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.
Thirty‐seven ischial pressure ulcers were repaired in 27 patients (eight quadriplegic, 19 paraplegic) between 1988–1993 using the V‐Y advancement hamstring myocutaneous island flap. Twenty‐one ulcers (57%) arose de now and 16 were recurrent, with five patients having bilateral ulcers. The average duration of the ulcer was 5 months (range 1–30). All ulcers extended through the deep fascia (clinical grade IV), with the average diameter being 4.7 cm (range 2–10). There were four major flap complications (11%). All but one of the ulcers healed at discharge (97%). Mean follow up was 20 months (range 5–54) in 21 patients (78%), with six patients being lost to follow up. Seven of the 21 (33%) patients developed recurrent ulcers, with four of these having flap re‐advancement with successful healing, and one patient having two re‐advancements. Overall, 18 of the 21 (86%) patients with follow up had healed ulcers at time of follow up.
The V‐Y advancement hamstring myocutaneous island flap is versatile, reliable, easy to perform, has few complications, and can be re‐advanced in the event of recurrence.
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