Burn Deformities of the Face and Neck: Reconstructive Surgery and Rehabilitation

Burn Deformities of the Face and Neck Reconstructive Surgery and Rehabilitation JOHN MARQUIS CONVERSE, M.D., F.A.C.S.*

Dupuytren, in 1832, in referring to the deformities resulting from burns, wrote: "We must here note a phenomenon which is peculiar to burns and which no other wound with loss of substance presents to the same degree: this is the power with which the edges of the wound are drawn toward the center." Contracture, the result of wound contraction during healing, is a characteristic deformity following any wound with loss of skin. In the face and neck, contractures and scars, the result of tissue destruction from burns, distort the soft tissue structures and may result in severe facial disfigurement and functional impairment. During the year 1962, 1,800,000 persons sustained burns and occupied over 11,000 hospital beds per day; 12,000 of these patients died (Report of the National Fire Protection Association, 1962). Facial burns represent between one-quarter and one-third of all burns (Roper-Hall, 1962; Skoog, 1963; Tubiana, 1967). These statistics give an indication of the magnitude of the task involved in the rehabilitation of these patients. The reconstructive surgical rehabilitation of the patient who bears scars and contractures following burns of the face and neck is a major task for the plastic surgeon. As important as the relief of functional disabilities is the reduction of the severity of facial disfigurement, and its attendant sociological, psychological, and vocational implications. It is now well recognized that early skin grafting minimizes subsequent contracture and hypertrophic scarring. It is also realized that despite early grafting subsequent deformity may result from tissue destruction in deep burns and from the relative inadequacy of the split-thickness graft employed to transform the open burn wound into a closed wound. Splitthickness skin grafts contract during and after the period of healing; the younger the patient, the greater the amount of contraction. The worst

* Lawrence D. Bell Professor of Plastic Surgery, New York University School of Medicine; Director, Institute of Reconstructive Plastic Surgery, New York University Medical Center; Chairman, Department of Plastic Surgery, Manhattan Eye, Ear, Nose and Throat Hospital; Director, Plastic Surgery Service, Bellevue Hospital; Consultant in Plastic Surgery, Manhattan Veterans Administration Hospital, New York, N.Y.

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deformities are those seen in patients in whom primary skin grafting has been delayed or unsuccessful. The extent of deformity and disability IS reduced by adequate early treatment of face and neck burns.

EARLY TREATMENT

In extensive body burns, facial burns must be considered within the context of a burn affecting a major portion of the body. Because of the frequency of respiratory tract involvement, facial burns should always be treated as severe burns. Early treatment of facial burns includes gentle cleansing, evacuating blisters, and removing loose epithelium and foreign bodies. The eyes should be carefully examined for possible corneal damage and the corneas protected by instillation of ophthalmic ointment. A tracheotomy is performed if indicated; the placing of the patient in a moist steam chamber and the provision of oxygen have considerably reduced the need for tracheotomy. The patient's head is kept elevated and emergency , tracheotomy equipment is maintained at the bedside. Within 24 hours the burned face and neck are the site of increasing edema, the facial and cervical tissues being ballooned out and the eyelids closed. It is difficult, if not impossible, to make an early diagnosis of the depth of the burn in the burned face. Analgesia to pinprick, helpful in the diagnosis of depth in the remainder of the body, is most unreliable in the face. The burned areas may be red, white, or black and the burn may be only of partial thickness. Early excision and grafting are not advisable in facial burns. Pressure dressings are not indicated in facial burns. The dressings are uncomfortable, cause mechanical irritation of the burned areas and the closed dressings tend to encourage bacterial proliferation. The exposure method (Wallace, 1949) is always preferable. The formation of a dry crust or scab is encouraged by the warm dry air of an electric hairdryer. Loose wet dressings may be employed after five or six days in order to assist in the cleansing of the sloughing wound. The removal of loose tissue, the separation scabs, and sloughs is assisted with forceps and scissors. The edema subsides and devitalized tissues become apparent. The devitalized scab of the superficial burn separates from the subjacent healed integument within ten days. A thicker scab separates more slowly in deep dermal burns, revealing alternating areas of healing epithelium and granulation tissue characteristic of the burn of mixed depth. The thick, rigid, black eschar of full-thickness burns begins to separate slowly and with difficulty usually within a period of 15 days, the deep hair follicles of the male face tending to retain the sloughing tissue. The wound becomes rapidly covered with healthy appearing granulation tissue in subsequent days and should be skin grafted. Facial wounds of partial skin thickness such as abrasions, either trau-

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matic or surgical, and superficial burns heal best under the dry crust which forms in the exposure method (Wallace, 1949). The introduction of two new techniques involving topical application of 0.5 per cent silver nitrate (Moyer, Brentano, Gravens, Margraf, and Monafo, 1965) and 10 per cent p-aminomethyl-benzene sulfonamide (Sulfamylon) has raised the question of their indications in burns of the face and neck. Limited experience in our own series of cases suggests that, while the silver nitrate technique does not appear to offer any particular advantage over the exposure method in the facial area, topical chemotherapy may be beneficial. Sulfamylon cream appears to suppress bacterial growth, particularly of Pseudomonas aeruginosa, preventing further destruction of surviving epithelial islands,

Figure 1. A, Total facial full-thickness burn resulting from gasoline explosion in an ll-year-old boy. B, Thick split-thickness grafts being applied to granulating areas. C, Appearance of the patient during the early postoperative period.

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thus favoring spontaneous re-epithelization (Lindberg, Moncrieff, Switzer, Order, and Mills, 1965). In full-thickness burns, skin grafting should be done as soon as the granulations have appeared after the separation of the sloughs. Systemic antibiotic therapy should precede the skin-grafting operation. Relatively thick split-thickness skin grafts of 14 to 18/1000 inch in thickness are satisfactorily revascularized and provide a resurfacing of better quality than the thinner Thiersch grafts (Fig. 1). Skin grafting in facial burns should be done not only in the areas of obvious full-thickness loss but also over areas of mixed deep dermal burns as soon as granulations appear. Skin grafting of the burn of mixed depth will greatly reduce the amount of hypertrophic scar formation which is characteristic after the healing of these areas. If skin grafting has been delayed because of concern for the general clinical status of the patient, the granulations may have become excessively hypertrophic. In such cases removal of granulation tissue by scraping the soft superficial layer from the deeper, more resistant layer provides a firm, well vascularized base for the skin graft. Vilain (1959) applies a pressure dressing containing hydrocortisone for a few days prior to skin grafting, a technique which, he claims, increases the chances of successful grafting. The open method of skin grafting has been employed successfully: this method has the advantage that direct observation of the skin graft permits the aspiration by suction of small blood clots and seromas. A compromise method, which we favor, consists in applying a pressure dressing over the skin grafts during the first 48 hours. The exposure of the skin graft at 48 hours permits the removal of blood clots and seromas sufficiently early to permit survival of the overlying skin. The skin graft is then left exposed until healing is complete. During this early period of treatment, rapidly increasing ectropion of the upper eyelid leading to corneal exposure and possible ulceration requires the application of thin split-thickness grafts to overcome the eyelid retraction; usually these early grafts require later replacement because of subsequent ectropion. If danger to the cornea does not exist, skin grafting of the eyelids should be postponed. Another painful and discouraging problem is that of suppurative chondritis, from exposure of auricular cartilage. Treatment is limited to incision and drainage of subperichondrial abscesses and elimination of cartilage sequestra. Crumpling of the auricle from loss of cartilage support is a frequent sequela. Ectropion of the lips from loss of skin and exposure of the gums and teeth is a cause of great discomfort to the patient. Early skin grafting has reduced the number of monstrous deformities formerly encountered when the face and neck burn wounds were allowed to heal spontaneously. Despite early grafting, contractures and hypertrophic scars still occur; improper timing, wound sepsis, inadequate fixation of the graft, hematoma: these are some of the causes of failure, either partial or total.

