Reconstruction of the burned breast.

Fundamental principles of management of breast burns begin with recognition and preservation of any viable breast bud tissue. Reconstruction begins when the burned breast envelope is insufficient to allow unrestricted breast development. Complete contracture release is obtained by incision or excision of the restricting burn scar and thick split-thickness grafting. Occasionally, breast mound reconstruction with regional musculocutaneous flaps or tissue expanders is necessary. Balancing procedures, such as reduction or mastopexy of an opposite unburned breast, are often helpful. After a period of 6 to 12 months of compression garments, scar management, and settling, nipple-areola reconstruction is undertaken and consists of a combination of local flaps, full-thickness grafting, or composite grafts tailored to each patient's needs. Long-term follow-up is necessary to ensure that breast development continues satisfactorily and that contractures do not recur.

Tissue expansion in head and neck burn reconstruction.

The advent of tissue expansion has provided a useful tool for the reconstructive burn surgeon. As with many new techniques, there was an initial wave of enthusiasm surrounding the introduction of tissue expansion to burn reconstruction in the 1980s. High complication rates and many dissatisfying results followed. After early widespread use of tissue expansion, the authors have settled on a more refined approach to the reconstruction of head, neck, and facial burns. Today, head and neck burn reconstruction is accomplished best with a combination of skin grafting, local flaps, and occasional free flaps in addition to tissue expansion. In carefully selected head and neck burn patients and in many burn alopecia patients, tissue expansion can provide excellent functional and aesthetic results, with minimal donor site morbidity.

Reduction mammaplasty in postburn breasts.

Thermal injury to the anterior chest in the adolescent girl can lead to severe disfigurement of the breasts. Just as in certain non-burn female patients, mammary hyperplasia can occur in patients with previous full-thickness burns of their breasts. Most plastic surgeons have been reluctant to perform reduction mammaplasty in these patients for fear of devascularizing the skin graft or the nipple-areola complex. A series of six patients with full-thickness burns of the breasts and subsequent skin graft coverage before reduction mammaplasty is reported. Four patients had bilaterally burned breasts requiring reduction. Two patients had one burned breast reduced, and one required a balancing procedure on the unburned side. Reduction mammaplasty was performed using the inferior-pedicle technique. The mean amount of tissue removed for the left and right breasts was 454 and 395 g, respectively. There was no nipple loss, hematoma, infection, or major loss of skin flaps. Reduction mammaplasty in this group of patients is safe and carries minimal risk if certain key concepts are followed carefully.

Scalp autografts and hair transfer to the face in the burned child.

Hair transfer from split-thickness skin grafts harvested from the scalp is not a widely reported problem. The authors present their experience with hair transfer from scalp autografts in a pediatric burn population, with particular emphasis on hair transfer to the face. They retrospectively reviewed 3307 acute and reconstructive pediatric burn admissions over a 4-year period at a single institution and identified 109 cases in which the scalp had been used as a donor site and in which the patient survived the acute burn period. Data from 73 male and 36 female patients were analyzed with respect to age, race, sex, percent total body surface area burned, graft thickness, number of scalp harvests and time between harvests, and presence of donor site alopecia. Eighteen of the 109 patients had noticeable hair growth from their scalp grafts (17 percent). Fourteen of 18 cases of hair growth involved face or neck grafts (13 percent); the remaining 4 patients had hair growth elsewhere on the body. There was no difference between the two groups (hair growth versus no hair growth) when compared by age, sex, or graft thickness. There was a correlation between larger burn size and greater incidence of hair growth. Those who had multiple harvests of the same scalp donor site were more than twice as likely to have hair transfer (9 of 34 versus 9 of 75 patients), although time between harvests was not a significant variable. Caucasian children represented 77 percent of the study population yet 100 percent of the cases of problem hair growth. Thirty-three percent of the hair growth group (6 of 18 patients) and 4 percent of the remaining patients (4 of 91) had some degree of donor site alopecia. The scalp is a reliable and valuable donor site for skin grafting in children, particularly for facial burns. The authors note a moderate incidence of hair transfer (17 percent) and propose both suggestions for prevention and recommendations for management.

Tissue expander complications in the pediatric burn patient.

