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The management of severe burns constitutes a formidable challenge in modern medicine. The inherent complexity and severity of extensive burns render their treatment a demanding task that evolves in tandem with advancements in medicine. Historically performed by general surgeons, burn care has transitioned into a multidisciplinary endeavour, integrating expertise from numerous medical and non-medical fields. Consequently, the effective treatment of major burn injuries depends on a large, collaborative team. However, a direct consequence of improved survival rates has been the increased incidence of sequelae. The management of these functional and esthetic complications continues to pose significant hurdles, even within centres of excellence. Optimal planning and execution of treatment during the acute phase are critical for mitigating sequelae. Clinical observation reveals a rising incidence of burn sequelae, a trend attributed to the improved survival rates of patients following acute injury in the recent decades. It is crucial to recognize that the pathophysiology of most burn sequelae, whether functional or esthetic, is rooted in the development of hypertrophic scarring. Therefore, the quality of care delivered during the acute phase represents the most significant prognostic factor for the subsequent development of these complications. While many conventional therapeutic strategies established decades ago remain fundamental to burn care, the paradigm for managing sequelae has shifted. Non-surgical alternatives have gained prominence, leading to new approaches for managing the scars that are the primary drivers of sequelae. Modalities such as CO2 laser, pulsed-dye laser, intense pulsed light, and microneedling are now integral components of treatment in specialized centres.
Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Divisao de Cirurgia Plastica e Queimaduras, Sao Paulo, Brazil
Jun Wu
*
Department of Burn and Plastic Surgery, The First Affiliated Hospital, Shenzhen University, China
*Address all correspondence to: drmolina@drmolina.com.br
1. Introduction
The management of severe thermal injury constitutes one of the most formidable challenges in contemporary medicine. The paradigm of care has evolved from an isolated surgical practice into a comprehensive, multidisciplinary endeavour, incorporating advances in intensive care, wound healing pathophysiology, and tissue engineering [1]. This evolution has led to the unprecedented survival rates, particularly in paediatric populations, where patients with burns covering up to 98% of their total body surface area can now survive [2]. A direct consequence of improved survival, however, is the increased incidence and prevalence of long-term burn sequelae. The management of these complications remains a significant clinical challenge, even in specialized centres of excellence [3, 4].
The pathophysiology of most burn sequelae, both functional and esthetic, is fundamentally linked to aberrant scar formation, namely hypertrophic and keloid scarring [4]. Therefore, the quality and timeliness of treatment during the acute phase are the most critical prognostic factors [5, 6, 7]. The duration of wound healing is a key indicator; wounds requiring more than 10 days to epithelialize have a 33% probability of developing hypertrophic scars, a risk that increases to 80% after 21 days [1]. While conventional therapies remain foundational, the therapeutic landscape has expanded to include advanced technologies such as tissue engineering and energy-based devices like CO2 and pulsed-dye lasers [8].
Given this complexity, the standardization of care through the established protocols is essential, particularly in academic and training institutions. The development and implementation of treatment algorithms serve to facilitate this process, ensuring uniformity and quality of care. The continuum of burn management is conventionally divided into two distinct phases: the acute phase, which spans from the initial injury until complete wound closure, and the late or reconstructive phase, which begins thereafter. This text focuses on an algorithm for the late phase, emphasizing the prevention and treatment of burn sequelae.
Burn sequelae, with the exception of unavoidable outcomes like amputations from high-voltage electrical injury, are intrinsically related to the healing process. Deficient healing, influenced by acute care and patient-specific factors, leads to scars of poor quality characterized by loss of elasticity, altered texture and thickness, dyschromia, and contracture.
For clinical and therapeutic purposes, sequelae are broadly classified as either functional or non-functional. Functional sequelae are defined by the impairment of normal physiological function. Severity is context-dependent and ranges from mild (e.g. slight limitation in limb extension) to severe (e.g. complete inability to extend a limb, resulting in a fixed contracture). A universal severity classification is lacking; thus, a thorough assessment of each unique clinical situation is required to determine the appropriate treatment strategy.
Non-functional sequelae, also termed esthetic sequelae, involve alterations in appearance without direct functional impairment. Examples include alopecia, loss of eyebrows, and changes in skin colour and texture. Although significant to patient quality of life, the correction of these issues is generally not prioritized over functional restoration. The therapeutic hierarchy dictates that functional sequelae be addressed before non-functional ones. In practice, however, functional and esthetic goals are often addressed concurrently, aiming for the best possible cosmetic result during a functional reconstruction [9].