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WOUND HEALING AND SCARS

Contraction is a characteristic phenomenon in wound healing. A granulating wound always contracts. Contraction and the resultant contracture are reduced by early skin grafting. Unfortunately, wound contraction does not cease after skin grafting but continues to progress after the skin graft has healed. The greatest amount of contraction occurs in mobile areas of the face, eyelids, lips, cheeks, and in the cervical area and when thin split-thickness skin grafts are employed; contraction is minimized by thick split-thickness or full-thickness grafts. Thick split-thickness skin grafts are well vascularized over granulation tissue. In extensive burns, however, donor areas may be sparse, and required for additional repeated crops of skin; in such cases there is no choice and thin split-thickness grafts are obligatory. Contraction is not limited to the full-thickness burn wound. The second degree burn wound which involves only the partial thickness of the skin also contracts during healing. The re-epithelization of second degree burns originates from the epidermal inclusions in the dermis: remnants of the rete pegs between the dermal papillae, hair follicles, sebaceous glands, sweat glands and their excretory ducts. On the surface of the dermal wound appear islands of epidermis which originate from these remaining epithelial elements. Each island enlarges in size through a process of multiplication, enlargement, and migration of its epidermal cells. This outburst of epidermal mitotic activity has been attributed by Bullough and Lawrence (1960a, b) to a reduction in the concentration of mitotic inhibitors presumed to be present in undamaged skin in which mitotic activity is normally controlled by such inhibitors. All wounds contract during healing and dermal wounds are no exception to the rule. Contraction of the wound tends to approximate the islands of epithelium to facilitate their eventual junction (Fig. 2). This phenomenon has been called inter-island contraction (Converse and Robb-Smith, 1944). It is this contraction which explains the tightening of the skin following a burn involving an appreciable thickness of the dermis. Epidermal continuity is restored but there results a generalized shortness of skin in the area, an invisible skin loss. Thus contractures occur, despite the fact that the full thickness of the skin was not destroyed, in the mobile areas of the face, eyelids, nares, lips, cheeks, and the cervical areas. A superficial burn may heal without leaving any visible scar in its wake. Bishop (1945) showed, in experiments conducted upon himself, that full-thickness regeneration of the skin occurs after partial excision when the reticular layer of the dermis is not included. Varying degrees of resultant scarring in the healed burned area are dependent upon a number of factors. 1. The intensity of the burning agent and the length of time of exposure to the agent, factors which determine the depth of the burn: the

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Figure 2. Diagrammatic representation of the mechanism of production of interisland contraction. A, Islands of regenerating epidermis on the surface of a dermal burn wound. B, Islands have coalesced by a dual process of epithelial spread and contraction between the epidermal islands. The result is a contraction and diminution of the healed surface area.

deeper the burn, the fewer number of epidermal elements and the poorer the epidermal resurfacing. 2. The thickness of the skin. Obviously, the thinner the skin the more easily it can be destroyed. The skin of the eyelids, which is the thinnest skin of the body, will be more frequently destroyed than the remainder of the facial skin. 3. The rapidity of healing. Uncomplicated, relatively superficial der mal burns may heal without a scar or with the changes that are observed following mechanical dermabrasion or chemical peeling-changes which are characterized by a smoothing and tightening of the skin of the area (inter-island contraction). Delayed healing from wound sepsis and the re sultant vascular thromboses in the dermal vessels, or from mechanica injury by loose-fitting dressings, may lead to tissue destruction into the deeper reaches of the dermis or even result in a full-thickness skin loss. The process of healing is similar to that of the donor areas of skin grafts and of areas which have been mechanically dermabraded or chemical ly peeled. The line of demarcation between live and destroyed tissue i more distinct after skin has been mechanically removed than it is afte

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thermal or chemical destruction. In the latter there is an intermediary area between the healthy and destroyed tissue in which the tissue is partially devitalized. This area may recover its full vitality and become re-epithelized. Histochemical studies of dermal burns have shown that beyond the area of irreparably damaged tissue lies an area of tissue in which metabolic activity has been only temporarily reduced as a result of thermal injury, and may therefore recover (Converse, Platt, and Ballantyne, 1964; 1965). Considerable attention has been given to the preservation of the recuperative power of this injured dermal layer and particularly to the avoidance of wound sepsis which interferes with wound healing and re-epithelization (Lindberg et aI., 1965). The healing of a superficial burn wound is characterized by the re-epithelization of the denuded dermis forming the base of the blister. The epithelial newgrowth is at first a thin layer which progressively becomes stratified and rapidly assumes the undulated junction line with the underlying dermal papillae and the characteristic tethering. Beneath this epidermis a new layer of reticular fibers is laid down, arranged in a loose network; collagen fibers appear later. At first no elastic fibers are found in this newly formed connective tissue layer; within weeks new elastic fibers are seen. The healed epidermis and dermis progressively assume an appearance, both gross and histological, which varies only slightly from the normal in burns involving the superficial papillary dermal layer only, to varying degrees of permanent change in texture and color when the dermis is more deeply destroyed. EPIDERMIS

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CROSS SECTION OF FAT COLUMNS Figure 3. A, Diagram illustrating the junction line of the dermis and subcutaneous tissue and the protrusion of the columns of subcutaneous fat into the dermis. B, Cross section at the base of the dermis showing the protruding columns of adipose tissue.

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When an appreciable amount of the reticular layer of the dermis is destroyed, the reappearance of elastic tissue in the degenerated superficial layer is greatly retarded or may never occur. In such wounds the re-epithelization has taken place much more slowly and the laborious resurfacing may have been further retarded by superimposed wound sepsis. When tissue destruction extends into the lower reaches of the reticular layer of the dermis, areas of full-thickness loss may alternate with areas in which the dermis is still viable. The alternating full-thickness and partial-thickness areas are explained by the fact that the junction line between the base of the dermis and the subjacent adipose layer is not a straight line. It is an irregular junction line with many variations in different areas of the body, and of the face and neck. The adipose layer of the subcutis sends extensions into the dermis (Fig. 3) known as the "columnae adiposae" (columns of fat). Slow healing and contraction of these punctate areas is a further cause of fibrosis and generalized contracture. When healed, a dry, scaly, shiny covering epithelium with areas of hypertrophic scarring interspersed within the scar epithelium is characteristic. In the early stages after healing, occasional surviving hair follicles in male patients may become embedded and surrounded by purulent exudate requiring drainage of the abscess or extraction of the hair follicle. The scarred healed skin surface is devoid of lanular hair, of glandular elements, lacks flexibility and elasticity. The healed area is contracted, and the skin shortness thus resulting plus the relative rigidity of the healed tissue causes a contractile pull on the loose structures of the face, eyelids, nares, and lips. The superficial musculature of expression imprisoned beneath this carapace is unable to function, giving a rigid, masklike, expressionless appearance of the face.

