Burn Reconstruction

BURN RECONSTRUCTION PROCEDURES

At the time of your initial consultation, the goal is to come up with a comprehensive plan to restore NORMAL. Our patients have taught us to listen to their priorities, their fears, and respect for other aspects of rebuilding their lives. A comprehensive plan involving surgical and non-surgical therapies will be formulated. The priorities, timeline, and expectations will be set. We look forward to meeting you and helping you with your burn reconstructive needs, including surgery, physical therapy, occupational therapy, and laser.

Z-PLASTY

A Z-plasty is a commonly used technique that borrows adjacent local tissue to add to deficient areas in a “Z” configuration. This geometric rearrangement transforms both the orientation of and adds length to a contracted scar. While the technique is elegant and the recovery short, it is reserved for limited burn contractures. Typically, a Z-plasty is performed when a burn scar contracture is linear and there is adjacent tissue laxity.

This procedure is typically done as a day-surgery where patients are discharged on the same day of the operation. Both internal and external sutures are applied so there will be sutures to be removed after 14 days (or 5 days on the face). You will likely be discharged with a gauze dressing that will stay in place until your follow up visit at one-week. You will be asked to limit your activities while the Z-plasty flaps are healing which usually takes about a month.

All operations have risks. We believe that you should be informed about them and also everything that we do to minimize those risks for you. In the case of your Z-plasty operation, besides the standard risks of bleeding, and infection which are rare and we take great care to minimize, there is risk of wound healing problems and incomplete release of your contracture or even recurrence of your contracture. Wound healing problems may require an additional period of time when you are wearing a dressing. This is particularly problematic for smokers. Those who undergo this procedure should also know that the scars will first appear to be a zig-zag manner, which generally improve and lighten with time. Finally, unlike other procedures, a Z-plasty has no donor sites and has the least recovery period.

FULL AND SPLIT SKIN GRAFTS

As opposed to a Z-plasty, broad contractures often require transverse scar release or excision with tissue interposition. Often the wound bed is sufficiently vascular after the release that a full (FTSG) or split thickness (STSG) can be applied. While FTSG gives better esthetic appearance, STSG provides versatility, especially when large areas needing coverage are involved. When considering STSG donor sites, the upper postero-lateral thigh is preferred, but any available, healthy skin can theoretically be used. Consideration should be given to the concealability of the donor scars, color match as well as accessibility during surgery. In the case that minimally available donor skin is available, options include repeat harvesting, meshing and use of a dermal regeneration template with STSG. FTSG are usually reserved for reconstructions with functional (hands or neck) or aesthetic (eyelids, perioral) areas. The required donor site must have redundant skin and typically the supraclavicular, lateral thoracic, lower abdominal or groin areas are chosen.

This procedure is typically done as a day-surgery where patients are discharged on the same day of the operation. However, you may be asked to stay overnight for pain control, especially if this is your first time undergoing this type of operation. The donor site of the full thickness skin graft is closed with both internal and/or external sutures which may need to be removed after 14 days. Your split thickness skin graft donor site will have no sutures but there will be a yellow dressing covered by an outer cloth dressing. The other cloth dressing will be removed after the first day and the yellow dressing left to dry out. As the dressing dries, it will be removed similar to a scab. You will likely be discharged with a gauze dressing that will stay in place until your follow up visit at one-week. Your release will be dressed with either a bulky tie-over bolster or a wound vac. Both will stay in place between 1-2 weeks and you must keep this dressing dry. You will be asked to limit your activities while the skin graft is healing. On the hands, a splint will also be applied as a reminder for immobilization.

All operations have risks. We believe that you should be informed about them and also everything that we do to minimize those risks for you. In the case of your skin graft operation, besides the standard risks of bleeding, and infection which are rare and we take great care to minimize, there is risk of wound healing problems and incomplete release of your contracture or even recurrence of your contracture. Wound healing problems to either your donor site or the area of release may require an additional period of time when you are wearing a dressing. This is particularly problematic for smokers. Those who undergo this procedure should also know that once the initial dressing comes off, it may look discolored or indented but will generally improve and flatten and lighten with time.

FREE-FLAP CLOSURES

Flaps are chosen over grafts when the underlying wound bed either cannot support a graft or the possibility of re-contracture is not tolerated. Skin flaps are not vascularized by the wound bed but carry its own blood supply. For that reason, it can be used to cover areas where graft loss is common because of movement or poor vascularity . Local flaps are from adjacent areas while distant flaps come from non-adjacent areas. A free microvascular flap, a type of a distant flap, involves micro-anastomoses of the donor and recipient arteries and veins. Flaps are very useful in burn resurfacing but does have disadvantages of being very bulky and often additional revisional operations are required. These procedures are highly custom and will require individualized discussions.

TISSUE EXPANSION

Tissue expansion is sometimes used as a technique to create additional skin to be used as flaps or full thickness skin grafts. This is a staged procedure where the first operation involves insertion of tissue expanders (saline filled bags) under the skin. Once the incisions are healed, around two weeks, the bags will be inflated through a port, which may be located remote from the tissue expander or within the tissue expander itself. The expansion process takes approximately 2-3 months with weekly fills. A second operation then uses the tissue expanded skin for resurfacing.

The procedure for insertion of the tissue expander is typically done as a day-surgery where patients are discharged on the same day of the operation. However, you may be asked to stay overnight for pain control, especially if this is your first time undergoing this type of operation. You will have external sutures which may need to be removed after 14 days. Your second operation, usually 3 months later, may or may not be a same day surgery.

All operations have risks. We believe that you should be informed about them and also everything that we do to minimize those risks for you. In the case of your tissue expander operation, besides the standard risks of bleeding, which we take great care to minimize, there is risk of infection and wound healing problems, particularly with the first operation. Signs of infection include redness, drainage or even exposure of the expander necessitating removal. This is particularly problematic for smokers and the process has to start again once the tissues have had a chance to heal and soften after 6 months.

DRAINS

Drains may be placed during your operation, exiting on the side of your incision. They stay in place for approximately 1 week, or until their output is less than a certain amount. You will be taught the care of these drains and how to empty them.

WHAT TO EXPECT

At the time of your initial consultation, the goal is to come up with a comprehensive plan to restore normal. Our patients have taught us to listen to their priorities, their fears, and respect for other aspects of rebuilding their lives. A comprehensive plan involving surgical and non-surgical therapies will be formulated. The priorities, timeline, and expectations will be set. We look forward to meeting you and helping you with your burn reconstructive needs, including surgery, physical therapy, occupational therapy and laser.