PERMANENT (MEDICAL) IMMOBILIZATION WITH DENTAL TIRES WHEN FACIAL BONES OF  THE SKULL DAMAGED:  REQUIREMENTS, TYPES, ADVANTAGES AND DISADVANTAGES. OSTEOSYNTHESIS, DEVICE METHODS OF  FIXATION OF  THE FACIAL SKULL BONES FRAGMENTS.

THERMAL INJURIES OF THE FACE IN PEACETIME, UNDER EXTREME CONDITIONS. DIAGNOSTIC CRITERIA FOR BURN INJURIES. DETERMINATION OF THE AREA AND DEPTH OF BURN. FORMULATION OF THE DIAGNOSIS OF BURN DISEASE.

CLINICAL MANIFESTATIONS OF BURN DISEASE. STAGE OF BURN SHOCK, ACUTE TOXEMIA AND SEPTYKOTOKSEMIYA.

Jaw wiring

Jaw wiring (also known as maxillomandibular fixation) is a surgical procedurewhere metal pins and wires are anchored into the jaw bones and surrounding tissues to keep an injured jaw from moving.

Jaw wiring keeps the bones aligned and stable while the jaw heals. Wiring thejaw may also be used if it’s necessary to remove or reconstruct the jaw as aresult of cancer or disease. Wiring the jaws shut also has been used in thepast as a weight loss aid in cases of extreme obesity where other treatmentshad failed, although this procedure is rarely used for that purpose today.

Jaw wiring surgery can be performed by an oral surgeon or specially trained dentist called a maxillofacial surgeon, or by a doctor specializing in surgeries of the head and neck (otolaryngologist). The procedure may be done in a medical or dental office if the office is staffed and equipped to handle this type of surgery. More often, this surgery is performed in a hospital or medical center surgical area.

Depending on the extent of the facial injury or condition to be corrected, the patient may receive a sedative for relaxation, a local anesthetic drug to numb the area, or general anesthesia before surgery.

During surgery, the surgeon realigns the fractured bones. Every effort is made to restore the shape and appearance of the original jaw line. If any teethwere damaged, repair or replacement may be done at the same time. Small incisions may be made through the skin and surrounding tissue so the pins and wires can be set into the jawbone to hold the fracture together. To prevent the lower jaw from moving during healing, pins and wires may be inserted into thetop jaw, as well. The upper and lower jaws are then wired together in order to stabilize the fracture.

As with other types of bone fractures, the jaw may take several weeks to heal. Another type of jaw immobilization that has been developed more recently iscalled rigid fixation. This method uses small metal plates and screws ratherthan pins and wires to secure the jaw bones. The main benefit of this technique is that the jaws don’t have to be wired shut, allowing the patient to more quickly return to a normal lifestyle.

A patient whose jaw has been wired will not be able to eat solid foods for several weeks, but good nutrition is vital for the bone and surrounding tissuesto heal. A liquid diet that can be consumed through a straw will be required. Soft, precooked foods can be liquefied in a blender, but liquid diet formulas may be a good alternative. The patient will also have to be taught how tocare for the mouth, teeth, and injured area while the wires are in place.

There may be some scars from the small incisions used to insert the wires. With any surgical procedure, there are risks associated with the anesthetic drugs and the possibility of infection. If there is a risk that the patient mayvomit, the jaw wiring may pose a choking hazard. It may be recommended that wire cutters be kept available in case the wires need to be cut in an emergency situation.

Jaw, Collarbone, and Shoulder Fractures

a. Apply a cravat to immobilize a fractured jaw as illustrated in Figure 4-23. Direct all bandaging support to the top of the casualty’s head, not to the back of his neck. If incorrectly placed, the bandage will pull the casualty’s jaw back and interfere with his breathing.

Casualties with lower jaw (mandible) fractures cannot be laid flat on their backs
because facial muscles will relax and may cause an airway obstruction.

1.     Principles

Aftercare following ORIF of mandibular symphysis, body, angle and ramus fractures

If arch bars or MMF screws are used intraoperatively, they are usually removed at the conclusion of surgery if proper fracture reduction and fixation have been achieved. Arch bars may be maintained postoperatively if functional therapy is required or if required as part of the fixation.

Postoperative x-rays are taken within the first days after surgery. In an uneventful course, follow-up x-rays are taken after 4–6 weeks.