CONTRACTURES AND HYPERTROPHIC SCARS

Contractures are the result of the contraction of healing wounds. Contraction of the healing wound has been attributed to the centripetal traction exerted upon the wound edges by the maturing granulation tissue in the wound. When skin grafting is delayed, changes occur in the granulation tissue: the vessels decrease in number and the cell population also decreases; the wound consists of thick collagen fiber bundles with a few compressed nuclei of the original fibroblasts retained between them. The role of the granulation tissue in wound contraction has been questioned. According to Watts, Grillo, and Gross (1958), the machinery for the major part of contraction lies in the wound margins (the "picture frame" hypothesis) and the central granulation tissue is not required in the process of contraction. To date, the site of the wound contraction mechanism is not agreed. Abercrombie, Flint, and James (1956) cast doubt on the role of preformed collagen or newly formed collagen fibers when they demonstrated the unimpaired progressive wound closure in scorbutic guinea pigs despite almost complete absence of new collagen synthesis. The work of Abercrombie, James, and Newcombe (1960) also suggests that the "picture frame" hypothesis cannot be held to be generally applicable. Whatever the mechanism of wound contraction, the fact is that wounds in which an appreciable surface area of the skin has been destroyed are submitted to an inexorable contraction if the surrounding tissues are sufficiently lax to permit the contraction. In the forehead and scalp areas, where the cutaneous tissues are relatively tightly adapted to the

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underlying cranial vault, wound contraction is limited and often the clinical evolution of such wounds is arrested healing with exposed cranial bone. The Lines of Minimal Tension and Healing Burns In the face and neck, maximum contracture results in wounds whose long axis crosses at right angles the lines of minimal tension. The lines of minimal tension are the result of adaptation to function, the skin being constantly pulled and stretched by underlying muscle and joint activity; the connective tissue fibers, collagen, and elastic are arranged in bundles which are perpendicular to underlying muscles. A scar parallel to the lines is not subject to the intermittent pull of the subjacent muscle: thus the term "lines of minimal tension" (Converse, 1964*). In an ordinary section of human skin, the collagen fibers of the dermis appear to be arranged haphazardly (see paper by Gibson, Fig. 8). If the skin is held in a stretch position during fixation, a proportion of the fibers will be found oriented along the line of stretch (see paper by Gibson, Fig. 9). In the head and neck, the lines of minimal tension are the response to adaptation to two different types of functional mechanisms. The first type is the lines of habitual expression in the face, such as the lines in the forehead, the eyelids, the nasolabial folds, and other lines of expression around the mouth. The second type is the lines of skin relaxation of the skin, movements of flexion and extension, such as the horizontal circular lines in the neck. A scar which traverses at right angles the lines of minimal tension of the skin is subjected to alternating stress and strain and relaxation, and constant changes in tension as the result of the activity of the underlying musculature: hypertrophy of the scar results. In burn wounds with loss of skin, a similar phenomenon occurs when the long axis of the wound traverses the lines of minimal tension. In the course of the contraction of the healing wound, hypertrophic scar tissue is laid down. The push-and-pull and alternating tension and relaxation to which the scar is subjected promotes the proliferation of fibroblasts which continues long after wound healing has been completed. Thick contractile cords and bands are formed which consist of longitudinally arranged bundles of collagen fibers between which are flattened fibroblasts. Proliferating endothelium is seen in histologic sections of these fibrous bands; a manifestation of their vascularity is their turgescent appearance in the early stages. Microscopic tears and hemorrhages from forceful exercise produce additional fibroblastic proliferation in the repair process of these tears. Wider tumor-like hypertrophic scars, red and turgescent in the early stages, also occur in various areas of the face. These hypertrophic scars are often referred to as keloids. This term should be reserved to the pro-

* Gibson refers to these lines as "lines of maximum tension," thus designating the area in which the fibers are in a stretch position. The term "lines of minimal tension" is employed to mdicate that wounds parallel to these lines are not subject to tension from the activity of the musculature.

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gressively growing invasive scars seen in predisposed individuals, particularly in the Negro. Hypertrophic scars are seen in areas of contracture after the healing of full-thickness burns and also in areas of deep dermal burns, at the junction line between skin grafts, and between skin grafts and the surrounding skin. They are particularly frequent in children. The propensity of children to hypertrophic scars is well known and similar scars occur in the donor areas, following the removal of split-thickness skin grafts of excessive thickness. In the child, the skin is relatively thinner because it is distended over a subcutaneous adipose layer which is thicker than in the adult and penetrates into the base of the dermis through larger and more numerous "columnae adiposae."

Intrinsic and Extrinsic Contracture Particularly liable to contracture are four areas characterized by mobility and flexibility, the eyelids, the cheeks, the lips and perioral tissues, and the cervical area. Contracture is intrinsic, the result of loss of tissue in the structures themselves, or extrinsic, the contracture being caused by the pull of a healing contracting wound in the periphery. The upper eyelid is submitted to extrinsic contracture from the healing tissues of the brow and forehead; the lower eyelid, from contracture exerted by the cheek tissues; the upper lip, through intrinsic contracture, is pulled up toward the columella while the lateral portions of the upper lip are subjected, in addition, to the extrinsic contracture exerted from the cheeks; the lower lip and chin are pulled downward by intrinsic contracture and also by the downward pull of the contracting cervical area. The healing of the burned tissues in the temporal area may result in the formation of vertical cicatricial bands around the lateral canthus of the eye, cicatricial epicanthus which interferes with elevation of the upper eyelid and shortens the horizontal dimension of the palpebral fissure. Extrinsic contracture may also affect the medial canthus following burns over the dorsum of the nose. The medial canthal tissues are pulled forward, tending to ride up to the level of the dorsum of the root of the nose. The lacrimal puncta are pulled away from the conjunctival sac and lacrimal lake: functional disturbance of the lacrimal apparatus is the consequence of this anatomic disruption and septic dacryocystitis is not an infrequent complication. Circumferential constricture around the oral fissure has a purse stringlike effect diminishing its horizontal dimension and limiting the patient's ability to open his mouth. Burning of the narial border and of the perinarial portion of the nasal vestibule may cause destruction of part of the naris itself and a circular intranarial contracture resulting in stenosis. The tip of the nose tends to be pulled down into the lip. The base of the columella disappears in a large mass of hypertrophic scar involving the upper lip. Loss of tissue in the cheek tends to obliterate the nasolabial folds. Contracture is exerted not only in the cervical area itself, but also the supraadjacent portion of the face; the lower lip and the soft tissues of the chin

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are contracted down toward the sternal notch. The profile contour of the neck and lower part of the face tends to be a straight line with a disappearance of the normal suprahyoid cervical angle,the lower lip is in ectropion, the labiomental fold has disappeared and the chin pad occupies a submandibular position. All hypertrophic scars tend to become less vascular, less prominent, and paler in color with the passage of time. Postponement of definitive reconstructive surgery is therefore indicated in most cases. While patient waiting is permissible in large surface scars that do not cause distortion, contractile scars may cause serious functional impairment which require an earlier correction. THE WAITING PERIOD: CONVALESCENCE AND SOFTENING OF SCARS

Following the primary coverage of burn wounds by means of splitthickness skin grafts, and the spontaneous epithelization of residual defects between the grafts, the patient is discharged to his home for convalescence (Table 1). The severity of the remaining ectropion, of contracture-distortion of the feature of the face, and neck contracture depends largely upon the efficiency of the early skin grafting. It is at this stage that both patient and family undergo considerable psychological stress if the patient suffers residual facial disfigurement. The initial period of treatment in the hospital has concentrated upon the ensurance of survival; facial disfigurement now becomes a major problem if contractures and hypertrophic scars mar the patient's facial features. The return of a patient to his home after a long period of hospitalization may be a traumatizing experience. It is essential that the patient be forewarned of the reaction of members of his family, friends, and neighbors. A thorough understanding on the part of the patient's spouse and other members of the family is important. One of our patients recalls that when he returned home his two small children recoiled, screaming, at the sight of their disfigured father (Fig. 4). Unless eyelid ectropion menaces the integrity of the cornea, a waiting period should be allowed before attempting definitive reconstructive procedures. This furlough is essential to allow the patient to regain his psychological balance after the often long ordeal he has been through during the period of hospitalization. It is also necessary to allow metabolic and immunological stabilization, to provide for change in bacterial Table 1. Successive Stages in the Treatment oj Facial Burns 1. The stage of primary skin grafting 2. The waiting period: convalescence and softening of scars 3. Early reconstructive stage: Z-plasties and additional grafting 4. The final reconstructive stage

