BURNS
PLASTIC SURGERY
detached. Hand and leg prostheses combine function and
cosmesis but are fortunately rarely necessary.
Restoration of volumes
This is a more recent area of development in post-burn
reconstruction. It is largely cosmetic in scope and is mainly for
reducing the impact of burns on the development of children
and adolescents.
Craniofacial principles: burns to a child’s face result in local
developmental problems due to the rigidity of the scar tissue
and its inability to grow. In cases where the facial skeleton is
affected by facial and neck scars, the reconstructive process may
include restoration of bony contours as well as soft tissue work.
This is usually achieved using bone grafts or implants.
Fat transfer: the patient’s own fat can be harvested from areas
such as the abdomen or thighs, and injected in areas of post-burn
contour deficit, mainly in the face. The technique can be used
under supple scars, and aims to restore symmetry.
Implants: implants (usually malar or chin implants) have been
used successfully to provide a more balanced facial appearance
following facial burn. Girls who have sustained burns to the
chest wall may have unilateral or bilateral problems with
breast development, and breast implants may be used in
conjunction with cutaneous reconstruction to improve symmetry
or compensate for the deficit.
Amputations
Unfortunately, severe burns carry a significant risk of un-
reconstructable deformities, either in the lower or upper limb.
Fingertip amputations are the most common, and they are
most often carried out once the acute management stage is
over. Lower limb injuries, particularly those that result in large
areas of exposed tendons and compartment muscle loss, may
require amputation, followed by appropriate rehabilitation. A
summary detailing the late management of burns is shown in
Figure 3. u less than 1 cm2 in area. Healing by secondary intention is useful
FURTHER READING
Press B. Thermal, Electrical and Chemical Injuries. In: Grabb and
Smith’s Plastic Surgery. Aston S J, Beasley R W, Thorne C H M,
eds. Baltimore: Lippincott Williams and Wilkins, 1997.
SURGERY
Grafts and Flaps
Guy D Sterne
Fazel Fatah
Skin loss can occur for a number of reasons. The more common
causes include trauma (e.g. burns, avulsions, degloving), tumours
(e.g. following ablative tumour surgery) and infections (e.g.
meningococcal septicaemia, necrotizing fasciitis).
The reconstructive ladder (Figure 1) is a useful decision-
making tool when faced with any skin loss, irrespective of the
cause. It takes the user from the simplest option on the first rung
to the most difficult at the highest rung. Before using the
reconstructive ladder, the defect needs to be assessed accurately
and the general principles of wound care adhered to. Then, each
rung of the ladder should be considered in turn, looking at the
advantages and disadvantages of each reconstructive option. The
correct choice of reconstruction can then be made, together with
justification for this choice. The two important considerations
for any reconstructive procedure are function and appearance,
for the donor as well as the recipient site.
Secondary intention
The simplest method of achieving wound closure is to allow it
to heal by secondary intention. The wound contracts as a result
of myofibroblast contraction, shrinking the defect and recruiting
surrounding skin. The defect re-epithelializes from the periphery.
One of the few established facts of wound healing by secondary
intention is that moist wounds heal faster than dry ones;
therefore, semi-occlusive dressings can be effective.
The resulting scar is usually much smaller than the original
defect. This is the method of choice for skin loss of the fingertips
in patients who are not fit for, or who refuse, surgery.
Healing by secondary intention can prolong the time to wound
closure. Wounds which do not have a well-vascularized bed will
not heal by secondary intention, for example exposed bone,
exposed cartilage, exposed tendon. (Note: periostium, perichon-
drium and paratenon will all heal by secondary intention but
will die rapidly if they dry out.)
Guy D Sterne is a Specialist Registrar in Plastic Surgery at the
University Hospitals, Birmingham, UK. He qualified from Birmingham
University. He undertook research into peripheral nerve regeneration
at the Blond McIndoe Centre for Surgical Research, East Grinstead,
and has just completed Higher Surgical Training in plastic surgery,
specializing is breast reconstruction, skin cancer and aesthetic surgery.
