Abstract
The management of postburn reconstruction is complicated by the frequent occurrence of multiple reconstructive needs in a single patient. This article presents a simple, comprehensive approach to burn scar reconstruction. The primary aim of the surgeon is to prevent burn scar deformity by rapid wound closure, correction of tissue deficiencies, and assiduous attention to postoperative splinting and compression therapy. The initial step in managing secondary deformities is to prioritize reconstructive needs. Reconstruction is then carried out in a stepwise fashion aiming to restore active function first, followed by passive function, and finally addressing aesthetic reconstruction. Reconstructive techniques are applied in a hierarchy from simplest to most complex. Primary excision and closure of scars by reorientating the scar to the lines of relaxed skin tension can significantly improve appearance. The use of z-plasty, flap repair, and tissue expansion are also reviewed. Skin expansion, in particular, has become the standard management of postburn alopecia and, although associated with a relatively high rate of complication, has significantly improved the aesthetic appearance of such patients. The management of common problems affecting the face is discussed with particular reference to management of the eyelids, oral commissure, and lips. These areas need to be reconstructed as aesthetic units and each requires individualized management of donor tissue. The reconstruction of the burn patient is often a long process requiring multiple procedures. The approach presented here advocates a stepwise, prioritized approach aiming at both maximum function as well as optimal appearance.
Résumé
La reconstruction après brûlure est souvent compliquée par le fait que plusieurs procédés de reconstruction sont nécessaires chez le même patient. Cet article présente une approche simple et globale de la refection des cicatrices dues aux brûlures. Le premier travail du chirurgien comporte la prévention des malformations secondaires aux brûlures par la fermeture rapide des plaies, la correction des pertes tissulaires et l'utilisation obligatoire des attelles et de moyens de contention. La première phase du traitement a pour but d'établir la priorité des besoins de reconstruction. La reconstruction est alors entreprise étape par étape dans le but, d'abord, de rétablir les fonctions actives, puis les fonctions passives et enfin d'améliorer l'aspect esthétique. Les techniques de reconstruction suivent une hiérarchie bien déterminée du plus simple en plus complexe. L'excision et la fermeture primitive des cicatrices orientant les cicatrices vers les lignes de relaxation maximale est un premier pas pour améliorer l'aspect morphologique. Les indications des lambeaux en Z, et de l'expansion tissulaire sont passées en revue. L'expansion cutanée est devenue une méthode standard pour le traitement de l'alopécie postbrûlure. Bien que le taux de complications soit relativement élevé, cette technique améliore grandement l'aspect physique des brúlés. La tactique opératoire des problèmes des brûlés du visage est envisagée avec une référence particulière à la reconstruction des paupières, des commissures de la bouche et des lèvres. Ces régions doivent être traitées comme des unités esthétiques et chacune d'entre elles nécessite un site donneur de tissu individualisé. La chirurgie reconstructive chez un brûlé est souvent longue et nécessite de multiples procédés. L'approche présentée ici vise une restauration maximale de la fonction et de l'aspect physique par un traitement progressif.
Resumen
El manejo de la reconstrucción de lesiones por quemadura se hace más complejo debido a los frecuentes y múltiples requerimientos de reconstrucción en el paciente individual. El presente artículo presenta un enfoque simple y comprensivo de la reconstrucción después de la cicatrización de la quemadura. El propósito primario del cirujano es prevenir la deformación por la cicatrización de quemadura mediante el cierre precoz de la herida, la corrección de las deficiencias tisulares y une vigorosa utilización de férulas y de terapia de compresión. El paso inicial en el manejo de deformaciones secundarias es establecer las prioridades en cuanto a los requerimientos de reconstrucción; la reconstrucción es luego practicada en forma secuencial para lograr función activa, seguida de función pasiva, para finalmente realizar la reconstrucción estética. Las técnicas de reconstrucción son aplicadas en forma jerárquica desde las más simples a las más complejas. La resección primaria de cicatrices y el cierre mediante la reorientación de la cicatriz hacia las lineas de relajación de la tensión cutánea puede mejorar significativamente la apariencia del paciente. También se revisa el uso de plastias en Z, la reparación con colgajos y la expansión tisular. La expansión cutánea, en particular se ha convertido en el método estándar de tratamiento de la alopecia por quemadura y aunque se asocia con una tasa de complicaciones relativamente alta, ha mejorado significativamente la apariencia de tales pacientes. El manejo de los problemas comunes que afectan la cara es tratado con referencia particular a los párpados, la comisura oral y los labios. Estas áreas deben ser reconstruidas como unidades estéticas y cada cual requiere un manejo individualizado del tejido donante. La reconstrucción del paciente quemado con frecuencia es un proceso prolongado que presenta preconiza un enfoque secuencial y de prioridades con un propósito tanto de resultados funcionales, máximos y estéticos óptimos.
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Robson, M.C., Barnett, R.A., Leitch, I.O.W. et al. Prevention and treatment of postburn scars and contracture. World J. Surg. 16, 87–96 (1992). https://doi.org/10.1007/BF02067119
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DOI: https://doi.org/10.1007/BF02067119