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Figure 4. A, A 30-year-old dental surgeon burned by gasoline when the fuel tan of the rear engine automobile exploded in his face in a crash with another car. Note th eyelid margin deformities resulting from inopportune tarsorrhaphy; the loss of eyebrow and auricle and extensive scarring of the skin grafted left half of the face. B, Less than one year after the beginning of treatment the patient returned to th private practice of dentistry. Note the improvement in the texture of the skin after releas of tension by means of full-thickness supraclavicular skin grafts and Z-plasties. The eye brow was reconstructed by means of a scalping flap. The patient is wearing an auricula prosthesis and a hairpiece.

environment and to allow time for the maturation of scar tissue, whic is often preceded by a characteristic low grade, nonspecific inflammator reaction. The surgeon must resist the pressure placed upon him by bot the patient and the family to undertake early reconstructive procedures Such operations present technical difficulties because of the activity o the scar tissue and the rapid recurrence of hypertrophic scars whic may be larger and more hypertrophic than the original scars. The re cently healed tissues are inadequately vascularized and latent patho genic organisms in the area may cause local infections and contribute t the failure of the skin grafts. Patients do not react as well to anesthesia a later in convalescence and there is considerably more bleeding during th operations.

The clinical observation that a prolongation of skin allograft survival may occu in the severely burned patient caused us to undertake studies of delayed hyper sensitivity reactions as the delayed hypersensitivity reaction has many similaritie to the allograft rejection phenomenon (Rapaport and Converse, 1966a, 1966b Casson, Solowey, Converse, and Rapaport, 1966). Twenty-four burned patient were studied comprising 16 with burns between 5 and 25 per cent of their bod surface area and 8 with over 30 per cent. These were compared with 80 norma control individuals. Both groups of burn patients were tested with a series of anti gens, including tuberculin and streptokinase-streptodornase.

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It was noted that there was a significant depression of delayed hypersensitivity responses in the burn group and the degree and duration of this depression was related to the extent of the burn. In the over-30 per cent group, all patients were anergic at their first testing and in those who were followed through the postburn phase a return of positive delayed hypersensitivity responses was noted. This observation is of clinical interest in that it may be of significance in the understanding of the alterations in the immune mechanisms, in particular, those related to allograft immunity in the severely burned individual. A lymphopenia is constantly observed, and hemagglutinins may be detected in burned animals in the thoracic duct from the fourth day after injury in high titer with persistent elevation during the ensuing 5 to 6 weeks (Kano, Milgrom, Witebsky, and Rapaport, 1966; Rapaport, Casson, Kano, Milgrom, Solowey, and Converse, 1967). One of the hemagglutinins has been tentatively identified as a 7s globulin and is absorbed by red cells which may account for the failure to detect such antibodies in the serum of burned animals and man. These altered immune manifestations bear a resemblance to some of the effects of total body irradiation and also of the administration of adrenal corticosteroids; they may play a role in the lack of resistance to invasion of micro-organisms. In both the laboratory animal and the burned human subject these disturbances persist well into the recovery phase of the burn illness.

These findings of severe alterations in the immune mechanisms of the severely burned patient explain the difficulties encountered in operations done in the early stages after recovery and suggest that reconstructive surgery be postponed until stability has been achieved. When extensive disfigurement is present, reassurance of the patient and his family and careful explanation of the reasons for postponement are essential. Moderately active exercises of the facial musculature of expression, opening and closing the eyes and the mouth, movements of flexion and extension of the neck, massage and other techniques of physical therapy may assist in loosening the tissues and softening the scars and are of considerable psychological value. Other areas of the body may also be involved and require a program of physiotherapy and exercises for the re-establishment of normal joint movement in burned hands and extremities. Frequent psychosocial interviews are necessary during this period. The patient is interviewed alone and with one or more members of his family. While reassurance is necessary the patient should be brought to a slow realization that rehabilitation will, of necessity, be prolonged, that he must keep himself usefully occupied during this period. Discussions should be held with the patient about the possibility of his returning to work either on a part-time or a full-time basis during intervals between operations. Serious consideration should be given at this stage to the vocational problems posed by serious facial disfigurement; the patient must be made to realize that, despite the successful reconstructive surgery, his face will still show some of the ravages of the burn and traces of the passage of the surgeon's knife. Consideration may even have to be given to a change in the patient's occupation. Visits to the hospital every six weeks permit establishing a rapport between the surgeon and his patient and give the surgeon an opportunity

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to observe the progress of the convalescing tissues, to study his patient and make plans for future reconstructive surgery. THE RECONSTRUCTIVE STAGE

Let us consider a patient who has suffered a massive burn of the face from a high-intensity heat burn, such as that incurred in a gasoline explosion. The burn wounds have healed by a combination of spontaneous epithelization and skin grafting. The healed tissues are red, indurated, painful. Contractures may cause considerable disability and discomfort. The patient and his family are depressed because of his appearance and the reactions of repulsion on the part of outsiders. This is, in brief, the clinical picture with which the plastic surgeon is often faced. McIndoe (1949) emphasized the tediousness and difficulty in the rehabilitation of the patient with the burn-deformed face. For the patient, the numerous and repeated operations may represent a test for the most courageous; for the surgeon, the results obtained, often satisfactory from a functional standpoint, are frequently disappointing from an esthetic standpoint. Because of the often protracted period of treatment and numerous operations, the importance of the psychological management of the severely burned patient is obvious; most of this management will rest upon the surgeon in whom the patient has placed his confidence and who must also act as his psychiatrist. THE EARLY RECONSTRUCTIVE STAGE. A palliative skin graft may be necessary to protect the cornea by releasing a severe ectropion of the upper eyelid. A Z-plasty or a skin graft may be an emergency early reconstructive procedure to relieve contracture of the corner of the mouth. These are two examples of early reconstructive surgical procedures. All other than essential surgery is postponed until the final reconstructive stage. THE FINAL RECONSTRUCTIVE STAGE. Reconstructive surgery should not be undertaken until the hypertrophic scars have begun to show signs of becoming paler in color, softer in texture and show signs of regressing in size. Most important is the development of a slight degree of mobility of the hypertrophic scar over the underlying tissues, due to the formation of a subcicatricial plane of loose connective tissue (Tumbusch, 1962). Excision along this plane of loose connective tissue is facilitated, bleeding is more easily controlled, and skin grafting and other reconstructive surgical procedures are more satisfactorily performed. Mathews (1964) mentions that the best results were often obtained in repatriated prisoners of war who had had a delay of perhaps two years forced upon them. Planning the reconstructive surgery requires an analysis of the deformities, the diagnosis of the size of the tissue loss and resultant defect, the choice of the techniques of repair and of the donor sites for the tissues to be transplanted. In the severely scarred total face and neck burn patient, the tight contracted tissues are "hungry for skin." After each procedure, whether a skin graft, a pedicle flap or a Z-plasty, it becomes evident that more skin

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is needed to restore adequate skin surface until the tightness disappears and the functional and expressive movements are resurrected. PRINCIPLES OF TREATMENT