Tissue expanders have become a useful adjuvant in pediatric burn reconstruction. We reviewed our experience with tissue expanders from June of 1984 to July of 1995. There were 403 expanders used in 301 patients. Complications relative to specific anatomic areas from July of 1987 to July of 1995 were compared with previously published data in the journal from June of 1984 to June of 1987. Complications were defined as absolute if they resulted in the loss of expanders or in additional surgery, or none of the preoperative plan was satisfied. The relative complications were defined as spotty alopecia, alopecia greater than 50 percent, or the operative plan was only partially satisfied, sometimes implying poor surgical judgment. The overall complication rate for the period June of 1984 to June of 1987 was 30 percent (37 complications in 122 expanders). In the July of 1987 to July of 1995 study, the complication rate was only 18 percent (51 complications in 281 expanders). This was a statistically significant decrease between the periods (p = 0.010). In the recent 8-year period, there was a decrease compared with the previous study in both the absolute and relative complications. The most common absolute complication in this period was infection (15 of 31, 48 percent) with 12 (39 percent) being early infection. With regard to the nine complications in the neck, face, ear, and supraclavicular area, two-thirds were related to leakage or exposure of the expanders, resulting from the tight anatomic area causing mechanical damage of the expanders as well as ischemia to the overlying skin. Early in the study, the lower extremities proved to involve difficult or unsatisfactory areas to expand, and lower extremity expansion was abandoned throughout the remainder of the study period. The overall decrease in absolute and relative complications is likely the result of increased operative experience as well as a developed protocol for the prevention of perioperative complications relating to infection and expansion in high-risk anatomic sites.

The effect of full-thickness abdominal wall burns sustained during childhood on subsequent childbearing ability.

The effect of full-thickness burns of the abdomen during childhood on subsequent pregnancy was evaluated. Eight hundred female pediatric patients treated for acute burns during a 14-year period (1975-1989) at the Shriners Burns Institute were reviewed. Through a combination of clinical follow-up, questionnaires, or phone interviews, data were obtained regarding the histories of 31 pregnancies in 19 patients who had required excision and skin grafting of > or = 50% of their abdominal wall during management of their acute burns. These patients sustained a mean burn size of 59.8% total body surface area (TBSA; range, 23-87%) with a mean full-thickness burn of 43.8% TBSA (range, 10-78%). The mean age at the time of burn was 7.6 years (range, 1.5-15 years). Normal rates of vaginal and cesarean section deliveries, prematurity, and infant mortality were observed in these 31 pregnancies. Despite a subjective sensation of increased tension on the scar in 25% of the patients, no interference with these patients carrying a full-term pregnancy directly attributable to the burn scar was identified. Follow-up and examination during the third trimester of pregnancy demonstrated how the burned and unburned portion of the abdominal wall accommodated the enlarged uterus. This review demonstrates that after extensive burns to the abdomen, which have been treated with excision and skin grafting during childhood, the scarred abdominal wall accommodates full-term pregnancy without the need for surgical release.

Cleft lip micronostril: the problem and proposed solution.

Micronostril is a cicatricial stenosis that may occur in the caudal-most portion of the nasal cavity of cleft lip patients. This stenosis can be severe and functionally debilitating. Previously proposed solutions have offered disappointing results. Our solution has three key elements: adequate scar release; restoration of the lining and support by way of chondrocutaneous composite graft; and post-operative custom acrylic splinting.

Comparison of postoperative wound complications and early cancer recurrence between patients undergoing mastectomy with or without immediate breast reconstruction.

The incidence of postoperative wound complications and early cancer recurrence was studied in 289 patients who had mastectomy alone and in 113 patients who underwent immediate reconstruction following mastectomy. Patients undergoing immediate reconstruction were younger and had less advanced disease than patients who had mastectomy alone. The postoperative hospital stay was 3.8 days and 4.4 days (p < 0.05) in patients with and without reconstruction, respectively. The overall incidence of postoperative complications was similar in the two groups of patients: 31% and 28% in patients with and without reconstruction, respectively. The incidence of postoperative seroma was higher among patients with mastectomy alone (19% versus 3%, p < 0.05), whereas the incidence of other wound complications was similar in the two groups of patients. Prosthesis-specific complications occurred in 17%. Eight prostheses were removed because of complications. During the relatively short follow-up period (approximately 20 months), local recurrence was noted in 16 patients (6%) who had mastectomy alone and in 1 patient (1%) who had immediate reconstruction after mastectomy (p < 0.05). There was no significant difference in the incidence of distant metastases between the two groups of patients. The results suggest that immediate breast reconstruction can be performed following mastectomy for cancer without increased risk for overall postoperative complications, prolonged hospital stay, or local recurrence. However, patients who choose to have immediate reconstruction need to be informed about risks for specific complications associated with the procedure, especially if an implant is used.