The timing of surgical intervention is dictated by clinical urgency. Emergencies, such as severe ectropion with risk of corneal injury or microstomia impairing nutrition, necessitate early surgery. In non-urgent cases, procedures are typically deferred for at least six months post-injury to allow for scar maturation and subsidence of the inflammatory response, which minimizes the operative challenges like bleeding [9].
The treatment cascade for functional sequelae begins with optimizing non-surgical modalities, such as compression therapy, massage, silicone application, physical therapy, and advanced treatments like laser therapy and microneedling, ideally combined with drug delivery. Surgical intervention is considered once the potential benefits of these conservative measures have been exhausted. Throughout this process, the treatment plan remains dynamic, allowing for a return to non-surgical strategies as needed to support and enhance surgical outcomes.
Non-surgical treatment is an integral component in the management of all types of burn sequelae and should be consistently evaluated throughout patient follow-up. At any stage of care, these modalities must be considered, and in some clinical scenarios, they may constitute the sole intervention necessary. Recent technological advancements have led to the significant improvements in clinical outcomes. The therapeutic armamentarium includes compression therapy, massage, silicone application, physical therapy, laser treatment, and microneedling. The latter two techniques are ideally combined with drug delivery to enhance efficacy, as illustrated in Figure 1.
Figure 1.
Example of a non-surgical treatment with compression garment, laser, and small Z-plasty in the lateral and medial eye regions.
Some principles must be respected in all patients:
Preservation of expressions;
Normal appearance at conversational distance;
Balanced and symmetrical face;
Imperceptible scars;
Skin texture that allows for at least corrective makeup;
Preservation of movement dynamics.
3.1 Definitions in burn sequelae
The indication for treatment is determined by the specific type of sequela, which primarily includes contractures, retractions, adhesions (synechiae), and pathological scars [10, 11].
3.1.1 Linear band or linear contracture
These retractions manifest as palpable, linear, cord-like bands, as shown in Figure 2. Typically, these retractions do not present as solitary bands but are found in complex patterns or multiple formations.
Figure 2.
Example of linear band in the axilla and neck.
3.1.2 Broad contractions or retractions
A contracture is defined by a reduction in the range of motion, typically affecting a joint. Unlike a linear retraction, this limitation is caused by a diffuse area of inelastic scar tissue rather than a discrete, restrictive cord-like band as illustrated in Figure 3.
Figure 3.
Example of broad contracture in the neck.
3.1.3 Synechiae
A synechia is a particularly severe form of contracture, characterized by the pathological fusion of adjacent anatomical surfaces that are normally separate (Figure 4).
Figure 4.
Example of synechiae in the neck.
3.1.4 Pathological scars
These diagnostic categories are often conflated; however, a clear differentiation is essential for effective therapeutic planning, as management strategies vary substantially depending on the underlying pathology.
3.1.4.1 Hypertrophic scars
Hypertrophic scars are the most prevalent type of post-burn scar, typically arising from deep partial-thickness burns that have healed spontaneously (Figure 5). These scars begin to form shortly after the injury and are clinically characterized by being raised, erythematous, indurated, and often pruritic, while remaining confined within the boundaries of the original wound. They generally show a favourable response to non-surgical management, especially when therapy is initiated early in the scar maturation process [10, 12].
Figure 5.
Example of hypertrophic scar.
3.1.4.2 Keloids
Keloids are pathological scars that present as firm, rubbery lesions, or shiny, fibrous nodules. Their coloration can range from pink or skin-toned to red or dark brown. A defining characteristic of keloids is their tendency to grow beyond the boundaries of the original wound (Figure 6). In contrast to hypertrophic scars, keloids exhibit an unpredictable and often poor response to non-surgical treatments [10].
Figure 6.
Keloids developed as a result of acne vulgaris.
3.2 Commonly performed procedures and surgeries
Excision and primary closure: Simple excision with primary closure is the most fundamental technique for managing certain scar lesions. The procedure involves the complete removal of the lesion followed by direct, edge-to-edge suturing of the wound. In instances where the size or location of the lesion precludes complete removal in a single procedure, staged or serial excisions are performed [1, 12].
Local flap: Local flaps are the preferred surgical method for the release of linear scar bands and minor contractures. The most commonly utilized technique is the Z-plasty, typically designed with 60-degree angles, along with its variations such as sequential Z-plasty (Z-sequence) and the double-opposing Z-flap. This technique can be safely performed within scarred tissue, provided that meticulous care is taken to preserve the vascularity of the flaps by ensuring they are sufficiently thick and minimizing subcutaneous dissection [1, 13].