The techniques of surgical reconstruction in extensive burn deformities of the face and neck are so numerous that they could fill the contents of an entire textbook. Certain principles of treatment can be outlined, however, in the approach to this difficult problem: 1. The relief of contractures is the first objective of treatment with priority to the eyelid region. The correction of extrinsic contracture should precede that of intrinsic contracture. 2. Skin grafts should be employed in preference to pedicle flaps whenever possible. 3. Pedicle flaps are indicated in deep tissue loss defects, under certain conditions in the nose, chin, and cervical areas, and as local flaps for the repair of small areas of burn scars. Skin replacement should be done, in stages, successively in the various regional entities of the face: forehead, upper eyelid, lower eyelid, nose, upper lip, lower lip, anterior cheek area, posterior or parotid-masseteric cheek area, chin, neck. 4. The Z-plasty technique is an ever-present aid in the course of the treatment. 5. The treatment of the burn scarred skin of the face includes replacement of the full thickness of the skin by grafting, surgical abrasion without, or with, overgrafting, radiation for the prevention of recurrence of hypertrophic scarring, and the use of triamcinolone acetonide to soften hypertrophic scars. 6. Additional adjuvant measures include improvement of the chin contour by horizontal osteotomy of the mandible, the use of cosmetics to remedy color disparity of the grafted skin, a hairpiece to replace the destroyed hair-bearing scalp and the prosthetic ear, in cases of total destruction of the auricle. 1. Relief of Contractures: From the Extrinsic to the Intrinsic

The extrinsic contracture should always be corrected prior to tackling the problem of the intrinsic contracture. This order of treatment is particularly important in contractures involving the mobile areas of the face, i.e., the eyelids and the lips and perilabial tissues. A contracture in the forehead or temporal area may exert a pull on the upper eyelids; contracture of the cheek may pull the lower eyelid into ectropion or exert an upward traction upon the corner of the mouth; the lower lip and chin may be pulled downward by a neck contracture. These causes of extrinsic contracture should be remedied by the suitably indicated technique, Z-plasty, skin graft or pedicle flap. Only after a suitable time interval after healing should the intrinsic contracture be remedied. The best results are obtained when this order of procedure is followed. As previously mentioned, how-

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ever, there are exceptions to the rule which may require earlier palliative measures such as skin graft to an upper eyelid, everted in ectropion and endangering the cornea by exposure, or an extreme contracture involving the corner of the mouth which can be partially relieved by a skin graft or Z-plasty. 2. Skin Grafting: Immediate and Delayed

Progress in restorative surgery for burn deformities of the face and neck has been associated with the increased use of skin grafts. The thin split-thickness (or Thiersch) skin graft was found to wrinkle and shrink after transplantation. For this reason pedicle flaps were employed in preference to skin grafts, particularly in burn contractures of the cervical area (Dowd, 1927; Mixter, 1933; Kazanjian, 1936; MacCollum, 1938; Coughlin, 1939; Aufricht, 1944; Smith, 1950). It was also noted that the full-thickness graft resisted the tendency to shrink and remained smooth and this type of graft was advocated in preference to pedicle flaps by Padgett (1932), Brown and Blair (1935), Sheehan (1939) and Blocker (1941). Brown, Blair, and Byars (1935) showed the advantages of the thicker split-thickness graft over the thin variety; Padgett (1939) took a thick split-thickness graft with his dermatome which he called "threequarter thickness graft." After the development of the dermatome, successful results using thick split-thickness skin grafts were reported by Greeley (1944), Kazanjian and Converse (1949), McIndoe (1949), Frackleton (1957). Emphasis was made by these authors on the need for the postoperative support of the grafted area by means of bandages. A great advance in the treatment of burn contractures in the neck was made by Cronin (1957) who stressed the importance of precise postoperative splinting in order to avoid secondary contracture. Cronin employed a molded splint worn continuously for five to six months after thick split-thickness skin grafting. After resection of scar tissue down to normal subcutaneous tissue, the vertical margins of the defect are broken up by means of Z-plasties. The skin grafts are applied immediately or preferably the skin grafting is deferred for a few days in case of persistent bleeding after the scar resection (Fig. 5); the skin grafts are stored in a refrigerator at above O°C. temperature. Delay of grafting is also advised in those patients in which an incomplete neck extension was noted after resection of the scar tissue. A halter, such as is used in injuries to the cervical spine, is employed to complete the full extension within a few days. A large bulky dressing, maintained by elastic bandages, insures adequate pressure over the skin grafts and immobilization of the area. Twenty-four hours after the grafting procedure the dressing is removed and the grafts are inspected. Hematomas or serum collections are removed by means of suction through a small incision practiced in the skin graft. If any skin is lost the area is immediately grafted with excess of skin graft which has been preserved in the refrigerator.

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Figure 5. Repair of cervical burn contracture by split-thickness skin grafting. A, Neck contracture resulting from burns. B, Result obtained by delayed split-thickness skin grafting and long-term (6 months) fixation by means of appliance shown in Figure 6, A. C, Skin graft inlay technique to increase the cervicomandibular angle. After incision the skin is undermined and a split-thickness graft maintained by means of a tieover pressure dressing.

Figure 6. Fixation appliances following cervical skin grafting. A, Prosthetic appliance made in brace shop. B, Cervicollar in position on patient.

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Figure 7. Technique of correction of burn ectropion of the upper lip. A, Drawing of ectropic upper lip. B, The scar tissue has been resected and a full-thickness skin graft (retroauricular or supraclavicular, if possible) placed over the resulting defect. The long suture ends serve to maintain a tie-over pressure dressing.

The technique of construction of the postoperative splint (Fig. 6, A) is well described by Cronin (1964). Frackleton (1957) has described a plastic shell which can be constructed before the operation. In our own series of cases of neck contracture we have found a prefabricated splint (Cervicollar) to be as effective as the specially constructed prosthetic appliance on condition that it is worn continuously, night and day, for many months after grafting (Fig. 6, B). From experience gained, it appears that continuous application of pressure is equally important to the maintenance of neck extension by the collar. An added advantage of the continuous application of pressure is the absence of hypertrophic scarring after long-term continuous pressure. It is generally agreed that the thick split-thickness or three-quarter thickness skin graft has the advantages of the full-thickness skin graft with the added advantage that the revascularization is more efficient than that of the full-thickness graft. A particular disadvantage is that the closure of the donor area of a full-thickness graft may be a problem in large grafts. The donor areas of thick split-thickness grafts, comprising nearly the entire thickness of the dermis, may require resurfacing by means of a thin split-thickness graft taken from another area. Full-thickness grafts of retroauricular skin are excellent when available. These full-thickness grafts are relatively thin and become rapidly revascularized. They are excellent to resurface the lower eyelids and the lips (Figs. 7, 8). Full-thickness skin grafts from the inner aspect of the arm have similar qualities but the color match of these grafts is often not as satisfactory. Skin grafting of the eyelids for burn ectropion is an important part of the rehabilitation of the patient (Fig. 9). When all four eyelids must be grafted, preference is given to grafting both upper eyelids in the same operating session, covering the eyes and thus eliminating vision for a few days. There is no inconvenience to doing this when the patient is forewarned. Both upper eyelids are covered with pressure dressings. When one eye is left open, synergistic ocular globe movement on the grafted side may disturb the graft. The upper eyelids are grafted with split-thickness grafts cut at 14/1000 inch; this thickness graft preserves the necessary mobility of the upper eyelids. In contradistinction, the lower eyelids are usually resurfaced with full-thickness retroauricular or supraclavicular

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G

Figure 8. Technique of correction of burn ectropion of the lower lip. A, Incision at the vermilion border. B, After excision of scar tissue the lower margin of the defect is undermined. C, Excess ectropic mucous membrane is resected. D, Saggital section illustrating the eversion of the lower margin of the defect in order to introduce a wider surface of skin graft. E, Full-thickness skin graft (supraclavicular or retroauricular, if possible) or a three-fourths thickness skin graft sutured in position. Note that the skin graft extends beyond the oral commissures. F, G, The long ends of the sutures are employed to maintain a tie-over pressure dressing.