Tissue expanders in the lower face and anterior neck in pediatric burn patients: limitations and pitfalls.

Radovan's 1982 landmark work on the clinical use of tissue expanders was felt to be a panacea for multiple reconstructive problems. We have used and probably overused tissue expanders for reconstruction of many complicated pediatric facial burn problems. This has enlightened us to some of the limitations of their use, and we have, therefore, reassessed our indications for their use. From 1984 through 1990, 52 tissue expanders were used in 37 pediatric patients for face and anterior neck burn scar resurfacing. This experience, combined with the unique problems encountered with face and neck tissue expansion, provided the groundwork for operative guidelines. The long-term effects of gravity, growth, and scarring on facial features adjacent to expanded skin led to the following principles. (1) Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening or possible lip or eyelid ectropion needs to be considered when planning these flaps. Extreme overexpansion is necessary to advance unburned neck flaps over the mandibular border to avoid these problems. (2) After advancement or rotational flaps neck flaps to the face, vertically directed suture lines in the neck may need redirection to prevent linear contracture. This correction may be performed during the primary operation or during revisions. (3) Expanded cheek or neck skin should preferably replace burned areas, but at the same time, not violate unburned facial aesthetic units. (4) To counteract the affects of gravity, expanded cheek skin in conjunction with expanded neck skin, if unburned, may be the best choice for face or mandibular border scar replacement.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of free fasciocutaneous and muscle flaps for reconstruction of the foot.

Seventeen free flaps were used to reconstruct severe injuries to the foot over the last 36 months at the University of Cincinnati College of Medicine. The type of free flaps used included six fasciocutaneous free flaps and eleven free muscle flaps with split-thickness skin grafts. The fasciocutaneous flaps were either radial forearm or scapular flaps. The muscle flaps used were gracilis, rectus, or latissimus dorsi muscle flaps. Each type, with their specific advantages, disadvantages, and indications for use as they apply to the anatomical areas of the foot, are described. Regardless of the type of free flap used, careful preoperative planning, attention to the size and location of the anatomical defect, and correct contouring and insetting should allow for maximal functional result and minimize postoperative morbidity.

Technical successes and functional failures after free tissue transfer to the tibia.

A retrospective study evaluated functional outcome in 59 patients with 61 successful free tissue transfers performed after open tibial fractures. Twenty-one patients had transfers done within 7 days, 13 between 7 and 21 days, and 25 were done greater than 3 weeks after injury. All 59 patients had Type III injuries as classified by Gustilo and Anderson. Nineteen patients (32%) were identified as late functional failures. Each of these patients underwent as average of 10 procedures. In this group chronic osteomyelitis was noted in 13 of 19 patients and chronic venous insufficiency with skin ulceration in 9 of 19 patients. Fracture nonunion was seen in 8 of 19. Degenerative joint problems and foot deformities were identified in 7 or 19 patients. Seven patients (12%) ultimately required below-knee amputation. Functional failure did not correlate with the timing of flap application, but rather with the severity of the initial injury. Free tissue transfer is not a panacea. It is but one step in the overall reconstruction of complex tibial wounds.

Changes in articulation and resonance after tongue flap closure of palatal fistulas: case reports.

This paper describes speech changes in three patients after tongue flap closure of various sized palatal fistulas. In all three patients articulation and lingual mobility appeared to be unaffected by excision of tongue tissue for the procedure. However, a large protruding tongue flap was noted to interfere with the articulation of sibilants in one patient. All patients showed a reduction in overall hypernasal resonance and nasal emission, although one patient developed nasal turbulence postoperatively and another required a pharyngeal flap for total elimination of hypernasality. This paper points out the need for a systematic investigation into the effects of this surgery on speech.

Complications of controlled tissue expansion in the pediatric burn patient.

All patients at the Burn Institute reconstructed with tissue expanders between June of 1984 and June of 1987 were included in this review. There were 122 expanders used in 77 patients. Complications were defined as "absolute" (23 of 122 expanders, 20 percent) if they resulted in loss of expanders or additional surgery or none of preoperative plan was satisfied or "relative" (14 of 122 expanders, 11 percent) if they included spotty alopecia or alopecia greater than 50 percent or the operative plan only partially satisfied, reflecting poor judgment. The most common absolute complication was prosthetic exposure secondary to wound dehiscence occurring in the scalp area. Complications relative to specific anatomic areas were neck and face, 2 of 20 (10 percent); lower extremity, 1 of 4 (25 percent); trunk, 0 of 6 (0 percent); and scalp, 20 of 92 (22 percent). We feel that this high complication rate in the use of tissue expanders may be unique to the pediatric burn patient. Knowledge of indications for use and potential complications is essential to add this entity to the armamentarium of the burn reconstructive surgeon.