Fazel Fatah is a Consultant Plastic Surgeon at Selly Oak and
City Hospitals, Birmingham, UK, with special interest in breast
reconstruction, facial reanimation and aesthetic surgery.
134 © 2002 The Medicine Publishing Company Ltd
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1 graft may be ‘quilted’ by placing sutures within the body of the
Primary closure
Primary closure is the next simplest method of reconstruction.
During primary closure the scar should be oriented along wrinkle
lines, Langer’s lines, relaxed skin tension lines and at the
boundaries of cosmetic units. Undue tension can be minimized
if consideration is given to the direction and availability of spare
skin.
Primary closure results in the least scarring and the fastest
healing times. However, it is limited to smaller defects and to
sites where there is adequate spare skin.
Skin grafts
A skin graft is a piece of skin which is taken completely off one
site (the donor site) and moved to another site (the recipient site),
and which picks up its blood supply from the recipient site. The
skin can be either full-thickness (Wolfe graft) or split-thickness
(Thiersch graft). Skin grafts will survive (‘take’) only on a well
vascularized bed of tissue. As a general rule, any tissue which
forms granulation tissue will support a skin graft (i.e. not bare
bone, tendon or cartilage).
The process of a graft ‘taking’ can be subdivided into graft
adhesion and graft revascularization.
Adhesion occurs in the first 48 hours by means of fibrinogen
(in the plasma which exudes from the recipient bed) converting
to fibrin. This ‘glues’ the skin graft to the recipient bed. During
this early stage, the graft is nourished by plasma imbibition
(diffusion of nutrients from the exuding plasma).
Once a layer of fibrin has stuck the graft to the bed, the graft
can revascularize. This occurs in one of two ways:
• Inosculation. From 48 hours post-graft, new blood vessels from
the recipient site grow across the fibrin layer and join up end to
end with the vessels in the graft. Initially, all vessels are afferent
and the graft swells up with blood and appears dusky. After a
few days, afferent/efferent differentiation is established and the
graft becomes pinker.
SURGERY
• Neovascularization. If inosculation is delayed or does not
occur, the graft becomes relatively ischaemic and produces
various substances which promote neovascularization. New
blood vessels from the recipient site grow across the fibrin layer
and solid chords of these vessels penetrate into the graft along
the course of the old graft vasculature. These solid chords of
vascular endothelium subsequently canalize and graft perfusion
commences.
The common factors that impair the take of a skin graft (Figure
2) will affect either adhesion or revascularization. Certain
bacterial infections (in particular Lancefield group A beta-
haemolytic streptococci, also called Streptococcus pyogenes)
produce streptokinase which dissolves fibrin and prevents initial
graft adhesion. The presence of a seroma or haematoma beneath
the graft prevents it from adhering to the bed, creating a gap
between the vascular bed and graft, which vessels cannot cross.
Any movement of the graft on the bed can shear delicate new
vessels growing into the graft and prevent revascularization.
When applying a graft to a bed, certain techniques can be used
to minimize these potential complications. The graft should be
anchored at the edges by means of sutures, staples or glue. The
graft to hold it on to the bed. Drainage holes may be made in the
graft, or the graft may be meshed to allow any build-up of blood
or seroma to escape, leaving the graft adhering to the bed. A graft
is meshed by passing a sheet of skin through a mesher, which
creates a series of lines in the graft, giving a ‘string
vest’appearance. Meshing is popular as it reduces graft loss due
to haematoma or seroma, and allows the surface area of the graft
to be expanded 2-, 3- or even 6-fold.
A pressure dressing may be applied, usually in the form of a
‘tie-over’ (a wad of cotton wool tied over the graft by silk sutures
placed around the margins of the graft). This prevents shearing,
haematomas or seromas lifting the graft off the bed.
Split-skin grafts
These may be harvested as thin, intermediate or thick split-skin
grafts, depending on how much dermis is harvested
(Figure 3). However, for any split-skin graft, the least that can be
removed is the full-thickness of the epidermis together with the
basement membrane and some dermis. The usual donor site is
the thigh or buttocks.
