HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Wong et al

most commonly to the eyelid, perioral, and cervical regions, to minimize acute contractures that can cause lasting damage. 24 Intermediate occurs months to years following the initial burn and scar modification is the surgical goal. Some surgeons suggest that as scars continue to improve it is best to allow them tomature and intervene when this nat- ural progress diminishes. Once a patient presents with established and stable deformities, treatment is in the late phase of reconstruction. All potential reconstructive needs and all potential donor sites should be first established and prioritized so that optimal use of remaining donor tissue is assured. Particularly in the intermediate reconstructive phase, intralesional steroids may reduce pruritus and induration of the scar. They should, however, be used judiciously and not in excess to minimize atrophy and erythema. Scar revision Z-M-W-plasty reconstructive techniques lengthen linear scars by recruiting lax adjacent lateral tis- sue. This may affect the physiology of hypertro- phic scarring, causing the breakdown of collagen and relief of tension. It also camouflages the scar by creating more irregular borders and is useful in linear scar contracture release. Five-flap jump- ing man plasties are especially useful for redefining concave surfaces (eg, lateral neck). Laser therapy The pulsed dye laser uses a 585 nm wavelength and is best suited for red, immature scars. It re- duces erythema and accelerates scar matura- tion. 25,26 Timing of initial laser treatment, age of patient, and ideal number of treatments are the current subject of multiple clinical studies. Fat grafting Significant tissue contour deformities may exist even after skin grafting. Fat grafting can then be used to correct depressions and has been used to decrease pruritus associated with hypertrophic burn scars. 27 Skin grafting Skin grafts are used for reconstruction following release or excision of scar contractures. Split- thickness skin grafts can often lead to recurrence because they undergo more secondary contrac- ture than full-thickness grafts. They also result in more folding or wrinkling and can remain glossy in appearance. Thus it is ideal to use them only on the peripheral aesthetic units of the face. Cheeks, Options for Scar Intervention and Reconstruction Steroids

drape well compared with thicker grafts. However, full-thickness skin grafts may lead to decreased rates of retraction and ectropion. 20 Full-thickness skin grafts are almost always chosen for lower eyelid reconstruction, again, to decrease the rate of secondary contraction and ectropion of the lower eyelid. Temporary tarsorrhaphies may be necessary to protect the cornea while the grafts mature. Partial-thickness and full-thickness burns to ears are treated acutely with topical antimicro- bials. Mafenide acetate, when applied twice daily, is the treatment of choice for burns to the ears given its superior eschar penetration and preven- tion of chondritis. For patients who cannot tolerate the painful side effects of this treatment, betadine ointment or silver sulfadiazine can also be applied to the burn eschar. Full-thickness burns to the ears should be managed expectantly, allowing the eschar to spontaneously separate, at which point autografting can be performed over granulation tissue, or local flaps, if available, can be used for coverage of exposed cartilage as needed to main- tain 3-dimensional ear contours. 21 Once open burn wounds have healed, there are several therapies in which to minimize scars and assist in their maturation. Topical silicone gel is a mainstay in therapy to encourage scar matura- tion. 22 Compression therapy is known to minimize hypertrophy of scars. Computer-molded compres- sion masks allow direct pressure to the point of blanching of the scars. Splints are also used to maintain optimal length of scars and prevention of postoperative contractures. Often the neck is splinted in the acute phase in the neutral position and serially with increasing extension to improve range of motion andminimize contracture. Physical therapy and range of motion is rarely started in the emergent phase but is initiated in the acute phase. Massage and stretching are initiated at this time as well. Massage can be used to encourage orienta- tion of the collagen fibers. 23 Postoperative Management HEAD AND NECK BURN RECONSTRUCTION Timing of Reconstruction Timing of reconstruction following facial burns is classified into acute, intermediate, and later inter- ventions. In general, reconstruction should not be completed if the patient has open burn wounds because this increases the risk of infection. Addi- tionally, inflammation and incomplete contraction will compromise the reconstructive efforts. Acute reconstruction occurs within the first months, especially if functional deficits are detected,

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