Skin grafts: The surgical management of burn sequelae preferentially utilizes unmeshed sheet grafts, either split- or full-thickness. This preference is based on the superior clinical outcomes associated with sheet grafting compared to meshed techniques, including an improved esthetic appearance (colour and texture), a reduced rate of pathologic scar formation, and the containment of incisional scarring to the suture lines. The principle of replacing “like with like” governs donor site selection: scalp grafts are ideal for facial resurfacing due to their excellent tissue match, whereas plantar arch skin is favoured for reconstructing palmar defects [13, 14, 15, 16, 17, 18].
Tissue expander: Tissue expansion is a procedure that can reduce scarring and yield high patient satisfaction, but it requires significant patient cooperation and adherence. Despite its conceptual simplicity, the selection and placement of expanders involve a notable learning curve and a risk of complications, such as suture dehiscence and distortion of adjacent structures. Outcomes tend to be less favourable when the expanded flap must be elevated and transposed. In particular, the use of expanders on the face and neck can lead to challenging results, including loss of natural contours and traction on nearby features, which may result in an esthetically suboptimal appearance.
Dermal regeneration matrix: Dermal regeneration templates are generally not considered a first-line reconstructive option, given their substantial cost and the demanding learning curve required for consistent results. Their primary advantage lies in the mitigation of donor site morbidity by allowing the use of thinner split-thickness skin grafts. However, this is balanced by a unique profile of potential complications, including infection, matrix loss, failure of the definitive graft to revascularize, and late-stage contraction. The adjunctive use of Negative Pressure Wound Therapy (NPWT) has been demonstrated to mitigate these risks, improving the rates of matrix incorporation and graft take while reducing hospital stays and enhancing patient comfort [13, 19].
Regional and expanded flaps: Regional flaps are the optimal solution for specific reconstructive challenges, like breast reconstruction, but their use can be limited by the insufficient local tissue volume or surface area. These limitations can be overcome by utilizing tissue expansion to augment the available donor tissue before flap transposition. While this staged approach is demanding, it produces reliable and esthetically favourable outcomes. The success of this technique is contingent upon technical proficiency with both the principles of tissue expansion and the design and execution of the regional flap itself [1, 20].
Free flaps: Microsurgical flaps are utilized in complex cases characterized by severe functional impairment, particularly when no other reconstructive options are viable. The most commonly employed flaps for these indications include the anterolateral thigh (ALT) flap, the transverse rectus abdominis myocutaneous (TRAM) flap, and the latissimus dorsi flap [21].
Hair implant: For the reconstruction of the eyebrow, hair transplantation serves as the first-line surgical modality. This procedure can produce superior esthetic outcomes that closely resemble a natural brow; however, achieving optimal density often necessitates multiple sessions, typically two to three. A critical aspect of patient counselling involves explaining the requirement for lifelong maintenance, specifically the regular trimming of the transplanted grafts. This is because the follicles retain the anagen-phase dominance of their scalp donor site, resulting in continuous growth unlike that of native eyebrow hairs [1, 13].
Corticosteroid infiltration: Intralesional corticosteroid therapy is most commonly performed with triamcinolone acetonide at a concentration of 20 mg/ml. The technique requires precise intradermal administration directly into the fibrotic scar tissue; care must be exercised to avoid injection into the underlying subcutaneous plane, which can lead to fat atrophy. The treatment regimen typically involves a series of injections at monthly intervals, with most patients requiring approximately three sessions to achieve a significant therapeutic response.
3.3 Reconstruction ladder
For decades, the “reconstructive ladder” has served as a guiding principle in plastic surgery, dictating a stepwise progression from simple to complex solutions for defect closure. The fundamental tenet of this framework is to select the least complex method that will achieve a successful outcome. However, contemporary reconstructive philosophy has evolved this concept into the “reconstructive elevator,” which acknowledges that for specific, complex defects, the most effective and efficient solution may be an advanced technique, thus justifying the bypassing of simpler options from the outset (Figure 7) [22].
The decision to proceed with surgical management is made upon the failure or exhaustion of non-surgical modalities. Subsequently, the formulation of a surgical plan is contingent upon a definitive diagnosis of the specific pathology being addressed, which guides the selection of the optimal procedure (Figure 8).
Figure 8.
Overview of functional sequela treatment.
4.1 Linear band
The formulation of a surgical plan is contingent upon an accurate diagnosis of the sequela. In the presence of a linear scar band causing contracture, local tissue rearrangement via Z-plasty is the indicated procedure. Common variations, including sequential and double-opposing Z-plasties, may be employed for longer or more complex bands. The principal advantage of this technique is its ability to elongate a contracted axis by reorienting local tissue through the transposition of triangular flaps. The theoretical gain in length is directly proportional to the angle of the flaps utilized, as outlined in Table 1 [23].