The patient is examined approximately 1 week postoperatively and periodically thereafter to assess the stability of the occlusion and to check for infection of the surgical wound. During each visit, the surgeon must evaluate the patients ability to perform adequate oral hygiene and wound care, and provide additional instructions if necessary.

Adequate dental care is required in most patients having suffered a mandibular fracture.

If a malocclusion is detected, the surgeon must ascertain its etiology (with appropriate imaging technique). If the malocclusion is secondary to surgical edema or muscle splinting, training elastics may be beneficial. The lightest elastics as possible are used for guidance, because active motion of the mandible is desirable. Patients should be shown how to place and remove the elastics using a hand mirror.

If the malocclusion is secondary to a bony problem due to inadequate reduction or hardware failure or displacement, elastic training will be of no benefit. The patient must return to the operating room for revision surgery.

Follow-up appointments are at the discretion of the surgeon, and depend on the stability of the occlusion on the first visit. If a malocclusion is noted and treatable with training elastics, weekly appointments are recommended.

Postoperatively, patients will have to follow three basic instructions:

1. Diet
Depending upon the stability of the internal fixation, the diet can vary between liquid and semi-liquid to “as tolerated”, at the discretion of the surgeon. Any elastics are removed during eating.

2. Oral hygiene
Patients having only extraoral approaches are not compromised in their routine oral hygiene measures and should continue with their daily schedule.
Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch-bars and any elastics makes this a more difficult procedure thaormal. A soft toothbrush (dipping in warm water makes it softer) should be used to clean the surfaces of the teeth and arch-bars. Any elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris. A Waterpik® is a very useful tool to help remove debris from the wires. If a Waterpik is used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence.

3. Physiotherapy
Physiotherapy can be prescribed at the first visit and opening and excursive exercises begun as soon as possible. Goals should be set, and, typically, 40 mm of maximum interincisal jaw opening should be attained by 4 weeks postoperatively. If the patient cannot fully open his mouth, additional passive physical therapy may be required such as Therabite or tongue-blade training.

 

1.     Principles

Ideal line of osteosynthesis

The ideal line of osteosynthesis in the body region runs at the vertical height of the tooth apices from the canine region to the oblique line. This carries into the oblique ridge which turns into the anterior outer rim of the ramus.

This line is located directly underneath the mucogingival sulcus that can be exposed with ease. The bone thickness of the lateral cortex varies between 6 and 8 mm approximately. To avoid injury of the tooth roots, monocortical screws less than 6 mm long should be used for plate fixation along this section of the ideal osteosynthesis line.

This single plate fixation method is contraindicated in the anterior mandibular body because of the existing rotational forces in that area that have to be neutralized. Two miniplates should be applied to neutralize those forces.

In the posterior transition to the angle and ramus, a second plate just below the oblique ridge may be advantageous in case of reduced bone stock (eg, an impacted wisdom tooth) or significant fracture displacement.

Special considerations

Following special considerations may need to be taken into account:

• Multiple fractures

• Edentulous atrophic fractures

• Teeth in the line of fractures

• Involvement of alveolar area

• Infected fracture with or without bone loss

• Complications

2.     Reduction

MMF

In the isolated mandible body fracture, preferably, an arch bar is applied for MMF. The arch bar provides additional stability by tension banding. This equates to a second line of resistance in particular with biting load anterior to the fracture line. The arch bar should include at least all teeth in the affected quadrant of the jaw. It is not necessary to encompass the whole dental arch.

MMF bone screws provide temporary fixation only during surgery and do not contribute postoperatively to stabilization.

Manual reduction

Reduction is done manually. Since the indication for single miniplate fixation is limited only to minimally displaced fractures, there will be no major discrepancies to be overcome.

The maintenance of the reduction with a conventional clamp becomes more difficult the further posterior the fracture is located. The clamps can be applied into tiny predrilled holes in the outer cortex that do not interfere with later plate placement.

In the midbody and posterior body, the reduction can alternatively be held by the intermaxillary ligatures, or manually by the assistant using an instrument, eg, a periosteal elevator.

3. Fixation

Choice of implant

A variety of implants can be used. In the original Champy version a 4-hole miniplate without center space was used.

Today, the same type of plate is still applicable. The following alternatives provide similar or incrementally higher stability:

• 4- or 6-hole mandible plate 2.0 with or without center space

• 4- or 6-hole small profile locking plates 2.0

• 4- or 6-hole medium profile locking plates 2.0

The plate of greater strength is used for additional stability and safety.