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Figure 9. A, Patient with burn ectropion of the eyelids resulting from a gasoline explosion. B, Postoperative result after skin grafting of the eyelids and bilateral doubleopposing Z-plasties to correct the epicanthal deformity (See Fig. 17). C, Appearance of burn ectropic eyelids with incomplete occlusion of the palpebral fissures. D, Adequate occlusion obtained following skin grafting.

skin grafts. The lower eyelid is less mobile and the full-thickness graft provides more adequate support. The technique of skin grafting for burn ectropion of the eyelids is described in considerable detail in another publication (Converse and Smith, 1967). It is important to introduce an excess of skin graft in order to counteract subsequent contraction. This is achieved by the "overlapping" technique illustrated in Figure 10. After an incision made along the eyelid and extended well laterally into the temporal area, the eyelid is freed of scar tissue and by means of traction sutures pulled downward, overlapping the lower eyelid. By this means a wide surface of skin graft is assured. A similar technique is done in the lower eyelid at a subsequent session. 3. Pedicle Flaps: Local and Distant While skin grafts are preferable to pedicle flaps, particularly in the mobile areas of the face, they do not provide a satisfactory repair in burns

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with deep tissue destruction extending to bone over the frontal bone and other cranial bones, the nose and the mandibular area, particularly the region of the mental symphysis. When cranial bone is exposed, the outer table is removed, and skin grafts are applied over the area after it has become covered by a layer of granulation tissue. A scalp flap or a flap from a distant area may be necessary to provide definitive repair of such skingrafted areas. Pedicle flaps may also be necessary to reconstruct the nose and to provide sufficient tissue in case of deep tissue destruction over the mandible. Because of the tendency of thinner skin grafts to wrinkle and shrink, pedicle flaps have often been considered, in the past, to constitute the method of choice in the repair of burn deformities of the face and neck. In the treatment of burn contractures of the neck tubed pedicle flaps are transferred in stages from the abdominal or scapular regions. When ab-

Figure 10. Technique of skin grafting for burn ectropion of the eyelids. A, The upper eyelids are freed of scar tissue and overlap the lower eyelids being in this position by traction sutures. B, Pattern grafts of split-thickness skin placed over the eyelid defects. C, Skin graft sutures in position. D, Lower eyelid defects ready for skin grafting. The lower eyelids are maintained elevated by traction sutures. E, Full-thickness retroauricular graft sutured in position.

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Figure 11. Technique of transfer of scapular tubed pedicle flap for the repair of cervical burn contracture. A, Tubed pedicle flap constructed in the scapular area. B, Lower end (b) of the tube transferred to the posterior aspect of the left shoulder. C, Upper end (a) of the tube transferred to the anterior aspect of the right shoulder. D, End (b) of the tube brought around and implanted into the left aspect of the cervical area. E, Tube opened and spread over th4:\ cervical area.

Figure 12. A, Burn contracture of the cervical area with severe ectropion of the lower lip. B, Repair by means of tubed pedicle transfer as illustrated in Figure 11 and thick split-thickness skin graft over the lower lip and chin.

dominal tubed pedicle flaps are employed they are usually transferred via the wrist. Scapular tubed pedicle flaps may be transferred by successive detachment and reimplantation of each extremity of the tubed flap (Figs 11, 12). Tubed pedicle flaps have lost favor, as a method of repairing neck contractures, because of the multiple-stage, long-drawn-out period o treatment. After they have been placed in the cervical area they mus usually be defatted. In addition they have the inconvenience that th mandibulocervical angle, normally situated at the level of the hyoid bone

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is obliterated. Despite these disadvantages, tubed pedicle flap repair is indicated in certain types of burn deformities of the neck, particularly in radiation burns. Pedicle flaps are generally considered to be contraindicated in the mobile portions of the face and particularly around the mouth. The rigidity of the flaps, when they are taken from an area such as the abdomen, prevents the flap from adapting to the underlying mobile tissues (see Aubry and Levignac, 1957). The patient smiles beneath his flap. Pedicle flaps are indicated in certain areas, however. The region of the chin is an area particularly suited to flap repair when tissue destruction has extended deeply to the mandible and in cases in which repeated grafting has been attempted and has left a wake of contracted tissues and hypertrophic scars. A tubed pedicle flap mobilized from the dorsal area, if this donor area is utilizable, or from the abdomen via the wrist as a carrier, adapts itself well to the convex surface of the chin and the mandibular area. This area of solid and relatively nonmobile flap tissue breaks the continuity in the contracted tissues of the lower lip and neck. The lower lip can then be relieved from its position of ectropion and a thick split-thickness graft utilized to furnish the required skin cover. A bipedicle (visor) forehead flap based on temporal pedicles can also be employed for this purpose. When the face alone is involved in the burn and the skin of the neck is available for transplantation a particularly useful flap, in male patients, is the 1-2 flap (Fig. 13). This flap permits transplanting hair-bearing skin

A

\:

~

) ' I.

., I

Figure 13. The 1-2 advancement flap (Converse, 1964). A, After excision of scar tissue and release of the downward contracted lower lip, the cervical skin is undermined and advanced. B, The patient's neck is flexed in order to release tension upon the advancement flap. C, Ten to 14 days later, the advanced cervical skin over the mandibular area is separated from the remainder of the cervical skin; it is now an island of skin. The submandibular defect is covered with a thick split-thickness skin graft.

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Figure 14. Repair of neck contracture by 1-2 advancement flap and local cervica and chest flaps. A, Contracture involving the lower lip, chin and cervical areas resultin from the explosion of a chemical set. B, Result obtained following 1-2 advancement flap horizontal advancement osteotomy of the mandible (see Fig. 19) and local cervical an chest flaps. C, Final appearance showing the 1-2 flap in position and the healed cervica flaps. D, Cervical flaps have been moved upward and chest flaps transferred to cover th resulting defect at the base of the neck. E, Appearance of the patient after the first dress ing. Note the imbricated position of the cervical flaps and the skin grafted secondar defects on the chest.

from the cervical area to the chin and lower lip regions. In a first stag the scarred contracted tissues of the chin are excised and the cervical ski is advanced over the defect (Fig. 13, A). The patient's neck is maintaine in flexion in order to relieve tension (Fig. 13, B). Two weeks later a sub mandibular incision detaches the advanced cervical skin which is now a island of skin placed over the chin and lower portion of the face (Fig. 13 C), the neck is extended and the resulting cervical defect is grafted with thick split-thickness graft (Converse, 1964). This method has given exce lent results in favorable cases when the burn scars are limited to the facia area only (Fig. 14). Straight advancement, transposition, and rotation o flaps of cervical skin have also been employed successfully for the re placement of burn scars in the lower portions of the cheeks (Sanvenero Rosselli, 1964). All of these flaps are useful in relatively limited burn and have the merit of restoring hair-bearing skin to the facial area of mal patients. Successful skin grafting of cervical defects has made it possibl for the surgeon to utilize cervical skin for the repair of a facial defec

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knowing that he can repair the cervical defect with impunity by means of a thick split-thickness skin graft. Local flaps have been successful in neck contractures when utilized in the manner illustrated in Figure 14. In this patient two flaps of cervical skin were imbricated and the resultant defect at the base of the neck was covered by two flaps taken from the chest. The secondary defects on the chest were covered with split-thickness skin grafts. Forehead flaps are required for the resurfacing of the nose when the scar tissue resulting from the bum extends deeply to the level of the nasal bones and cartilages or when the nose requires elongation to correct the upward contraction of the cartilaginous portion of the nose. Experience with the use of forehead flaps for the repair of cheek defects has shown that they have the same inconvenience as distant flaps in this area, namely their rigidity interferes with the mobility of the cheeks. Experience with composite grafts of hair-bearing scalp which comprise the subcutaneous adipose tissue and the matrices of the hair follicles has been disappointing. To be successfully revascularized the grafts must be narrow. Partial failures and hairless spaces between the grafts, probably due to the poorly vascularized recipient bed in the midst of bum-scarred tissues, have lead to the systematic use of long scalp flaps for eyebrow reconstruction (Fig. 15). After a preliminary outline delay operation the flap is transferred. Free grafts are reserved to those cases in which a scalp flap is not available.