Angles of z-plasty
Theoretical gain in length (%)
30–30
25
45–45
50
60–60
75
75–75
100
90–90
125
Table 1.
Z-Plasty, angles, and theoretical gain.
The fundamental principle of Z-plasty is the transposition of two interdigitating, triangular flaps to lengthen a linear scar contracture (Figure 9). While technically uncomplicated, successful execution is contingent upon several critical details. To prevent retraction and ischemia at the flap tip, the limbs of the “Z” should be incised with a slight curvature. The limbs must also be of equal length to ensure symmetric transposition and tension-free closure. Most importantly, dissection in the subcutaneous plane should be performed judiciously, incising only the amount necessary to permit flap transposition. This approach ensures the preservation of the subdermal vascular plexus, a paramount consideration when operating on scarred or previously burned tissue with compromised vascularity (Figures 9 and 10). The standard surgical technique is illustrated in the accompanying video (Video 1http://bit.ly/4n8IkA4) [23, 24, 25].
Figure 9.
Clinical example illustrating the use of Z-plasty in the axillary region and neck.
Figure 10.
Schematic representation depicting the preoperative marking for the Z-plasty technique.
Of particular note, the release of the underlying longitudinal tension is achieved upon incision alone, permitting the spontaneous transposition of the flaps into their recipient sites with minimal to no subcutaneous undermining. This illustrates the efficiency of the technique in redistributing tissue forces to achieve contracture release.
4.2 Retraction
The indicated surgical approach for a retraction or synechia is a complete release of the restrictive tissue. This is typically achieved via an incision that transects the scar without excising underlying tissue, unless the tissue quality is exceptionally poor. The inherent tension within the scar results in immediate separation of the wound edges upon incision, creating a resultant soft tissue defect that requires subsequent coverage. The primary and most common method for covering such defects is the application of a skin graft. Should skin grafting not be a viable option, a dermal regeneration matrix is considered the second-line treatment. The third-line and most complex option involves the use of regional or distant (microsurgical) flaps.
4.2.1 Skin graft
The standard of care for the surgical reconstruction of burn sequelae involves the use of unmeshed sheet grafts [26]. This preference is based on their demonstrated superiority over meshed grafts in yielding favourable esthetic outcomes—including improved texture and colour match—and better functional results. Furthermore, sheet grafting is associated with a lower incidence of pathologic scar formation (hypertrophic and keloid) and confines incisional scarring to the graft’s perimeter (Figure 11) [13, 14, 15, 16, 17, 18, 27].
Figure 11.
First case, a cervical contracture release with split-thickness skin graft. Pre-operative, intra-operative, and post-operative views. Note the enhance of the jawline contour. The second case involved severe facial scarring secondary to poor wound healing and loss of a previous skin graft. The entire affected area was resurfaced with a new split-thickness skin graft harvested from the scalp. Note the excellent colour match and the significant improvement in skin texture.
While partial-thickness grafts are most commonly employed (Figure 12), specific clinical scenarios dictate the choice of graft thickness. Thick split-thickness skin grafts are recommended for areas subject to high mechanical stress, such as the hands and joints, assuming donor site availability. Conversely, full-thickness skin grafts are the optimal choice for eyelid reconstruction, as their inherent resistance to secondary contraction mitigates the high rate of ectropion recurrence. Donor site selection is governed by the principle of replacing “like with like”; consequently, the scalp is a preferred donor site for facial resurfacing, and the plantar arch is favoured for palmar defects [13, 14, 15, 16, 17, 18, 27].
Figure 12.
Surgical release of a gluteal synechia and subsequent skin grafting, performed to restore the intergluteal cleft and facilitate proper hygiene.
In scenarios where coverage with a standard split-thickness skin graft is not feasible, alternative reconstructive options are considered. The primary contraindications for standard grafting include a paucity of suitable donor sites or a history of previous graft failure. In such cases, the second-line option is the application of a dermal regeneration matrix. This approach is indicated provided that a very thin split-thickness skin graft can still be harvested to cover the matrix [23]. In the event that no suitable donor tissue is available for any form of grafting, the defect must be addressed with vascularized tissue, such as a regional or microsurgical free flap [20].
4.2.2 Dermal substitutes
For the last three decades, dermal substitutes have been instrumental in advancing the care of both acute burns and their resulting sequelae. Originally established for acute wound management, the indications for these dermal regeneration templates have expanded to include various reconstructive challenges where achieving high-quality, pliable skin coverage is paramount to the final outcome (Figure 13) [28, 29].
Figure 13.
Surgical management of a chronic ulcer that developed within an unstable skin graft on the wrist. The treatment consisted of complete excision of the ulcer and surrounding scar tissue, followed by reconstruction with a dermal regeneration matrix and a subsequent thin split-thickness skin graft.
