Post Burn Reconstruction
Whether they’re caused by accidents or by surgery- scars are unpredictable. The way a scar develops depends as much on how your body heals as it does on the original injury or on the surgeon’s skills.Many variables can affect the severity of post burn scarring, including the size and depth of the burn, the blood supply to the area, the thickness and color of your skin, the immediate post burn care and treatment protocols followed to reduce the chances of scarring in an individual etc.It should be emphasised that, no scar can be removed completely, however,plastic surgeons can often improve the appearance of a scar, making it less obvious through the injection or application of certain steroid medications or through various surgical procedures.Many scars that appear large and unattractive at first may become less noticeable with time. Some can be treated with steroids to relieve symptoms such as tenderness and itching. For these reasons, we recommend waiting as long as a year or more after an injury or surgery before you decide to have scar revision.
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They are thick, puckered, itchy clusters of scar tissue that grow beyond the edges of the wound or incision. They are often red or darker in color than the surrounding skin. Keloids can appear anywhere on the body, but they’re most common over the breastbone, on the earlobes, and on the shoulders. They occur more often in dark-skinned people than in those who are fair. The tendency to develop keloids lessens with age.
Treatment: Keloids are often treated by injecting a steroid medication directly into the scar tissue to reduce redness, itching, and burning. In some cases, this will also shrink the scar. This treatment is repeated several times with intervals of 4 weeks in between treatments.
If steroid treatment is inadequate, the scar tissue can be cut out and the wound closed with one or more layers of stitches. This is generally an outpatient procedure, performed under local anesthesia. You should be back at work in a day or two, and the stitches will be removed in a few days. A skin graft (see the section on skin grafting) is occasionally used, however the site from which the graft was taken may then develop a keloid.
No matter what approach is taken, keloids have a stubborn tendency to recur, sometimes even larger than before. To discourage this, the surgeon may combine the scar removal with steroid injections, direct application of steroids during surgery. Or you may be asked to wear a pressure garment over the area for as long as a year. Even so, the keloid may return, requiring repeated procedures every few years.
They are often confused with keloids, since both tend to be thick, red, and raised. Hypertrophic scars, however, remain within the boundaries of the original incision or wound. They often improve on their own-though it may take a year or more-or with the help of steroid applications or injections.
Treatment: If a conservative approach doesn’t appear to be effective, hypertrophic scars can often be improved surgically. The plastic surgeon will remove excess scar tissue, and may reposition the incision so that it heals in a less visible pattern. This surgery may be done under local or general anesthesia, depending on the scar’s location. You may receive steroid injections during surgery and at intervals for up to two years afterward to prevent the thick scar from reforming.
Hyaluronic acid is a naturally occurring complex sugar molecule that forms large matrices in the connective tissue of the body, such as skin and cartilage. Much like a sponge, its primary function is to bind and absorb water molecules, which creates volume in the face. Hyaluronic acid fillers are generally used to treat facial wrinkles and folds and to enhance the appearance of the lips. One of the fastest growing dermal filler treatments available, hyaluronic acid fillers work by replacing the hyaluronic acid in the body that has depleted over time, which restores the volume beneath the skin’s surface.
Correcting a contracture usually involves cutting out the scar and replacing it with a skin graft or a flap. In some cases a procedure known as Z-plasty may be used. And new techniques, such as tissue expansion, are playing an increasingly important role. If the contracture has existed for some time, you may need physiotherapy after surgery to restore full function.
This is a surgical technique used to reposition a scar so that it more closely conforms to the natural lines and creases of the skin, where it will be less noticeable. It can also relieve the tension caused by contracture. Not all scars lend themselves to Z-plasty, however, and it requires an experienced plastic surgeon to make such judgments.
This procedure is performed under local, the old scar is removed and new incisions are made on each side, creating small triangular flaps of skin. These flaps are then rearranged to cover the wound at a different angle, giving the scar a “Z”pattern. While Z-plasty can make some scars less obvious, it won’t make them disappear. A portion of the scar will still remain outside the lines of relaxation.
Post burn hair loss can result in small focal areas of hair loss or large areas. Reconstruction of the scalp following burns present a unique problem because it requires to be replaced by “hair bearing tissue”, for a cosmetic appearance. Depending on the site and the extent of areas the modalities of treatment are worked out and customised to every case for an optimum result. The options include hair transplant by follicular unit grafting or tissue expansion.
Skin Grafting involves the transfer of skin from a healthy part of the body (the donor site) to cover the injured area. The graft is said to “take”when new blood vessels and scar tissue form in the injured area. While most grafts from a person’s own skin are successful, sometimes the graft doesn’t take. In addition, all grafts leave some scarring at the donor and recipient sites.
Flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels, and sometimes the muscle, is moved from a healthy part of the body to the injured site. Regional & Local flaps involve flaps,where the blood supply remains attached at one end to the donor site; Free flaps/ Free Tissue transfer involves reattachment of the blood vessels in the flap to vessels at the new site using microvascular surgery.
Skin grafting and flap surgery can greatly improve the function of a scarred area. The cosmetic results may be less satisfactory, since the transferred skin may not precisely match the color and texture of the surrounding skin. In general, flap surgery produces better cosmetic results than skin grafts.
Following any kind of post burn reconstruction, it’s very important to follow our instructions after surgery to make sure the wound heals properly. Although you may be up and about very quickly, we will advise you to gradually resume your normal activities.
The treated area may take several weeks or months to heal, and a support garment or bandage may be necessary for up to a year. Insurance usually doesn’t cover cosmetic procedures. However, if scar revision is performed to minimize scarring from an injury or to improve your ability to function, it may be at least partially covered. Check your policy or call your carrier to be sure.
As you heal, keep in mind that no scar can be removed completely; the degree of improvement depends on the size and direction of your scar, the nature and quality of your skin, and how well you care for the wound after the operation.
If your scar looks worse at first, don’t panic-the final results of your surgery may not be apparent for a year or more.
Sameer Karkhanis, MD
Board-Certified Mumbai Plastic Surgeon
Chief Plastic Surgeon & the Director at CCRS is a qualified Aesthetic Plastic and Reconstructive Surgeon. He is Board Certified, with the qualification of DNB Plastic Surgery (Diplomate of National Board). He is an active member of the International Society of Aesthetic Plastic Surgery.