Giorgio C. La Scala

1. Giorgio C. La Scala, MD, PD
Basic surgery for burn scars
during humanitarian missions
Pediatric Plastic Surgery
Division of Pediatric Surgery
University of Geneva Children’s Hospital
ISPeW 2nd International Meeting
Rome, December 11-12, 2014

2. Global health problem
3rd most frequent cause of trauma death
Fire burns: in Top-15 overall causes of death
11 # higher death rate in low-income and middle-income countries
(LMIC)
Burns Epidemiology
Forjuoh & Gielen, World Report On Child Injury Prevention, World Health Organization, 2008

4. Fire burns mortality
4+
0.5–3.9
<0.5
No data
Forjuoh & Gielen, World Report On Child Injury Prevention, World Health Organization, 2008

5. Disproportionately higher rate of burns in children < 5 years in LMIC
Africa: incidence of fire-related burns < 1 of age = 3 # the world average
After a burn
49% of children with some form of disability
8% of children with a permanent physical disability
Burns Epidemiology
Forjuoh & Gielen, World Report On Child Injury Prevention, World Health Organization, 2008

6. Fire
Burn-related deaths
Disabilities
Scalds and contact burns
Disabilities
Burns Epidemiology
Forjuoh & Gielen, World Report On Child Injury Prevention, World Health Organization, 2008

7. Most common burn sites
Fire: lower extremities
Scalds: trunk and upper extremities
Contact: hands
Burns Epidemiology
Forjuoh & Gielen, World Report On Child Injury Prevention, World Health Organization, 2008

10. The problem
Physical long-term consequences
Hypertrophic scarring
Keloids
Chronic wounds ! Marjolin’s ulcer
Significant contractures
Need to amputate an extremity

12. Who to operate?

13. “... to help, or at least to do no harm.”
Hippocrates, Epidemics (Book I, Chapter XI)

14. Not surgical candidates
ASA $ 3
Poor nutrition
Obviously malnourished
Height, weight or head circumference ! expected for age
Hb < 100 g/L (greater at altitude)
Significant airway anomalies
Age < 1 year
Intercurrent illness
Guidelines for the Care of Children in the Less Developed World - ASPS, 2009 (tinyurl.com/mk7g4p8)

15. Surgical candidates
Maximum gain in function
Simplest and most reliable surgical approach

16. Acute phase reconstruction
Prevent irreversible secondary damage
Intermediate phase reconstruction
Relieve tension influencing scar maturation
Late-phase reconstruction
Release contractures, improve scars
When

17. Reliable on-site partners
Organisation
Preoperative management
Follow-up
How

18. Aseptic technique
General Anesthesia
Local anesthesia / nerve blocks
Lidocaine (max 5 mg/kg " 0.5 mL/kg 1% solution)
Lidocaine-Adrenaline (max 7.5 mg Lidocaine/kg)
Bu%er adding 1 mL of 8.4% NaHCO& per 10 mL Lidocaine 1%
Ketamine
How

19. Inadequate nutrition = no wound healing
Treat scars from proximal to distal
Prefer Z-plasties or variation
Bring normal skin into the scar
Flaps with superficial fascia to enhance blood supply
Minimal mobilization of scarred tissue
How

20. Prefer flaps allowing direct closure of harvest site
If in doubt about viability, delay flap (incise, but not raise)
Skin grafts = increased complications
Early dressing changes
How

21. Tourniquets
Electrocautery
Diluted adrenaline infiltration (1:500’000 or 1:1’000’000)
Concentrated adrenaline for open wound application (1:33’000)
Limit blood loss

22. Surgical approach
Germann, Sherman, Levin: Decision making in reconstructive surgery, Springer Verlag, New York, 1999
Burned skin
Linear scar
Not over joint Excision with Z-plasty or flap
Over joint
First correction Z plasty, V-Y plasty
Secondary correction Z plasty, flap

23. Surgical approach
Germann, Sherman, Levin: Decision making in reconstructive surgery, Springer Verlag, New York, 1999
Burned skin
Linear scar
Not over joint Excision with Z-plasty or flap
Over joint
First correction Z plasty, V-Y plasty
Secondary correction Z plasty, flap
Wide scar
Over joint
First correction Full thickness skin graft
Secondary correction Flap
Not over joint Excision with Z-plasty or flap

24. Z-plasty
+73%
Scar
60°
60°

25. -36.5%-36.5%
Z-plasty
+73%

26. Z-plasty
Stereometric technique
Best for contractures (webs)
Huang & Ogawa. Plast Reconstr Surg Glob Open 2014, 2:e149

27. Types
45° !1.5 60° !1.73
90° !2.2475° !1.99
Data on gain in scar length from: Davila. Plast Reconstr Surg 2012, 129:890e-2e

28. Types
Jumping man !1.5 4 45° !2.13
6 45° !2.654 60° !2.65
Hirshowitz, Karev et al. Br J Plast Surg 1977, 30:48-51
Data on gain in scar length from: Davila. Plast Reconstr Surg 2012, 129:890e-2e

