypertrophic scars with severe contracture. Finger contracture was corrected with a cross-arm flap (results shown in our previous work). A few months later wrist contracture was corrected with an abdominal flap.

This different reconstructive techniques in three subsequent phases, shows the importance of a surgical re-educative approach to obtain biological and social reintegration for these severely afflicted patients.

Fig. 3a Post-burn scar of the face (chin scars have already been removed by means of tissue expansion) Fig. 3b Final photograph after complete removal of scar of the face, reconstruction of the auricular lobe and chin augmentation by osteocartilaginous tissue from septoplasty

In the 'Tarly Surgical Re-education" phase we use traditional or cultured skin autograft. We have been using the latter since 1989. For burns between 50 and 70% we employ the two kinds of graft together, whereas cultured skin is used alone for bums over 70%. The results are very similar, even though the structural fragility and sensitivity to infection of the cultured skin autograft may affect its take, causing some delay to the whole re-educative process.

Fig. 4a Post-burn breast contracture: pre-operative view Fig. 4b Post-operative view after debridement and remodelling of the right breast and reduction mastoplasty of the left breast Fig. 5a Severe contracture of 3rd and 4th fingers and of the wrist. Pre-operative view Fig. 5b Post-operative view after removal of scar tissue of the finger by cross-arm flap and of the wrist by abdominal flap

If possible, we therefore prefer to reintegrate functional areas by traditional grafts; nevertheless, cultured skin graft has the advantage of requiring no donor sites.
In the "Elective Surgical Re-education" phase the extent of the damaged area is of primary importance: for small areas we prefer basic techniques, like Z-plasties or local flaps: for larger but circumscribed surfaces we use expanded skin flaps, taking into account the expandability of the area and the risk of complications (infection, decubitus of the prothesis).
Of the two distant flaps, cross-abdominal flaps have a lower incidence of post-operative complications than microsurgical flaps, the failure of which may disappoint the patient, inducing him to abandon further re-educative programmes. We therefore use microsurgical flaps only after strict selection on the basis of age, site of burn, and circulatory integrity.
The Sequelae Surgical Re-education", while exploiting so-called "complementary" techniques, is of great importance inasmuch as it shows the interest of burned patients in improvement of their aspect, also as regards aesthetic considerations.
This represents the evolution from a biological to a psychological healing, which should be the ultimate purpose of re-educative therapy.

RESUME Dans les brfilures graves les proc6dures chirurgicales, A chaque pas th~rapeutique, ont une perspective r66ducative: avant tout, le c16bridement et le recouvrement des surfaces brGI6es sont nkessaires pour permettre une gu~rison plus rapide et pour r6duire les complications; le traitement pr~coce impropre des surfaces brdl~es reste toujours la cause principale des contractures cicatricielles et de I'mvalidit6. Tr6 souvent it est n~cessaire Wintervenir chirurgicalement par la suite pour anifflorer le r6sultat et la r6int6gration sociale. Pour aborder en mani~re compl&e la th~rapie du patient brfil~, it faut que chaque manoeuvre chirurgicale soit associ& A un traitement conservatif, e'est-A-dire it faut fournir un soutien alimentaire et des supports physioth~rapeutiques dans les phases post-aiguds. De cette mani~re it est possible de r6duire les proc~d~s chirurgicaux et la r~adaptation compl&e est plus efficace.

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