HSC Section 3 - Trauma, Critical Care and Sleep Medicine

Head and Neck Reconstruction

lower eyelid contracture. These incisions are extended the full length of the eyelid. Split- thickness skin grafts for the upper eyelid and full- thickness skin grafts for reconstruction of the lower eyelid have been recommended in the past; however, many investigators now recom- mend full-thickness skin grafts for both because this leads to less secondary contraction. Donor sites chosen for skin graft harvest are based on what provides the best color and texture match. If the contralateral upper eyelid is uninjured, this is the first choice for the donor site, followed by postauricular or preauricular, supraclavicular, inner arm, and groin skin. Recalcitrant burn ectropion of the lower lid can be corrected by suspending the eyelid with a tem- poralis fascia or fascia lata sling that is secured to the medial canthal tendon and lateral orbital rim. 31 The nose represents a challenge in burn recon- struction. Not only should the aesthetic units of the nose be respected during operative planning but full-thickness injury requires reconstruction of not only the skin covering but the mucosal lining and skeletal support as well. When structural sup- port and nasal lining are preserved, the skin coverage may be reconstructed with regional flaps, such as the forehead flap when available, or with split-thickness, instead of full-thickness, skin grafts. Reconstruction of the nasal lining can be accomplished with skin grafting to a vascular- ized flap, turnover flaps, or local vascularized mucosal flaps. Reconstruction of the skeletal sup- port of the nose requires cartilage grafting, which may be in the form of composite grafting for smaller defects. The most common deformity resulting from scar contracture of the nose is asymmetry of the nasal ala. The nasal ala is more prone to injury due to its distal exposed location. 32 A nasolabial flap can be used to correct resulting alar notching. Another useful flap to simulate alar lobules and provide adequate nasal length and projection is a nasal turndown flap. This is an inferiorly based flap con- sisting of tissue from the nasal dorsum. The flap is turned over and functions as nasal lining, whereas the resultant defect along the dorsum is skin grafted. 33 Nasal Reconstruction

upper and lower lips, and dorsum of the nose are excellent sites for full-thickness skin grafting. Full- thickness grafts result in improved color match compared with split-thickness grafts. Contractures must be overcorrected and managed postopera- tively with conformers and pressure. 28 Tissue expansion This form of reconstruction is best used when normal donor sites for skin are inadequate but should be used cautiously. Tension in burn defor- mities is almost always due to tissue deficiency. Stretching adjacent tissue can often create more tension when attempting to reconstruct burn scars. The complication rate is high. Rectangular or oval expanders are most commonly used to provide excess tissue for advancement, rotation, and transposition flaps. One must allow for adequate growth of tissue during expansion but without rapid expansion, which can thin the skin inappropriately. In general, expansion is completed 2 weeks before tissue transfer to help minimize contraction and optimize tissue growth. This type of reconstruction if especially useful for the correction of less than 50% alopecia. 29 Flap reconstruction Ideal color match, skin thickness, and texture are possible using local regional flaps for reconstruc- tion. The rate of contracture is also diminished when compared with skin grafts. Random flaps, such as Z-plasty, are the most commonly used in burn reconstruction. Advancement flaps are gener- ally avoided, especially if they cross aesthetic units because they tend to retract. Rotational and trans- position flaps are useful, and the closure of the donor site eliminates deforming tension. 30 Cervico- pectoral flaps provide the best color and texture match to facial skin, whereas distant flaps are often a poor match. In panfacial burns, however, it is not uncommon to sustain concomitant burn injury to the neck and chest. This, therefore, eliminates any local flaps available for reconstruction of the face or scalp. In these cases, free tissue transfer is often the only solution. The radial forearm, when available, provides supple donor tissue along with a long pedicle capable of reaching the neck ( Fig. 1 ). Scar contracture of the periorbital region leading to upper and/or lower eyelid ectropion remains a priority in reconstruction of facial burns because early surgery will reduce the risk of exposure ker- atopathy. Release of the upper eyelid contracture should be performed in the upper eyelid crease, whereas a subciliary incision is used to release a Eyelid Reconstruction

Perioral Reconstruction

Contractures that result from perioral burn injury commonly result in microstomia and lip ectropion. Speech therapy and early use of custom oral splints are recommended in severe cases of full- thickness facial injury. Upper lip shortening can

144