29. Modifications
opposed squares !2" Z (I-C)

30. Squares-Z
#-90-45° !2.80 #-45-45° !2.41
#-#-# !3#-60-60° !2.73
Data on gain in scar length from: Davila. Plast Reconstr Surg 2012, 129:890e-2e
Hyakusoku & Fumiiri. Br J Plast Surg 1987, 40:40-6

31. Advancement flaps
Interdigitating Y-VY-V

32. Treatment by region

33. Neck

34. Neck

35. Neck (2 Z-plasties)

36. Neck

37. Neck

38. Neck (I-C)

39. Neck (I-C)

40. Neck (I-C)

41. Neck (I-C)

42. Neck (I-C)

43. Neck

44. Neck (supraclavicular A. flap, STSG)
y

45. Neck (supraclavicular A. flap, STSG)

46. Neck (supraclavicular A. flap, STSG)

47. Neck (supraclavicular A. flap, STSG)
6 w

48. Neck (supraclavicular A. flap, STSG)
1 y

49. Wear collar until scar matures
Neck

50. Axilla (interdigitating Y-V flaps)

51. Axilla (interdigitating Y-V flaps)

52. Axilla (interdigitating Y-V flaps)

53. Axilla (interdigitating Y-V flaps)

54. Axilla (Y-V flap)

55. Axilla (Y-V flap)

56. Axilla (Y-V flap)
4 y

57. Axilla (Jumping man)

58. Axilla (Jumping man)

59. Axilla (Jumping man)

60. Axilla (Jumping man)

61. Axilla (Jumping man)

62. Axilla (Jumping man)

63. Axilla (Jumping man)

64. Axilla (Jumping man)
5 y

65. Axilla (expanded desc. parascapular A. flap)

66. Axilla (expanded desc. parascapular A. flap)

67. Axilla (expanded desc. parascapular A. flap)

68. Axilla (expanded desc. parascapular A. flap)

69. Axilla (expanded desc. parascapular A. flap)

70. 1 m
Axilla (expanded desc. parascapular A. flap)

71. Arm abducted for 6 weeks
Night splinting until scar matures
Axilla

72. Elbow (Z-plasty)

73. Elbow (Z-plasty)

74. Elbow (Z-plasty)
1 m

75. Elbow (Y-V & Z plasties)

76. Elbow (Y-V & Z plasties)

77. Elbow (Y-V & Z plasties)

78. Elbow (Y-V & Z plasties)

79. Elbow (Y-V & Z plasties)

80. Elbow (Y-V & Z plasties)

81. Elbow (Y-V & Z plasties)

82. Elbow (Y-V & Z plasties)
4 y

83. Hand

84. Hand

85. Hand (Jumping man, FTSG)

86. Hand (Jumping man, FTSG)

87. Hand (Jumping man, FTSG)

88. Hand (Jumping man, FTSG)
4 m

89. Hand (Jumping man)

90. Hand (Jumping man)

91. Hand (Jumping man)

92. Hand (Jumping man)

93. Hand (Jumping man)

94. Hand (Jumping man)
4 m

95. Hand (3 #, Z plasty, FTSG)

96. Hand (3 #, Z plasty, FTSG)

97. Hand • 3 # plasty
Dorsum
Palm
co
m missu
re
Dorsum
Palm Palm
co
m missu
re
Bandoh, Yanai et al. J Hand Surg Am 1997, 22:680-4

98. Hand • 3 # plasty
Bandoh, Yanai et al. J Hand Surg Am 1997, 22:680-4

99. Hand • 3 # plasty

100. Hand • 3 # plasty

101. Hand • 3 # plasty

102. Hand • 3 # plasty

103. Hand (3 #, Z plasty, FTSG)

104. Hand (3 #, Z plasty, FTSG)

105. Hand (3 #, Z plasty, FTSG)

106. Hand (3 #, Z plasty, FTSG)

107. Hip (skin expanders - delay flap)

108. Hip (skin expanders - delay flap)

109. Knee (transposition fascio-cutaneous flap)

110. Knee (transposition fascio-cutaneous flap)

111. Knee (transposition fascio-cutaneous flap)

112. Lower leg-Ankle (Ilizarov)

113. Lower leg-Ankle (Ilizarov)

114. Lower leg-Ankle (Ilizarov)

115. Lower leg-Ankle (Ilizarov)

116. Lower leg-Ankle (Ilizarov)

117. Select the patients
Keep it simple - primary closure of donor sites
Avoid split thickness skin grafts
Optimize conditions for healing
Reliable on-site partners
Follow-up
Secondary corrections?
Conclusions

118. Basic surgery for burn scars during humanitarian missions
Giorgio La Scala, MD, PD ' giorgio.lascala@hcuge.ch
Pediatric Plastic Surgery
Division of Pediatric Surgery
University of Geneva Children’s Hospital
Thank you