Classification and treatment of postburn proximal interphalangeal joint flexion contractures in children.

Two hundred and sixty-four surgically treated proximal interphalangeal joint flexion contractures in children were reviewed. A classification system on the basis of contracture severity was devised to assess the efficacy of treatment. Contracture severity was determined from preoperative radiographs and physical examination. Eighty-eight percent of the digits were successfully treated (postoperative contracture less than 20 degrees). Unsatisfactory results (12% of digits) were directly proportional to the severity of the contracture and tended to occur in older children with large total body surface burns. The time interval between burn and contracture release did not correlate with contracture severity or therapeutic failure. The most common cause of an unsatisfactory result was failure to fully release the contracture.

Carcinoma of the prostate metastatic to the mandibular condyle mimicking a parotid tumor.

An unusual case of adenocarcinoma of the prostate metastatic to the mandibular condyle that presented clinically as a parotid tumor is reported. Standard radiologic studies may be misleading in such cases, and a high index of suspicion is required for atypical masses in the parotid region.

Reconstruction following head and neck burns.

Burn reconstruction of the head and neck must first start with special care to this anatomic area in the early acute phase, with appropriate early débridement and coverage with sheet grafts of medium thickness into unit facial orientation. Postoperative garment and mask splinting, will help lessen the hypertrophic scar formation that frequently follows facial burns and skin coverage. Carefully planned reconstruction of these areas is indicated, with priority given first to the neck, then to the periorbital area, and then to perioral areas. Principles of scalp, ear, nasal, and cheek reconstruction following burns of the face are carefully outlined. The unit concept of burn scar resurfacing of the face has been the mainstay of our treatment. We have emphasized skin coverage of the face from similar donor site areas. The emotional and psychological effects of facial scarring secondary to severe burns are crippling to patients. Although numerous reconstructive surgical procedures may lessen the deformity, ultimately burn patients realize that their burn scars are permanent and no surgeon can give them back their original facial appearance. These patients need strong and continued support and reassurance from their physicians and nursing professional staff to maintain their self-identity and confidence.

Use of i.v. fentanyl in the outpatient treatment of pediatric facial trauma.

Fentanyl, a synthetic analgesic narcotic, was used in 2,000 cases of pediatric facial trauma between 1981 and 1984. A dose of 2 to 3 micrograms per kilogram of body weight was administered slowly intravenously to provide sedation and analgesia to facilitate the repair. The drug has advantages ideal for outpatient use, namely rapid onset, brief duration, and short recovery time. The major possible complication is that of apnea, which requires that resuscitation equipment be available. Three apneic episodes occurred in this series and all were successfully reversed with naloxone with no untoward effects.

Management of perioral burn scarring in the child and adolescent.

The experience gained in the treatment of 116 patients with perioral burn scarring is presented. Important considerations are the choice of unit release or simple release, the choice of donor site to match the prevailing skin of the remainder of the face, and the timing of the reconstruction. Delaying the reconstructive procedure with the routine use of pressure appliances until the scar was mature produced a more pleasing final result. In addition, we found that modifying the traditional aesthetic unit excised to include darts when there was severe burning of the surrounding facial cheek skin with loss of natural nasolabial folds improved the final result and reduced the need for secondary revision.

Classification and management of burned thumb contractures in children.

Based on the position of the thumb metacarpal, 102 burned thumb contractures in children were classified into four categories: adduction, opposition, extension and flexion. The contractures were further classified as mild, moderate or severe, based on the amount of motion lost. All thumbs were surgically released. Coverage was obtained with local flaps or Z-plasties, skin grafts or a combination of local flaps and skin grafts. Factors influencing the results were as follows: Classification category: Extension contractures generally did poorly, whereas flexion contractures did well. Severity of contracture: The more severe the contracture, the worse the final results. Complexity of contracture: Contractures with a subluxated or dislocated joint did not do as well as those with undisturbed bony alignment. Type of surgical release: There was a trend towards better results when skin grafts (as opposed to local flaps) were used, especially in the treatment of moderate and severe contractures.