Inventory of potential reconstructive needs in patients with post-burn contractures
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Background: The inventory of potential reconstructive needs records the specific reconstructive needs of the patient with burns and allows systematic planning for future reconstruction and rehabilitation. It also assists patients to evaluate and prioritize reconstructive options with the guidance of the plastic surgeon, as well as facilitating the adoption of realistic expectations on the part of the patient and family. Materials and Method: A survey of the potential reconstructive needs was carried out using the inventory of reconstructive needs form. The form is applicable to all body regions and is divided into three sections. Each section is subdivided into anatomic units: head and neck (anatomic units 1-5); upper extremity (anatomic units 6-9); and trunk and lower extremity (anatomic units 10-13). The results are presented in tabular form and analyzed using simple frequency distribution. Results: The anatomic region with the highest number of reconstructive needs was the head and neck in adults 25 (42%).The trunk and lower extremity accounted for the least reconstructive needs in adults 12 (20%). When the reconstructive needs were stratified by anatomic units in the head and neck, the upper eyelids 8 (32%) and the neck 6 (24%) had the highest frequency of reconstructive needs in adults. The upper extremity had the highest reconstructive needs in children 51 (52%). The upper eyelid, mouth and neck accounted for 13 (76%) of the reconstructive needs in children. Seventy-eight (50%) of the 157 patients had at least two contractures.Conclusion: There were more reconstructive needs in children than adults. The anatomic region with the highest number of reconstructive needs was the head and neck in adults and the upper extremity in children. This study underscores the importance of positioning and intensive therapy intervention in the prevention of post-burn contractures.Keywords:
Reconstructive Surgery
Reconstructive Surgeon
Muscle contracture
Scar contractures are a common complication of burn injuries, especially in the head and neck region. This paper presents a case of a middle-aged female who suffered severe scar contracture after a burn injury during the war in Syria. A 33-year-old woman with a severe neck scar contracture resulting from a neglected burn injury presented to a plastic surgery department. The contractures extended to the chin, mandible, chest, and upper limbs. The patient underwent contracture release and reconstruction surgery, which involved the removal of the platysma and the placement of split-thickness skin grafts. The patient was discharged after one month of hospitalization. However, burn injuries require immediate and deliberate treatment, which may include reconstructive surgery. Despite various efforts have been made to prevent the development of contractures, the contraction ratio of burn scars is still a badly controlled process, and reconstructive surgery is often indicated. There are many options to achieving the surgery, which vary in complexity. However, there is no preferable strategy and each option has advantages and disadvantages. Reconstructive is complete and technically demanded surgery, which needs special centers and professionals, this leads to poor results, especially in development countries like Syria.
Muscle contracture
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We have found that the pectoralis major myocutaneous flap is so reliable a flap that in seven selected patients we completely reelevated, isolated, and transposed it to a new reconstructive site in the head and neck. This may be accomplished safely, despite full courses of external-beam radiation therapy to the flap. We discuss the principles of this and propose that it can be extended and applied to other island, pedicle, or free flaps. The manner in which the flap can be reused and integrated with microvascular transfer or other regional pedicle flaps in complex secondary operations must be determined by the individual reconstructive surgeon on the basis of the requirements of the reconstruction. This technique will make one more tool available to the surgeon for reconstruction. (Plast. Reconstr. Surg. 93: 481, 1994.)
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Reconstructive Surgeon
Free flap reconstruction
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Reconstructive surgery in burn patients is difficult because of the intense scarring and the necessity to carry out multiple operative procedures for different reconstructive needs in a single patient. The primary aim of the surgeon is to prevent hypertrophic scar by early wound closure, and proper postburn treatment using a combination of silicone gel, splinting, and pressure therapy. Reconstructive procedures should be deferred until the wounds have matured. Accurate preoperative assessment and appreciation of the true tissue deficiency, appropriate application of different reconstructive options, and the establishment of the priorities of reconstruction in relation to individual requirements are essential for a successful outcome. In general, functional needs have to be met before attending to aesthetic concerns and priority should be given to restore active before passive function. Different reconstructive options using direct closure, skin grafts, flaps, free tissue transfer, and tissue expansion are discussed.
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Form and function
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We have found that the pectoralis major myocutaneous flap is so reliable a flap that in seven selected patients we completely re-elevated, isolated, and transposed it to a new reconstructive site in the head and neck. This may be accomplished safely, despite full courses of external-beam radiation therapy to the flap. We discuss the principles of this and propose that it can be extended and applied to other island, pedicle, or free flaps. The manner in which the flap can be reused and integrated with microvascular transfer or other regional pedicle flaps in complex secondary operations must be determined by the individual reconstructive surgeon on the basis of the requirements of the reconstruction. This technique will make one more tool available to the surgeon for reconstruction.