The donor site is simply dressed and re-epithelializes
spontaneously from epithelial remnants in the hair follicles and
glands. This process takes 7–14 days depending on the thickness
of skin harvested (the thicker the graft taken, the longer the
healing time). To avoid donor site healing problems, for example,
when a thick split-skin graft is harvested from an elderly patient,
the donor site can be ‘overgrafted’ with a very thin split-skin
graft (meshed and expanded) from an adjacent donor site.
Factors impairing skin graft take
• Infection
• Haematoma
• Seroma
• Shearing movement
2
135 © 2002 The Medicine Publishing Company Ltd
 BURNS
PLASTIC SURGERY

These plexuses receive blood from named arteries, either:

Structures in the skin • directly (for fasciocutaneous flaps), either by direct cutaneous
���� arteries or with perforators running in intermuscular septae
������ ����������� or through muscles
����� ����� • indirectly (for musculocutaneous flaps), via small unnamed
��������������
�������� branches after the majority of the blood from the named artery
�������� has perfused a muscle.
There are many classifications which attempt to encompass
all of the different flap types. A useful working classification is
��������� shown in Figure 5. Flaps can be classified according to their blood
supply, their pattern of movement and the tissue types they
contain.
������
Flap blood supply
Random pattern flaps: these have a random pattern of blood supply
and usually consist of skin and superficial fascia only. As a general
�����������������
������������������� rule, when planning the dimensions of a random pattern flap, the
������ flap length should never exceed the base width (a 1:1 ratio).

����������� Axial pattern flaps: these include a named artery or perforator

������������� in the flap. The inclusion of this axial vessel means that the flap
��������������� is not limited by the 1:1 ratio, and can be more easily customized.
3
Pattern of movement
The advantages of split-skin grafts are that very large areas of Local flaps: these are useful because they usually adhere to the
grafts are available. The thinner the graft the more readily it will principle of replacing like for like, providing adjacent skin which
take, and the graft surface area can be expanded up to six times best matches the colour, texture and contour of the defect. There
by meshing. are various designs of local flaps which take advantage of slack
The disadvantages are that split-skin grafts tend to contract tissue to close the donor site, while others require a skin graft.
(so should never be used on the lower eyelid, as an ectropion When moving a local flap from its donor site to the recipient site
may develop), they offer a poor colour, contour and texture match the flap can be advanced, rotated or transposed (Figure 6),
at the recipient site, they are not as robust as full-thickness skin depending upon tissue availability and final scar configuration.
and may blister or ulcerate more easily if subjected to wear and
tear, and there is a permanent mark at the donor site. Distant flaps: thes are mostly obsolete since the introduction of
free tissue transfer in the late 1970s/early 1980s. However,
Full-thickness skin grafts
The full thickness of the skin is harvested. Care is taken to
completely excise any subcutaneous fat from the graft which may Structures in the skin
impair plasma imbibition or revascularization. For the head and ���������
neck area, the usual donor sites are postauricular, preauricular ������
or supraclavicular. For the hands and feet the common donor �������������������������������������������
sites are the lateral groin crease or medial arm. The donor defect
is closed primarily.
The advantages of full-skin grafts are that they provide a better
colour, contour and texture match than split-skin grafts, they
contract less and they are more robust and hardy.
The disadvantages are that there is a limited amount of tissue
available, they take less reliably than split-skin grafts (which are
preferred if the bed is less than ideal) and the graft may be hairy.

Flaps
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A flap is a block of tissue which is moved from a donor site to a �������������
recipient site and which brings its blood supply with it. Proper ����� �������������������
planning of a flap is essential to its viability and success. ������ �����������������
The blood supply of skin is based on several horizontally �����������������
oriented vascular plexuses (Figure 4) connected by vertically ������ �������������������������
������������
oriented connecting vessels. The most important of these
���������������������������
plexuses are the two fascial plexuses and the subdermal plexus.