Dermal substitutes have been instrumental in advancing the treatment of both acute and chronic burns, as well as their associated sequelae, over the last three decades. These bioengineered materials are broadly categorized by their structure and composition. They may consist of a single layer, which can be covered with a skin graft either immediately or in a delayed fashion, or a double layer. Bilayer constructs typically feature a collagen-based scaffold covered by a protective film (e.g., silicone), which must be vascularized by the host bed before the definitive skin graft is applied. The origin of these matrices varies, including allogeneic sources and synthetic compounds, with some products being pre-seeded with cells such as fibroblasts or keratinocytes. Numerous commercial products are available, including Integra®, Matriderm®, Pelnac®, Hyalomatrix®, and Nevelia®, each with unique characteristics but similar underlying principles [21].
Integra®, introduced in the 1990s, was the first commercially available artificial dermis. It is a bilayer template composed of a bovine collagen and glycosaminoglycan matrix, covered by a thin silicone layer that prevents desiccation. Its application is a two-stage procedure. The first stage requires the complete adherence of the matrix to the wound bed to facilitate angiogenesis and remodelling, which results in the formation of a so called “neodermis.” The second stage, which involves removing the silicone layer and applying a split-thickness skin graft, is performed once the scaffold is adequately vascularized—typically within three weeks, or as early as 14 days when used in conjunction with Negative Pressure Wound Therapy (NPWT) (Figure 14) [30].
Figure 14.
Reconstruction of a neck contracture with a dermal regeneration template. Pre-operative, intra-operative and post-operative sequence.
Matriderm® is a single-layer matrix composed of bovine collagen and elastin, available in 1-mm and 2-mm thicknesses. It is a flexible sheet that conforms well to wound topography and provides a mild haemostatic effect. The 1-mm version can be used in a single-stage procedure with immediate application of the definitive skin graft, whereas the 2-mm version requires a delayed grafting procedure [30].
The use of a thin split-thickness skin graft is preferred with these matrices, and clinical results demonstrate the significant benefits in terms of elasticity and ease of application. The adjunctive use of NPWT has been shown to enhance the matrix integration, accelerate vascularization and improve conformity on contoured surfaces, thereby reducing the complications [31, 32].
The choice of a specific dermal matrix depends on product availability and the clinical indication. Bilayer matrices, which typically have a silicone outer layer, require a longer period for vascularization and are more challenging to apply to complex, curved surfaces. Based on these characteristics, single-layer matrices are often preferred for areas requiring early rehabilitation, such as the hands, or for anatomically complex regions. The use of bilayer matrices is indicated for less-demanding planar surfaces and for providing coverage over exposed tendon or bone [25, 33]. Their two-stage application is advantageous when definitive skin grafting must be delayed due to donor site unavailability. Furthermore, they appear to offer superior dimensional stability, with clinical evidence suggesting less secondary contraction compared to the single-layer templates [31, 32].
4.3 Regional and free flaps
As regional and free flaps are covered in a separate chapter, they will only be mentioned briefly in this section. In the realm of plastic and reconstructive surgery, flaps are a cornerstone for repairing complex defects that arise from trauma, cancer resection, or, notably, severe burns. Unlike a skin graft, which is a thin layer of skin that relies on the underlying wound bed for survival, a flap is a unit of tissue transferred from a donor site to a recipient site with its own blood supply intact. This vascular autonomy makes flaps robust and essential for reconstructing deep, poorly vascularized wounds, covering the exposed vital structures such as bone and tendons, and restoring both function and esthetic contour [34, 35, 36, 37].
There are two primary categories of flaps used in this context: regional flaps and free flaps. Both are indispensable in burn reconstruction. Regional flaps offer a simpler, effective solution for specific defects, while free flaps provide the ultimate versatility for repairing complex and extensive burn injuries, enabling surgeons to restore not only the integrity of the skin but also the patient’s function and quality of life [35, 36].
4.3.1 Regional flaps
A regional flap, also known as a pedicled flap, is a segment of tissue that is mobilized from an area near the defect and pivoted or tunnelled to cover the wound while remaining attached to its original blood supply through a “pedicle” of tissue.
Characteristics:
Proximity: The donor site is in the same general region as the wound.
Intact blood supply: The flap is never fully detached from the body.
Simpler procedure: These surgeries are generally less complex and time-consuming than free flap procedures as they do not require microvascular anastomosis (the reattachment of blood vessels).
Limitations: The reach of a regional flap is limited by the length of its pedicle, and the available tissue in the vicinity of a severe burn may also be compromised.
