Suchanek I., Rihova H., Kaloudova Y., Mager R.

Department of Burn and Reconstructive Surgery, University Hospital, Brno, Czech Republic

SUMMARY. The authors' aim is to summarize and generalize the knowledge acquired in the course of the last eight years of work with children with extensive burns. Reconstructive surgeries show a certain specific feature consisting in the considerable extent of the scarred area often exceeding 50% of the body surface, and with the gradual increase in number of operations they are gaining importance.

ZUSAMMENFASSUNG
Rekonstruktionseingriffe bei den schwer verbrannten Kindern.

Die Autore summeren die Erkenntnissen and Erfahrungen, die in den letzten acht Jahren im Rothman einer Behandlung von schwer verbrannten Kindern gewonnen wurden. Die Rekonstruktionseingriffe kennzeichnen sich durch einen grossen Umfang der narbigen Flache, die sehr oft 50 Prozent der K&rperoberflache ubertrifft.

Key words: reconstructive surgery, burnt children, cicatricial areas, contractures, tissue expansion, skin flap, psychological aspects

   The life of a burnt person, and all the more so of a child, is not easy. For the whole life he/she rolls before him/her a mountain of problems and complicated socio psychological relationships called posttraumatic stress syndrome. The degree of its gravity is determined, besides the extent and localization of scars, especially by the degree of isolation from the society, changes in social links, system of values and style of life. All these factors undoubtedly participate in forming one's personality, often as early as from childhood. Also we can, to a certain extent, exert an influence on the direction in which this complex process will proceed. A considerable progress in the treatment achieved in the last years enables the survival of a constantly growing number of patients with extensive burns. Consequently, the solution of an improvement in the quality of their lives will become one of the major issues of the burn-care medicine in the coming years.

   In our paper we do not offer any epoch-making solutions to this problem. The research on new biotechnologies in the field of skin substitution cover has not arrived at that point yet. Only a breakthrough in this field of development may introduce qualitatively new methods and revolutionary solutions. Our aim is to sum up the results of several years' work based on standard reconstruction methods, to mention some relatively new methods and to draw your attention to some special features of reconstructive surgeries in large cicatricial areas after burns.

DISCUSSION

   In the first bar chart (Tab. 1) there is a noticeable stabilized number of children hospitalized for burns in our region showing a marked increase in the number of reconstructive surgeries. We see the reasons for it on the one hand in the consistent dispensarization of all burnt children who at first undergo a conservative treatment of hypertrophic scars, and only gradually they "mature" for reconstructive surgeries. We continue intensive reconstructions in several patients with extensive burns from the late nineties. There is also a gradual increase in the social pressure on a better quality of further life which results in an increase in the number of mere "cosmetic" operations consisting in removal of "well matured" cicatricial areas of small extent.

   The next table (Tab. 2) summarizes the total numbers of patients hospitalized for burns and reconstructive surgeries in the course of the last eight years. During that period we hospitalized more than 1000 children and performed 230 reconstructive surgeries. On the average 124 burnt children are hospitalized every year and to this number corresponds the performance of 28 reconstructive surgeries. In view of the increase in the number of these surgeries in the past years we expect that their number will grow and will amount to app. 20-25% of the number of burnt patients treated every year, taking into account that it may further increase by 1015% of surgeries in patients from the past years. The total time necessary for performance of reconstructive surgeries on one patient can only be estimated at 10-15 years with an anticipated number of 2-3 operations per year. Thus, using a simple calculation, we will find out that the total number of reconstructive operations on one patient with extensive burns may range from 30 to 45.

  Table 3. states general indications for the reconstructive surgeries on burnt patients. We carry out the early reconstructions in the first six months only exceptionally, namely for reasons of possible irreversible functional changes (such as limitation of motility of big joints, deformity in the regions of hands, eyelids, neck, mouth etc., but also for example in cases of non-healing rhagades. If possible, we carry out the planned reconstructions on completely matured areas which may be ready in one to several years. Among the mentioned indications we have to emphasize the causes of psychological origin that sometimes stay in the background for various reasons. There is, of course, a broad spectrum of behaviour of burnt people from pretended ignoring of the aftereffects as a defence reaction, up to a maximized repulsion with absolute rejection of one's appearance. We should never assume that "a nicely matured scar" will be accepted without reservations. It is necessary to take this fact into consideration when we approach the individual patients, in most cases we have known them, including their family background, for several years which makes it possible for us to choose an individual and sensitive solution. We should not in any case rouse unrealistic expectations in them nor to destroy all their hopes.