4

SURGERY 136 © 2002 The Medicine Publishing Company Ltd

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PLASTIC SURGERY
Flap classification
Blood supply
• Random pattern
• Axial
Movement
• Local (advanced, rotated, transposed)
• Distant
• Free
Tissue
• Single tissue
cutaneous
fascial
muscle
bone
nerve
omentum
gut
• Composite
fasciocutaneous
musculocutaneous
osseocutaneous
tendofasciocutaneous
or any other combination
5 6
occasionally a situation will occur when a distant flap is still
indicated. One such example is the cross-leg flap, where a
fasciocutaneous flap is raised on one leg, transposed to the defect
on the other leg and the legs held together for three weeks until
the flap has picked up a new blood supply from the recipient site.
The base of the flap can then be divided and the legs separated.
Free flaps: free microvascular transfer of tissue has enabled
almost any defect to be repaired, provided the patient is fit
enough to undergo prolonged surgery. With such a wide range of
donor tissue available, the defect needs to be assessed accurately
in order to select the most appropriate flap. The size of the defect
(both surface area and thickness), the calibre and position of the
recipient vessels and the function of the recipient area (e.g. weight
bearing, gliding surface for tendon excursion, etc) must be taken
into consideration. When tissue other than skin is also lost, free
flaps may comprise skin and bone, skin and muscle with or
without bone, and other tissues such as tendons and nerves.
Flap tissue composition
Fasciocutaneous flaps: these are relatively simple flaps to raise
and transpose. The axial/perforating vessel is often identified
preoperatively using a hand-held Doppler probe. Then one edge
of the fascia is raised and the perforating vessel visualized. The
rest of the flap can then be raised and transposed. The donor
defect is usually closed by means of a split-skin graft (which is
often cosmetically unsightly).
Muscle and musculocutaneous flaps: local or free muscle or
musculocutaneous flaps tend to be bulkier than fasciocutaneous
flaps and can fill deep, irregular defects better. The perfusion of
SURGERY
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muscle is more reliable and this makes them most useful in
complex wounds such as those caused by osteomyelitis, vascular
insufficiency, chronic radiation necrosis and exposed, possibly
infected vascular grafts. Sometimes a defect is closed with a
combination of a muscle flap covered with a skin graft. This may
avoid an unsightly donor defect because healthy skin and fat is
left at the donor site, and provides better contour at the recipient
site because a musculocutaneous flap is bulkier than a
fasciocutaneous flap.
Fascial flaps: where extremely thin tissue is required (for
example to resurface the dorsum of the foot), there is a choice of
a superthin skin flap (e.g. lateral arm or anterolateral thigh flap)
or a fascial flap (e.g. radial forearm fascial flap) with a meshed
split-skin graft applied. The advantage of using a fascial flap is
that there is relatively little defect at the donor site as the
overlying skin and fat is simply reflected, then replaced.
The advantages of flaps are that they can provide like-for-like
replacement of virtually any tissue, and healing times are
generally faster than for grafts.
The disadvantages are that there is a definite learning curve
associated with the use of flaps, free flaps require a high level of
team expertise and the donor site may be subject to various
cosmetic and functional defects.
Complications: simple flaps tend to heal faster than skin grafts,
though occasionally a postoperative infection or haematoma can
result in partial or total flap necrosis. This is more likely in
smokers and patients with pre-existing radiotherapy damage or
impaired perfusion. Free flaps have a low but definite risk
(1–10%) of complete flap failure due to microvascular anasto-
motic complications or failure of tissue perfusion.
137 © 2002 The Medicine Publishing Company Ltd
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Tissue expansion
Tissue expansion is a mechanical process by which the surface
area of skin can be increased. A tissue expander consists of an
inflatable silicone balloon with a remote port connected by a
length of tubing. This is surgically inserted into a subcutaneous
position adjacent to the defect. The device is inflated, by
percutaneous injection into the port, to stretch the overlying skin.
The amount of each inflation is limited by pain and/or blanching
of the overlying skin. Over the following days the stretched
tissues react in the following ways:
• epidermal thickening and keratinocyte hyperplasia
• dermal thinning
• increased vascularity
• fat atrophy
• capsule formation around the expander.
As a result of these changes, the skin ‘expands’ and is ready
for further inflation of the expander. This process continues until
sufficient expansion has been achieved. The inflation period may
take several months. Once completed, the expanded flap can be
transposed and inset as required.