4.3.2 Free flaps
A free flap, or free tissue transfer, represents a more advanced microsurgical technique. In this procedure, a well-defined block of tissue, along with its artery and vein, is completely detached from a distant donor site on the body. This flap is then transferred to the defect, and its blood vessels are meticulously reconnected to recipient vessels at the new site under a microscope.
Characteristics:
Distant donor site: Tissue can be harvested from virtually anywhere on the body, allowing for optimal tissue matching in terms of size, thickness, and type.
Microsurgery: Requires specialized training and equipment to perform the delicate vascular anastomosis.
Versatility: Offers unparalleled freedom in reconstructing complex, large, or specialized defects where local tissue is unavailable or unsuitable.
Complexity: These are lengthy and demanding operations with a higher risk of complications, such as flap failure due to blood clots in the repaired vessels.
4.3.3 Common flaps in burn reconstruction
The choice of flap for burn reconstruction depends on several factors, including the location and size of the defect, the tissues required (skin, muscle, fascia, or bone), and the availability of uninjured donor sites.
Anterolateral thigh (ALT) flap:
Type: Primarily a free flap.
Description: Harvested from the outer thigh, the ALT flap is arguably the most versatile and widely used free flap in modern reconstructive surgery. It provides a large and reliable skin and fat paddle, which can be thinned to match the recipient site. It can also be harvested with a segment of the vastus lateralis muscle if bulk is needed (Figure 15).
Common uses: Excellent for covering large defects on the extremities, trunk, and head and neck. Its long vascular pedicle provides flexibility in reaching recipient vessels. The donor site can often be closed directly or with a small skin graft, with minimal functional loss.
Latissimus dorsi flap:
Type: Can be used as a regional (pedicled) flap or a free flap.
Description: This large, fan-shaped muscle in the back, with or without its overlying skin, provides a vast amount of well-vascularized tissue.
Common uses: As a regional flap, it can cover massive defects on the chest wall (Figure 16), back, shoulder, and even the head and neck. As a free flap, it is invaluable for large wounds on the lower extremities and scalp where significant soft tissue coverage is required. The functional deficit from losing this muscle is generally well-tolerated.
Radial forearm flap:
Type: Free flap.
Description: Sourced from the inner aspect of the forearm, this is a thin, pliable fasciocutaneous (skin and fascia) flap.
Common uses: Ideal for reconstructing areas that require thin, supple tissue, such as the face, neck (for releasing burn scar contractures), and the dorsum (top) of the hand. Its major drawback is the conspicuous donor site scar on the forearm.
Groin flap:
Type: Regional (pedicled) flap or free flap.
Description: One of the earliest described flaps, the groin flap is a reliable option that involves attaching the hand or forearm to the groin for a period of weeks to allow the tissue to transfer.
Common uses: Primarily used for covering defects on the hand and wrist. While effective, it requires immobilizing the limb to the body, which can be uncomfortable and has been largely superseded by free flaps in many centres.
Supraclavicular artery flap:
Type: Regional (pedicled) flap.
Description: A relatively newer option that has gained significant popularity, this flap is taken from the area above the collarbone.
Common uses: It is an excellent choice for releasing severe burn scar contractures in the neck that pull the chin down to the chest (Figure 17). The skin provides a good colour and texture match for the head and neck region.
Figure 15.
Oral sequelae with functional impairment secondary to a chemical burn. Reconstruction was performed using a microsurgical bipartite anterolateral thigh (ALT) muscle flap with a skin paddle. Images show the preoperative condition, the bipartite flap design, and the 1-week postoperative result.
Figure 16.
Breast reconstruction utilizing an expanded latissimus dorsi myocutaneous flap as a regional flap.
Figure 17.
A patient presented with a recurrent contracture in the cervical region, which was managed with surgical release and reconstruction using a regional suprascapular flap.
After this phase, the patient is treated as having non-functional sequelae.
In the context of burn reconstruction, a deliberate terminological distinction should be made. “Non-functional sequelae” is the preferred term over “esthetic sequelae” because the goal of treatment is restorative, not cosmetic. Esthetics, as a philosophical discipline, involves subjective judgments of beauty. The objective of our surgical intervention, however, is to return the patient’s appearance to their pre-burn baseline, a process of restoration rather than enhancement. The initiation of this treatment phase involves a thorough assessment of the patient’s primary concerns and desired outcomes for their scar tissue (Figure 18).
Figure 18.
Overview of non-functional sequela treatment.
The management of non-functional scar sequelae is guided by two primary objectives: improving the intrinsic quality of the scar tissue or reducing its overall surface area. To improve scar quality, non-surgical modalities are the first line of treatment. In this context, energy-based devices and mechanical stimulation, particularly laser therapy and microneedling, have demonstrated significant efficacy in enhancing scar texture, pliability, and overall esthetic appearance.