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Gottlieb and Krieger in 1994 suggested that reconstructive surgery involves creative parallel thought rather than simple sequential thought and devised the reconstructive elevator1 as an alternative to the reconstructive ladder2 that was prevalent earlier. Although the reconstructive ladder allowed unidirectional movement (from simplest to most complex options), the reconstructive elevator permitted bidirectional movements. Previously, plastic surgeons did not have many reconstructive options for a given defect, so the elevator or ladder was sufficient to address the reconstruction requirements. However, both are rigid constructs as far as selection of a reconstructive option is concerned and consider only the wound complexity to aid the reconstructive judgment. With improvement in understanding of tissue biology and availability of newer instrumentation, additional modalities have been added to techniques available to the reconstructive surgeon in the past two decades. Today, reconstruction specialists have multiple options for a given defect, and complex defects can now be reconstructed with ease when provided the right resources. Multiple factors determine choice of reconstruction; for example, using a groin flap for resurfacing a dorsal hand defect in an emergency setting where availability of a microscope may be an issue to carry out a medial sural artery perforator free flap when the patient is unwilling to have a visible scar from a posterior interosseous artery flap on the dorsum of the forearm. At this juncture, we would like to propose the "reconstructive grid" as an evolution over the reconstructive elevator to aid the judgment of reconstructive surgeons. (Fig 1). The reconstructive grid is a dynamic construct that takes into account the multiple reconstructive options available to the plastic surgeon. It also takes into consideration factors that help the reconstructive surgeon determine the best possible option to achieve the three reconstruction goals, namely, form, function, and aesthetics. The factors that aid the judgment of a reconstruction specialist, including wound complexity, surgeon skill, resources (and technology) available, and patient requests, form the boundaries of the reconstructive grid. The bottom row of the reconstructive grid houses the traditional modalities of reconstruction that are available in the ladder and elevator and the newer reconstruction modality, vascular composite allotransplant which, though absent in the reconstructive ladder, is mentioned in the modified reconstructive elevator.3 The boxes above these primary reconstruction modalities show techniques available within each modality of reconstruction. As can be seen, all primary modalities are at the same level, indicating that the most suitable option may be selected for a reconstruction rather than the simplest option and this selection would primarily be based on wound complexity tempered by the operator's skills; available resources; and, importantly, patient request.Fig. 1.: The reconstructive grid. NPWT, negative-pressure wound therapy.The spatial nature of the reconstructive grid permits the specialist to select multiple options for a given defect (e.g., using split-thickness skin graft with negative-pressure wound therapy for resurfacing a cutaneous defect where primary closure is not possible). The reconstructive grid includes newer wound healing techniques such as bioengineered skin, cell therapies (e.g., adipocyte-derived stem cells), and also still-developing reconstruction techniques including tissue engineering4 and gene therapies.5 The blank boxes represent available space to accommodate newer techniques as they arise, under each modality, thus making the grid future-ready. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.
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The very existence of plastic and reconstructive surgery, perhaps more than any other surgical specialty, is reliant upon innovation. Unlike other surgical specialties, plastic and reconstructive surgery does not “own” any one organ system or region of the body. Instead, plastic surgeons are experts in restoring form and function in all body regions and tissue types, relying on their expert knowledge of anatomy and creative use of the principles that define our specialty.1 In the wake of numerous medical and surgical subspecialties adopting techniques and practices developed by and originally unique to the field of plastic and reconstructive surgery, there are many who question the need for the specialty to exist as a separate entity. As margins have decreased across the healthcare industry, specialties such as ear, nose, and throat and oncologic breast surgery have begun to couple ablative and reconstructive surgery under the auspice of a single team (i.e., excising tumors in the head and neck and performing microvascular free tissue transfer without the presence of a reconstructive microsurgeon; placing implants after mastectomy without consulting the plastic surgery service), raising concerns regarding the future of plastic surgery as a specialty service.2 Despite being the pioneers of head and neck oncologic surgery, orthognathic surgery, nasal reconstructive surgery, upper and lower extremity reconstructive surgery, and complex pelvic and abdominal wall reconstructive surgery, in many centers around the world, plastic surgeons are rarely consulted for such cases. While the scope of practice remains extremely broad and diverse for plastic and reconstructive surgery, there has been a gradual loss of previously commonplace referrals as other specialties expand their own scope. The specialty of plastic and reconstructive surgery has thrived and survived beyond such challenges due to the drive toward innovation and research ever-present in the individuals and academic communities comprising our field.1,3 Ongoing and future innovation in plastic surgery is unlikely to be predominantly clinical; rather, innovation is more likely to be on the research forefront, as plastic surgeon-scientists lead the way in regenerative medicine and surgery.1,4 Combating the encroachment of other specialties on the procedures and technology created by plastic surgeons, the field has relied on plastic surgeon-scientists to constantly identify novel solutions within the realm of practice of the specialty.4,5 Unfortunately, the current era of practicing surgeons now suffers from a lack of individuals and institutions motivated to bolster the training of plastic surgeon-scientists. While we recognize the reality of the challenges in balancing a busy clinical plastic surgery practice with meaningful scientific investigation and innovation in the laboratory, we are compelled to encourage the rising generation to consider the impact they may have should they embark on a career aimed toward innovation in plastic surgery. The future of our specialty remains nebulous given recent decades of shift in clinical practice patterns. By securing our impact in scientific innovation applied toward clinical translation and patient care in plastic surgery, we will in turn secure the safety and prosperity of plastic and reconstructive surgery as a whole. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.
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in this study, patients with hypertrophic scars and/or contractures following burn injury were investigated retrospectively. Cases, 153 of !hem, that were admitted to Plastic and Reconstructive Surgery and Pediatric Surgery Clinics, were evaluated according to cause of burn, localization, postburn duration, age groups, where and when the initial care was taken, the place where they came from, those that were underwent operation, and what were suggested far postoperative care. The socio-economic and psychological impact of burn injury with hypertrophic scar and contractures is unbearable. Therefore, early and necessary at home treatment during and postburn injury is important. in this regard, the importance of the means to be used in reconstructive surgery and following the advances in medical treatment and tissue repairment is alsa stressed.
Muscle contracture
Hypertrophic scars
Reconstructive Surgery
Hypertrophic scars
Medical care
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