4. The Z-plasty The Z-plasty is the plastic surgeon's best friend in correction of the innumerable linear contractures which must be relieved in the course of the restorative treatment of the burned face. Linear contractures distorting the eyebrows, medial and lateral epicanthal folds, linear contractures at the lateral portions of the bony bridge of the nose, at the base of the alae, at the junction of the lateral nasal wall with the cheek, across the nasolabial folds, linear contractures distorting the vermilion borders of the lips, contractures at the angles of the mouth-all of these require correction by the Z-plasty technique. In contractile bands of the neck the Z-plasty must often be associated with a skin graft as it is often inadequate to elongate the contracted tissue sufficiently and thus remedy the deficiency of skin (Fig. 16). When the linear contracture is surrounded by healthy tissue, wide branched Z-flaps can be employed. The larger the flaps the greater the elongation and the more efficient the correction. Often, however, the Zplasty must be done in bum-scarred skin which shows a diminished vascularity as compared to normal skin. Large flaps of undermined scarred skin present the risk of the loss of the distal portion of the flap through avascular necrosis. The double-opposing Z-plasty technique (Converse, 1964) permits elongation of a contractile band with relatively small flaps

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Figure 15. A, Appearance of patient shown in Figure 1 after healing of the skin grafts. B, Appearance 7 years later following additional skin grafting and Z-plasties, eye brow reconstruction by scalp flaps, and horizontal osteotomy of the mandible (see Fig 19). C, Profile preoperative appearance. D, Three-fourths view showing postoperative appearance.

(Fig. 17). Another useful application of the double-opposing Z-plasty technique is in areas where the anatomy of the region limits the size of the flaps, for example, in the medial canthal region. Double-opposing Z-plasties have been efficient in the correction of the medial epicanthal fold which often occurs in conjunction with burns of the eyelids and naso-orbita region.

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Figure 16. A, A 5-year-old girl with a neck contracture resulting from a burn from boiling oil. B, Correction achieved by double-opposing Z-plasties (see Fig. 17) and splitthickness skin grafts.

B Figure 17. Double-opposing Z-plasties. A, Design of the double-opposing Z-plasties. B, Position of the flaps at completion of the operation. This procedure is as effective as Z-plasties done with longer flaps and is achieved with shorter flaps, an advantage in anatomically confined areas such as the medial canthus. Another advantage of the shorter flaps is that it permits the use of the Z-plasty with healed burned tissues of diminished blood supply.

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5. Treatment of Burn Scars One of the most difficult problems during the final stages of rehabilitation is that of the residual scars. The contractures have been relieved and an adequate surface of skin has been restored to permit functional and expressive movements, but scars remain in the wake of the injury and of the work of the surgeon. Scars between the grafts, small contractile scars, finely striated and plicated scars of healed areas of superficial burns, pigmentation of skin grafts: these are some of the remaining stigmata of the tragic accident. Removal or improvement of these scars has a marked psychological effect on the patient. In addition to the softening and flattening effect of the passage of time, Staige Davis had noted, in 1931, that release of scar contracture by means of the Z-plasty technique results in an improvement in the quality of the scar tissue, the tissue becoming softer and better appearing. He reaffirmed this observation in subsequent papers (Davis and Kitlowski, 1939; Davis, 1946). Longacre et al. (1966) have recently confirmed this longterm improvement following Z-plasty. Wide hypertrophic scars require Z-plasty combined with skin grafting to cover the resultant defect. It can be stated that the thicker the skin graft the better the result (Skoog, 1963). After an area of hypertrophic scarring has been dissected along the subcicatricial plane of loose connective tissue and resected, only a full-thickness or three-quarter thickness graft will prevent subsequent contraction, wrinkling, and possible recurrence of hypertrophic scarring. Superficial scars which are often seen following the spontaneous healing of deep dermal burns, and striations, wrinkling, and irregularities are

Figure 18. A, Burn scar of the cheek. B, Split-thickness grafting applied to the abraded area. C, Final result following overgrafting. The area is smooth; there is some disparity of color which can be hidden by means of cosmetics.

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improved by superficial surgical abrasion; abrasion may be repeated after a suitable interval of a number of months. Areas of extensive superficial scarring without contracture can be improved by dermabrasion followed by overgrafting with a relatively thin split-thickness graft (Hynes, 1957; Rees and Casson, 1966). These wide areas of scarring following burns are particularly suited to overgrafting as the scarred skin contains few glandular elements or hair follicles (Fig. 18). Overgrafting of normal skin is followed by a difficult period during which the excretory ducts and hair follicles must make their way through the grafted skin. Overgrafting following surgical abrasion is useful also in the replacement of grafted skin which shows a marked disparity in color. One of our patients showed grafted areas of his lower eyelids and cheeks which were deeply pigmented and detracted from an otherwise satisfactory surgical result. Overgrafting with split-thickness skin grafts removed from the supraclavicular area and the skin at the base of the neck, after ballooning out the skin of the area with a solution of procaine-epinephrine to facilitate skin graft removal, resulted in a marked improvement in the patient's appearance. Radiation to prevent recurrence of hypertrophic scars after their excision should be used with great prudence, and may be contraindicated, particularly in children. Most hypertrophic scars improve with time and do not require radiation. The technique of radiation is described in other publications to which the reader is referred (see the techniques of Levitt and Gillies, 1942; and Lenz and O'Krainetz in Kazanjian and Converse, 1959; see also Crikelair, Ju and Cosman, 1964).

Figure 19. Horizontal advancement osteotomy of the mandible. A, Outline of proposed osteotomy of the mandible. B, The mandibular segment has been advanced and is maintained in position by a stainless steel wire attached to a dental appliance. This wire fixation is maintained for 6 weeks postoperatively.

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Another recent addition to the armamentarium against hypertrophic scars and keloids is the periodic injection of the scar with triamcinolone acetonide (Kenalog) which has been reported to be effective for the resolution of hypertrophic scars (Murray, 1963; Pariser and Murray, 1963; Maguire, 1965; Griffith, 1966). 6. Additional Adjuvant Measures

Among the many procedures which assist in improving appearance, mention should be made of the advancement of the lower portion of the body of the mandible after horizontal osteotomy through an intra-oral approach (Fig. 19). This procedure corrects the flat chin frequently seen following burns in children. The deformity is the result of soft tissue destruction and continuous pressure exerted over the mandibular symphysis by the scarred tissues (see Figs. 14 and 15). Cosmetics to improve color disparity of the skin grafts, a hairpiece to replace hairbearing scalp (Fig. 4), a prosthetic external ear (Fig. 4), the application of cold permanent wave solution to reconstructed eyebrows in order to direct the hairs outwardly: these are some of the helpful aids in severely burned patients.