The advantages are that there is no donor defect, the expanded
flap produces an ideal tissue match from an immediately adjacent
site, the expanded skin usually maintains its innervation,
vascularity is increased (thus the flap is more robust), and it
provides specialized tissues, such as hair-bearing scalp, which
are not available from any other site.
Disadvantages: it is a staged procedure which takes a long
time, the patient has the ordeal of temporary disfigurement, the
stretched skin may develop stretch marks similar to those seen
in pregnancy, and there is a high complication rate.
Complications: the commonest complications of tissue
expansion are infection and implant exposure or extrusion. These
are dependent upon site (scalp is good but leg is poor), skin
condition (previous radiotherapy or poor vascularity are
contraindications) and smoking. Because of the high risk of
infection, tissue expansion is not used in the acute management
of a traumatic defect. A skin graft is used to resurface the wound
and tissue expansion is employed later to replace the skin graft
with good-quality, well-matched skin.
Topical negative pressure
Topical negative pressure is a new concept in the management
of skin loss. It was introduced in the mid-1990s and is gaining
widespread popularity. It is most suited to wounds which cannot
be managed by direct closure or simple skin grafting in those
patients who are considered to be a poor surgical risk.
An open-pore sponge dressing is laid onto the wound. The
size of the pores and density of the foam is important as they
have an effect on healing rate. A drainage tube is embedded in
the sponge and the sponge and wound are sealed with an
adherent film dressing. The tube is connected to a vacuum pump
set to suck at 50–125 mmHg either continuously or intermittently.
The resulting reduction in pressure is distributed evenly across
the entire surface of the wound.
Despite its clinical success, the mechanisms of action have
yet to be fully elucidated. A number of mechanisms may be
involved:
SURGERY
• increase in local blood flow
• reduction of local oedema, thus improvement in perfusion
• reduction in bacterial colonization
• removal of wound exudate which inhibits wound healing
• mechanical effect on angiogenesis and granulation tissue
formation.
The process has been shown to give remarkable results on
wounds that would not be expected to heal by secondary
intention, for example those with exposed bone, tendon and even
metalwork. It encourages granulation formation, which grows
over such avascular structures, thus providing a bed for grafting,
and with continued use it promotes spontaneous re-
epithelialization. The process can be used on acute or chronic
wounds to equal effect.
Advantages: non-invasive, simple, low risk, and can
downgrade wounds on the reconstructive ladder (e.g. from one
which required a free flap to one which requires a split-skin graft).
Disadvantages: the process is expensive and requires a long
hospital stay.
Complications: the process is relatively safe and no major
complications have been recorded.
Skin substitutes
The survival of patients with massive burns partly depends upon
prompt removal of all burned tissue and wound coverage.
Unfortunately, with considerable skin loss there may be few or
no donor sites available. Skin substitutes play a role in this
situation, though the ideal substitute has not yet been found.
Cultured keratinocytes
The technique of culturing human keratinocytes has been
available for 30 years. It takes about three weeks to expand 1 cm2
of skin to form large areas of confluent sheets of keratinocytes.
These sheets can be grafted straight onto a well-vascularized
wound bed. However, they are only several layers of cells thick
and the resulting cover is very fragile and contracts considerably.
Dermal substitutes
More recent work has concentrated on providing a dermal
substitute upon which cultured keratinocytes can subsequently
be applied to form a ‘composite skin’. Being acellular, revasculari-
zation into these dermal substitutes is poor and they are at greater
risk of infection and loss initially. There are two main types of
substitute:
• Human cadaveric dermis (with the epidermis and basement
membrane removed) is relatively non-immunogenic and can be
stored either frozen or glycerolized. One drawback is the potential
infective risk of prions or viruses.
• Synthetic dermis (e.g. IntegraTM Artificial Skin). This is a
synthetic dermal template consisting of bovine collagen and
chondroitin-6 sulphate covered with a silastic membrane. It is
free from the potential infective risk of human dermis, but is
very expensive. u
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