When the therapeutic goal is scar reduction, surgical excision is indicated. This may be performed as a complete, single-stage procedure or as a series of partial (serial) excisions. Meticulous surgical planning is required to avoid distortion of adjacent anatomical structures, especially on the face, and to ensure a tension-free closure. Excessive tension on the suture line is a primary cause of scar widening and can compromise the final surgical outcome.
Tissue expansion serves as a primary reconstructive option for large scar areas where simple excision is not viable. This technique is distinguished by its unique ability to generate new, well-matched skin, thereby replacing scar tissue with normal tissue. However, its application is not without significant challenges. The literature reports complication rates ranging from 20 to 40%, and the treatment course is demanding for the patient, involving a minimum of two surgeries and numerous interim inflation sessions. In some cases, serial expansion cycles are required to achieve the desired tissue gain. The results can be extremely gratifying for the patient, despite being exhausting (Figure 19). We must not underestimate the weight of the flap and, ultimately, the skin. Thus, whenever we need to elevate the flap, results tend to be poorer. The facial and neck regions often have poor outcomes with significant loss of contours and traction of structures, giving an often-unpleasant appearance [33, 38].
Figure 19.
Example of tissue expansion in the shoulder.
Some points should always be considered (Figure 20):
Incision as far as possible from the expander placement site;
Incision 2–3 mm away from the scar tissue;
The placement cavity should be larger than the expander;
More efficient when placed on a hard surface (bone);
Closure of the incision in at least three planes;
You may fill more than indicated on the label (sometimes 1.5–2x);
Fill 10–15% of the expander during the operation;
Wait 2–3 weeks to start filling the expander;
Capsulotomy during the flap advance, especially on the basis.
Figure 20.
A protective suturing method designed to mitigate scar expansion and prevent exposure of an underlying tissue expander, particularly in cases of the compromised skin viability. The suture indicated as (1) represents the key anchoring stitch of this closure. As the first and most important suture, it is placed to secure the expander’s position and relieve tension across the wound, thereby preventing the scar from widening. The subsequent sutures, (2) and (3), are then applied to achieve the final apposition of the skin edges and complete the closure. Besides that, the incision is made a few millimetres from the scar.
For patients who lack adjacent tissue of sufficient quality for expansion, or for those who are unable or unwilling to adhere to the prolonged treatment protocol, alternative reconstructive strategies must be employed. In these cases, the primary options revert to the use of split-thickness skin grafts or dermal regeneration matrices, as previously described in the management of functional sequelae.
The application of the preceding treatment algorithms must be adapted for certain anatomical areas that possess unique functional and esthetic requirements. Although the general principles are applicable, specific regions—namely the neck, breast, eyelids, eyebrows, ears, mouth, and nose—necessitate tailored reconstructive strategies.
6.1 Neck
The surgical management of extensive cervical contractures, while guided by the general reconstructive algorithm, incorporates several critical technical modifications. Sustained intraoperative hyperextension is mandatory. The procedure must include a complete release of the platysmal bands via a transverse incision, as failure to do so is a known predictor of recurrence. Preoperative assessment and surgical marking should be performed with the patient seated to accurately delineate the extent of the contracture, ensuring the planned incision reaches the unscarred lateral cervical skin. The craniocaudal placement of the incision is dictated by the zone of maximal tension [39]. Postoperative management may involve a compressive orthosis. While incisional release is the standard, pathologic tissue of exceptionally poor quality may the necessitate complete excision. Flap-based reconstruction is generally contraindicated due to the unique anatomical challenges of the neck. The thinness of the native skin, the large surface area of defects post-release, and the complex cervical contour make flaps a suboptimal choice, often resulting in significant contour deformities and inadequate functional release [31, 40].
6.2 Breasts
The management of post-burn breast sequelae is stratified by patient age and the nature of the deformity. In prepubescent patients, early intervention with tissue expansion is essential to ensure the skin envelope can accommodate future breast development. In adults, simple linear contractures of the inframammary fold are amenable to Z-plasty. For more complex deformities involving poor skin quality or significant volume loss, particularly of the lower pole, the reconstructive algorithm escalates to include techniques such as excision and grafting, dermal matrix application, or, most definitively, reconstruction with a latissimus dorsi myocutaneous flap [41].