Plate contouring

Contour the plate according to the surface anatomy adjacent to the fracture line on both sides using bending pliers. Longer adaptation plates should be bent starting at one end and successively proceeding towards the other end. Intermediate steps can be checked on the bony surface for correct seating.

Finally check the plate for precise fitting in-situ.

Drill first screw hole

Hold the plate with an appropriate instrument (eg, periosteal elevator or forceps).

Use a 1.5 mm drill bit with 6 mm stop to drill monocortically through the plate hole next to the fracture line in the anterior fragment.

The surgeon must be aware that a cortical plate may be very thin in this region and damage to the tooth roots is still possible even when using a 6 mm drill bit with stop.

Insert screw

Insert a 2.0 mm screw, 6 mm in length. Do not fully tighten it until the final reduction and plate position are confirmed.

Insert second screw

Insert a second screw in the hole next to the fracture line in the posterior fragment. The periosteal elevator is used now to keep the far end of the plate at the correct vertical level.

Tighten both screws.

The clamp can be removed afterwards.

Additional screw placement

Fill the remaining plate holes with screws in an orderly fashion continuing from the plate holes next to the fracture to the outer plate holes.

Confirmation of reduction

A splaying of the inferior border of the mandible can be ruled out by further soft-tissue exposure intraoperatively. In minimally displaced fractures this should not be necessary.

Prior to wound closure confirm adequate reduction along the exposed fracture line. The fracture alignment at the lower border can be palpated giving indication of major gapping.

Furthermore, a control of the fracture line in transverse plane is possible only indirectly by checking the occlusion and articulation. Prior to this, the MMF ligatures must be removed.

4. Case example

Temporary immobilization

Midbody fracture line at the level between the second premolar and the first molar. Ernst ligatures were applied for temporary immobilization of the lower jaw until surgical treatment.

Surgical approach

If arch bars are used, the incision is made more laterally in the vestibule.

However, in this case, since there is an open wound between the second premolar and the first molar, an alternative surgical approach is used. A mucogingival incision in the vestibular sulcus is chosen anteriorly to the wound. In the posterior vestibulum the gingiva of the molars is included in the mucoperiosteal flap after marginal incision.

The longitudinal exposure reaches from the lateral symphysis into the angle region. Two MMF screws are inserted into the maxillary alveolar ridge as anchor points for the wire ligatures. In this case no arch bars are used as they would interfere with surgical access and closure.

MMF screw application in lower jaw

The MMF screws in the lower jaw are applied after exposure of the bony surface.

Note the additional fixation of the fracture using an interdental wire loop.

Applying MMF

MMF is applied using MMF screws with wire loops bilaterally.

Choice of implant

A 6-hole medium profile locking plate 2.0 was selected in this case to provide additional stability. The plate exactly contoured to the bone surface is shown in place.

Drilling for the first screw

Drill for the first screw hole next to the fracture line in the anterior fragment using a drill bit with drill stop.

Insertion of first screw

Insert the first screw.

Insertion of second screw

After drilling, insert the second screw next to the fracture line posteriorly.

Screw insertion into the most posterior screw hole

The posterior end of the plate is accessible through lip retraction and does not necessitate an external incision.

Pearl: proper retraction of lips
Retractor tips parallel to instrumentation (not at angles) facilitate exposure with reduced retraction forces on the lips.

Additional screw insertion

Clinical photograph shows all screws inserted.

Checking the occlusion

After checking for correct occlusion, the MMF screws are removed and the wound is closed.

Completed osteosynthesis

X-rays show the …

… completed osteosynthesis.

5. Alternative case

Diagnosis/Indication

A nondisplaced vertically running midbody fracture in a fully dentate and compliant patient can be treated straightforwardly using arch bars and a single plate applied on the ideal line of osteosynthesis according to Champy.

Osteosynthesis

In this case, a 6-hole small profile locking plate 2.0 was used for stabilization.

Multiple fractures

1.    General consideration

The mandible is similar in shape to a hoop and therefore multiple fracture sites are common. They can be grouped into the broad categories listed below:

• Unilateral fractures (double or multiple unilateral)

• Bilateral fractures

• Fractures with contralateral condyle compromise

• Bilateral condyle fractures with symphysis/anterior body compromise

Whenever one fracture of the mandible is identified, the surgeon must always suspect that one or more additional fractures are present. Careful clinical and x-ray examination will assist in establishing the correct diagnosis.