As regards the contraindications (Tab. 4) of reconstructive surgeries, it follows from the above mentioned that they are never absolute. Sometimes we are just forced by the circumstances to carry out an operation both at the stage of the proliferative maturing of the scars and in case of a lack of'suitable tissue and presence of an infection, if the patient is in a bad condition, sometimes even in case of a concurrence of several or all adverse circumstances.

   The choice of an operating technique is mostly a part of the general long-term strategy of treatment. Individual operating techniques can be used both separately and in various combinations. In our case a direct suture is of no practical importance. We use more frequently split-thickness grafts (Fig. 1) of medium thickness taking into consideration the possibility of repeated harvesting which is not possible with full-thickness grafts. We use them in early reconstructive surgeries when we replace either fragile proliferative scars that keep breaking up or fast growing contractures that cannot be treated with conservative methods. And furthermore, according to a plan, for torpid hypertrophies or contractures in the middle of an large cicatricial area to which any other tissue cannot be transposed. For the same indication we can also use allogeneic dermis (i.e. cadaverous dermis without antigeneic identification) as a composite graft (allocorium + thin splitthickness graft) applied in one or two steps. Scars with a final lower tendency to contractility predominate among the results recorded up to now. Local flaps (Fig. 2, 3) count among basic standard reconstruction methods although they are not very often typical flaps. We do not form a classic pedicle, in simple terms it is an expansion of comparatively small islands of intact skin carried out gradually in all directions with the aid of elasticity and tension. After having made full use of this physiological capacity of the skin we can use a tissue expander for further expansion (Fig. 4, 5). As far as children are concerned, our attitude to their indications is more conservative particularly as regards the choice of the place of application. In principle we do not place it on soft bases, in places where neurovascular plexus are located, in the face, neck, and in little children we do not place them in the hairy part of the head. We always try to use an expander whose volume will be as big as possible and which can be placed in the given locality. We put its valve under the cicatricial tissue even at the price of its partial necrosis. The filling of the expander is usually carried out at weekly intervals and in one filling the volume of the applied liquid should not exceed 10% of the total volume of the expander. In most cases the children can stand them very well, including the filling. It is not necessary to considerably reduce their physical activity nor to suspend the school attendance. We use musculocutaneous flaps, distant or free, in the solution of extensive cicatricial defects only in a very limited extent. The disadvantage is their relatively small area, abundance of tissue causing failures of the contour and shape, creation of another cicatricial surface on the donor site. We indicate them e.g. to solve deep devastating injuries of a limited area, caused by electricity. The use of muscular flaps in combination with a graft comes into consideration as one of the methods of reconstruction of breasts in girls with extensive burns.

CONCLUSION

   Reconstruction of extensive cicatricial areas after burns requires a long-range concept and systematic planning. It may even take several decades. In comparison with usually managed skin defects, we are in the opposite situation when trying to replace a larger defective area by means of expansion of an incomparably smaller intact area. A different vascular blood supply to the scars formed after grafting using split-thickness skin grafts determines all our actions. The original anatomic vascular system has been devastated, also most of the anatomic structures of the subcutis are missing, the vessels that have been formed anew lead practically only vertically, they supply only very small areas of the new skin cover. Axial vascular supply is missing, the parallelly running axial skin arteries have been broken or damaged. Even the vascular structures of a higher order will often be destroyed perforating or segmentary vessels. This actually prevents any manipulation of the cicatricial area and results in only very limited possibilities of reconstruction. We must not forget the anesthesias either - there are dozens of them bringing complications. Reoperations cause psychological stress often accompanied by neurovegetative disorders both before and after the operation. Sometimes there may occur technical problems concerning tracheal intubation due to contractures of lips, neck, or strictures of larynx. In conclusion we once again point out the necessity of constant psychological support given to the patients by means of a sensitive, calm and understanding approach, and creation of a feeling that one has a secure base in the health-care establishment.

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