6.3 Eyelids
As the most common sequela affecting the eyelid, the management of post-burn ectropion is contingent upon a precise diagnosis of its underlying cause. A critical distinction is made between intrinsic ectropion, caused by scarring within the eyelid, and extrinsic ectropion, resulting from traction by adjacent scars. For intrinsic cases, the preferred treatment is a complete incisional release of the contracted tissue and reconstruction with a full-thickness skin graft. To counteract the high propensity for recurrence, a planned overcorrection is an essential component of the procedure. In contrast, the management of extrinsic ectropion requires that the surgical intervention be focused exclusively on the external scar causing the traction; upon its release, the eyelid position typically corrects passively. Only in rare cases involving extensive tissue damage is wide excision and complex reconstruction with grafts or dermal matrices indicated (Figures 21 and 22) [42].
Figure 21.
Treatment of ectropion with a full-thickness skin graft, noting the change in position of the lower eyelid.
Figure 22.
Example of severe deformation of superior and inferior eyelids corrected with single-layer dermal regenerate matrix. The left nasal ala and oral commissure were reconstructed with local flaps, and the ear was addressed with an external auricular prosthesis.
6.4 Eyebrow
Numerous techniques have been described for eyebrow reconstruction, including regional flaps and hair-bearing scalp grafts. However, the method that consistently yields the most superior esthetic results is follicular unit transplantation, a technique analogous to that used for treating the androgenetic alopecia. Despite the presence of scar tissue, transplanted follicular units demonstrate a high rate of engraftment, only slightly lower than that observed in non-scarred skin, providing a natural-appearing reconstruction. The primary disadvantage of this technique is the need for lifelong maintenance, as the transplanted hairs retain the continuous growth cycle of their scalp donor site and thus require regular trimming (Figure 23) [43, 44].
Figure 23.
Eyebrow reconstruction with hair-by-hair transplant.
6.5 Ear
The reconstruction of the external ear represents a formidable surgical challenge. For total auricular defects, the established technique is to create a framework from autologous costal cartilage, which is then draped with the local skin. This approach is often not viable in burn patients due to the compromised quality of the surrounding tissue. In these instances, a more complex solution is required, wherein the cartilage framework is covered with a vascularized temporoparietal fascia flap and then surfaced with a skin graft. While effective, this is a technically demanding procedure. In contrast, the management of partial defects, particularly of the common upper pole deformity, can often be accomplished with a simpler technique. The conchal chondrocutaneous transposition flap is a reliable and elegant solution for these cases, providing consistent and esthetically pleasing results with the less surgical complexity (Figure 24) [45, 46].
Figure 24.
Illustration of the conchal chondrocutaneous flap correcting defects in two different positions of the upper pole of the ear.
6.6 Mouth
The most common post-burn deformity of the mouth is microstomia, which may be unilateral or bilateral. Its correction is effectively achieved through local tissue rearrangement, typically utilizing Z-plasty or double-opposing Z-plasty. To counteract the significant tendency for recurrence, a planned overcorrection is a critical component of the procedure, aiming to restore the oral commissure to its normal anatomical position in line with the pupil. Another frequent alteration is frequently termed a “ventriloquist’s smile,” a linear scar along the nasolabial fold, which is amenable to release with a sequential Z-plasty. In cases of lower lip ectropion (eclabium), the definitive treatment is contracture release followed by skin grafting (Figures 25–27) [47, 48].
Figure 25.
Microstomia corrected with local flaps.
Figure 26.
Ventriloquist’s smile corrected with Z-Plasty sequence.
Figure 27.
Lower lip ectropion treated with skin graft.
6.7 Nose
The nose is an anatomically complex structure, and the most common post-burn sequela is retraction of the nasal ala. For this type of defect, reconstruction with a random pattern nasolabial flap can yield the excellent results. If the skin in the donor area is also scarred or of compromised quality, a surgical delay procedure can be performed on the flap prior to transfer. This technique enhances the flap’s vascularity and mitigates the risk of necrosis, particularly at the distal tip. For total nasal reconstruction, the paramedian forehead flap is the treatment of choice (Figure 28) [49, 50, 51].
Figure 28.
Nasal alar reconstruction with random autonomized nasolabial flap.
Burn sequelae represent a significant clinical challenge due to their heterogeneity and widespread anatomical impact. Effective management requires not only extensive surgical expertise and versatile techniques but also a long-term, collaborative approach involving both clinician and patient to restore form and function. While surgical reconstruction is a cornerstone of treatment, non-surgical therapies represent a powerful and rapidly evolving frontier. Continued innovation in this area is expected, making it essential for practitioners to remain current with these advancements and to incorporate them as integral options in patient counselling and treatment planning at every phase of reconstruction.
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Written By
Luiz Philipe Molina Vana and Jun Wu
Reviewed: 14 November 2025Published: 15 December 2025
Open access peer-reviewed chapter