2.    Unilateral fractures (double or multiple unilateral)

General considerations

This injury occurs when a large amount of force is applied to a specific area of the mandible.

Another example of a unilateral multiple fracture.

Treatment considerations

If the fractures are located unilaterally close to each other, the intermediate fragment is fixed with long spanning adaptation or more frequently reconstruction plates along the inferior border.

If the fracture lines are located further apart, the surgeon has additional options to treat the multiple fractures. One fracture is rigidly fixed while the other is commonly fixed with a less rigid osteosynthesis, eg, a single plate.

Fractures in the tooth-bearing area of the anterior mandible are generally treated first to establish the ideal occlusion. Fractures in the nontooth-bearing area (posterior body/angle/ramus/condyle) are usually treated secondarily.

Alternatively, the surgeon may choose to use rigid internal fixation at both fracture sites.

3.    Bilateral fractures

General considerations

It is very common that bilateral mandibular fractures are identified in clinical practice. The most common combination of fractures is an angle combined with a contralateral fracture through the body or symphysis.

Treatment considerations

Fractures in the tooth-bearing area of the anterior mandible are generally treated first to establish the ideal occlusion. Fractures in the nontooth-bearing area (posterior body/angle/ramus/condyle) are usually treated secondarily.

Most commonly, the angle fracture is treated with one miniplate fixation (Champy) and the contralateral fracture through the body/symphysis is treated with more rigid fixation.

Various fixation schemes are available for the fracture of the body/symphysis eg, two miniplates, a large, or extra-large profile locking plate 2.0, or a reconstruction plate.

The surgeon has the option of treating both fractures with rigid internal fixation.

Simple right angle fracture fixed with a miniplate in the external oblique line and simple left body fracture fixed by means of a large profile locking plate 2.0.

Simple right angle fracture fixed with a miniplate in the external oblique line and a left body fracture fixed by means of reconstruction plate 2.4.

4.    Fractures with contralateral condylar fractures

General considerations

This fracture is generally seen as a result of a direct blow to the ipsilateral mandibular body which fractures and also causes a mandibular condyle fracture on the contralateral side.

Treatment considerations

Fractures in the tooth-bearing area of the anterior mandible are generally treated first to establish the ideal occlusion. Fractures in the nontooth-bearing area (condyle) are usually treated secondarily.
Most commonly, the fracture through the body/symphysis is treated using stable fixation. This offers the choice of treating the condyle fracture closed or open.

One has the choice of various stable/rigid fixation schemes for the fracture of the body/symphysis. One can use two miniplates, a heavy locking plate 2.0, or a reconstruction plate.

If it is decided that the condylar fracture will be treated closed, postoperative arch bars and training elastics can be used. This will allow postoperative physical therapy to rehabilitate the condylar fracture.

5.    Bilateral condylar fractures with symphysis/anterior body fracture

General considerations

One of the most difficult fractures to manage is the bilateral condylar fracture with anterior body or symphyseal fracture.

Commonly, the condylar segments are displaced and the mandible is widened due to the “wishbone” effect of the three fractures together.

CT showing mandibular widening, resulting in a “U”-shaped mandible instead of the normal “V” shape.

Treatment considerations

Treatment of bilateral condyle and symphysis/anterior body fractures usually begins with the most anterior fracture component and ends with the most posterior one.

The reduction and stabilization of the anterior fracture is crucial for the restoration of the transverse dimension of the mandible. If the exact dimension is not restored, the transverse dimension of the subcondylar region could never be restored. Adequate reduction of the fracture in the lingual side before fixation is crucial. When the anterior osteosynthesis is performed with a strong plate, some overbending is required in order to close the lingual gap. Click here for a document also explaining the overbending procedure.

The fixation of the subcondylar fractures is usually performed secondarily. Alternatively, the condylar fractures could be treated closed.

Edentulous atrophic fractures

Diagnosis

General considerations

With increasing mandibular atrophy, the physical size of the mandible decreases. In the severely atrophic mandible, even very minor trauma can cause fracture. Additionally, pathologic fracture during mastication can occur. Very often, due to the fragile nature of the jaw, these fractures occur bilaterally.

Orthopantomogram (OPG), mandible series radiograph and CT scans can be used to diagnose and plan the treatment of the atrophic edentulous mandible fractures.