SUMMARY

The early treatment of burns of the face and neck is described. Wound healing, wound contraction and epithelization following burns of varying depth, extending to the full thickness of the skin, and the mode of production of contractures and hypertrophic scars are discussed. The importance of a waiting period of convalescence to allow for metabolic, immunological and psychological stabilization, and for softening of scars prior to undertaking reconstructive surgery is stressed. The techniques of reconstructive plastic surgery and rehabilitation in burn deformities of the face and neck are reviewed.

REFERENCES

Abercrombie, M., Flint, M. H., and James, D. W.: Wound contraction in relation to collagen formation in scorbutic guinea-pigs. J. Embryo!. & Exper. Morph. 4: 167, 1956. Abercrombie, M., James, D. W., and Newcombe, J. F. : Wound contraction in rabbit skin, studied by splinting the wound mar~ns. J. Anat. (London) 94: 170,1960. Aubry, M., and Levignac, J.: Repair of faCial defects due to burns. Total reconstruction of the face. Tr. Internat. Soc. of Plast. Surg. 1st Congress. Baltimore, Williams & Wilkins Co., 1957, p. 149. Aufricht; G.: Evaluation of pedicle flaps versus skin grafts in reconstruction of surface detects and scar contractures of the chin, cheeks, and neck. Surgery 15: 75, 1954. Bishop, G. H.: Regeneration after experimental removal of skin in man. Am. J. Anat. 76: 153, 1945. Blocker, T. G.: Free full thickness skin graft for the relief of burn contracture of the neck. South. Surgeon 10: 849, 1941. Brown, J. B., and Blair, V. P.: Repair of defects resulting from full thickness loss of skin from burRS. SUI·g. Gynec. & Obst. 60: 379, 1935. Brown, J. B., Blair, V. P.! and Byars, L. T.: Repair of surface defects from burns and other causes with thick split-skin grafts. South. M. J. 28: 408, 1935.

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Bullough, W. S., and Laurence, E. B.: Control of epidermal mitotic activity in the mouse. Proc. Royal Soc. B. 151: 517, 1960a. Bullough, W. S., and Laurence, E. B.: Control of mitotic activity in mouse skin. Dermis and hypodermis. Exper. Cell. Res. 21: 394, 1960b. Casson, P. R., Solowey, A. C., Converse, J. M., and Rapaport, F. T.: Delayed hypersensitivity status of burned patients. S. Forum 17: 269, 1966. Converse, J. M.: Introduction to plastic surgery. In Reconstructive Plastic Surgery (J. M. Converse, Ed.). Philadelphia, W. B. Saunders Co., 1964. Converse, J. M., and Robb-Smith, A. H. T.: Healing of surface cutaneous wounds; its analogy with the healing of superficial burns. Ann. Surg. 120: 873, 1944. Converse, J. M., and Smith, B.: Techniques of surgical treatment of burn ectropion of the eyelids. Plast. & Reconstr. Surg., In press, 1967. Converse, J. M., Platt, J. M., and Ballantyne, D. L., Jr.: Histochemical Study of Burns: A Preliminary Investigation. Fortschritte der Kiefer- und Gesichts-Chirurgie. Band IX. Stuttgart, Georg Thieme, 1964. Converse, J. M., Platt, J. M., and Ballantyne, D. L., Jr.: An experimental evaluation of a histochemical diagnosis of burn depth. J. Surg. Res. 5: 547, 1965. Coughlin, W. T.: Contractures due to burns. Surg. Gynec. & Obst. 68: 352,1939. Crikelair, G. F., Ju, D. M. C., and Cosman, B.: Scars and keloids. In Reconstructive Plastic Surgery (J. M. Converse, Ed.) Philadelphia, W. B. Saunders Co. 1964, p.161. Cronin, T. D.: Successful correction of extensive scar contractures of the neck using split thickness grafts. Tr. Internat. Soc. Plast. Surg. 1st Congress. Baltimore, Williams & Wilkins Co., p. 123, 1957. Cronin, T. D.: Deformities of the cervical region-scar contractures of the cervical region. In Reconstructive Plastic Surgery (J. M. Converse, Ed.). Philadelphia, W. B. Saunders Co., 1964, p. 1175. Davis, J. S.: Relaxation of scar contractures by means of the Z-, or reversed Z-type incision; stressing use of scar infiltrated tissues. Ann. Surg. 94: 871, 1931. Davis, J. S.: Present evaluation of the Z-plasty operation. Plast. & Reconstr. Surg. 1: 26, 1946. Davis, J. S., and Kitlowski, E. A.: Theory and practical use of the Z-incision for the release of scar contractures. Ann. Surg., 109: 1001, 1939. Dowd, C. N.: Some details in the repair of cicatricial contractures of the neck. Surg. Gynec. & Obst. 44: 396, 1927. Frackelton, W. H.: Neck burns-early and late treatment. Tr. Internat. Soc. Plast. Surg. 1st Congress. Baltimore, Williams & Wilkins Co., 1957, p. 130. Greeley, P. W.: Plastic repair of scar contractures, Surgery 15: 224, 1944. Griffith, B. H.: Treatment of keloids with triamcinolone acetonide. Plast. & Reconstr. Surg.38:202,1966. Hynes, W.: Treatment of scars by shaving and skin grafting. Brit. J. Plast. Surg. 10: 1, 1957. Kano, K., Milgrom, F., Witebsky, E., and Rapaport, F. T.: Immunological studies on thermal injury. Hemagglutinating factor in the lymph of burned rats. Proc. Soc., Exper. Biol., 1966. In Press. Kazanjian, V. H.: Repair of contractures resulting from burns. New England.J. Med. 215: 1104, 1936. Kazanjian, V. H., and Converse, J. M.: The Surgical Treatment of Facial Injuries. Baltimore, Williams & Wilkins Co., 1949, p. 430. Lenz, M., and Okrainetz, C. L.: In The Surgical Treatment of Facial Injuries, 2nd Ed., by V. H. Kazanjian and J. M. Converse. Baltimore, Williams & Wilkins Co., 1959, p. 391. Levitt, W. M., and Gillies, H.: Radiotherapy in the prophylaxis and treatment of keloids. Lancet 1: 440, 1942. Longacre, J. J., Seghers, M .•J., Berry, H. K., Wood, R. W., Munick, L. H., Johnson, H. A., and Chumekamsi, D.: L'ultrastructure du collagene et la relation avec la correction des cicatrices hypertrophiques. Ann. Chir. plastique 9: 111, 1966. Lindberg, R. B., Moncrieff, J. A., Switzer, W. E., Order, S. E., and Mills, W.: The successful control of wound sepsis. J. Trauma 5: 601, 1965. MacCollum, D. W.: The early and late treatment of burns in children. Am. J. Surg. 39: 275, 1938. Maguire, H. C., Jr.: Treatment of keloids with triamcinolone acetonide injected intralesionally. J.A.M.A. 192: 325, 1965. Mathews, D.: The late repair of burns. Fortschritte der Kiefer-und Gesichts-Chirurgie (K. Schuchardt, Ed.) Stuttgart, Georg Thieme, 1964 . McIndoe, A.: Total facial reconstruction following burns. Postgrad. Med. 6: 187, 1949 . Mixter, C. G.: Contractions of the neck following burns. New England J. Med. 208: 190, 1933. Moyer, C. A., Brentano, L., Gravens, D. S., Margraf, H. W., and Monafo, W. W., Jr.:

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