Clinical examination

The patient shows extraoral ecchymosis associated with an atrophic edentulous mandible fracture.

The patient exhibits pain and mobility of the anterior mandible.

Patient shows intraoral ecchymosis in the floor of the mouth associated with an atrophic edentulous mandible fracture.

Typical example of an atrophic edentulous mandible fracture.

Axial CT

scan showing bilateral fractures.
Note that although there appears to be a large bone stock, this patient’s mandible has only approximately 7 mm of vertical height.

Panoramic radiograph of atrophic edentulous mandible fractures.
Note the extreme amount of vertical atrophy.

3-D reconstruction of the same case.

2. Decision/Indication

Observation and soft diet

Observation may be indicated for patients medically unfit for general anesthesia. Atrophic edentulous mandible fracture patients are often elderly with medical problems presenting severe anesthetic risks.

One major complication of observation and soft diet would be nonunion of the mandibular fracture.

Closed reduction

Historically, atrophic edentulous fractures were treated closed by wiring in the patients dentures or fabricating Gunning style splints with postoperative mandibulomaxillary fixation (MMF).
Standard treatment with closed reduction often resulted in prolonged periods of MMF which was difficult for these patients. Additionally, the fractures were often poorly aligned. Postoperative malunions and nonunions were very common.
Photograph shows a patient denture.

Photograph shows a Gunning style splint.

ORIF

Indications for ORIF are any displaced atrophic mandible fracture requiring surgical intervention.

Following the AO principles of anatomic reduction of fractures and immediate function, ORIF of atrophic edentulous mandible fractures with load-bearing osteosynthesis has a distinct advantage for these patients. The technique has evolved to provide the patient with an excellent chance for mandibular union while the ability to masticate is preserved.

Literature has supported the efficacy of this technique.

External fixation

Indications of external fixator might be the temporary stabilization of a fracture while the patient is treated medically, or if soft-tissue maturation around the fracture site is required.

Complications,including malunion and nonunion are significant when external fixators are used as they do not provide absolute stability at the fracture site.

3. Treatment of an edentulous atrophic fracture with a reconstruction plate

In the following, the treatment of an edentulous atrophic fracture with a reconstruction plate is described step-by-step.

4. Approach

Extraoral appraoch

When treating atrophic edentulous mandible fractures, the surgeon will generally find it easier to use an extraoral surgical approach. The fracture fragments can be manipulated under direct visualization and stabilized while the reconstruction plate is being bent and applied to the mandible.

Intraoral approach

An intraoral approach is possible but technically more difficult as the surgeon will need several sets of trained hands just to retract the soft tissues of the cheeks and tongue. Additionally, stabilization and fixation of the fractures is much more difficult via an intraoral approach. One should also be aware that the inferior alveolar nerve is located on the superior surface of the atrophic mandible. Therefore one must be extremely careful making intraoral incisions to expose atrophic fractures, or the nerve can be damaged.

5. Principles

The atrophic edentulous mandible fracture presents with several factors which make treatment very difficult. There is a lack of bone which is generally cortical iature and has a lower healing potential. There are no teeth present to help reduce the fractures. Often the patients are elderly and medically compromised.

Atrophic mandible fractures require transfacial open reduction, load-bearing internal fixation, and often immediate bone grafting.

6. Choice of implant

General considerations

Load-bearing osteosynthesis is indicated in treatment of the atrophic edentulous mandible fracture. We currently recommend the locking reconstruction plate 2.4. The plate must be of sufficient length to place screws in adequate bone which is generally found in the symphysis and angle regions. The body region of the mandible is a common area of fracture and generally has bone of poorer quality unsuitable for screw placement. When dealing with bilateral fractures, the plate must span from angle to angle, covering the entire lateral surface of the mandible. At least three screws on either side of the fracture are recommended. Often more screws are necessary due to the poor quality of the bone.

The locking reconstruction plate is generally left in place and not removed unless clinical symptoms require hardware removal.

Pitfall: insufficiently stable implant

It may be tempting to use small plates when treating fractures in an atrophic “small” jaw. However, when using small plates, plate fracture and displacement is very common secondary to the muscle pull involved in the atrophic edentulous mandible.

X-ray shows fractured plate and fracture displacement.

Clinical photograph shows same case.

Alternatives to the locking reconstruction plate 2.4

There are fractures involving the edentulous jaws which are not atrophic iature. When there is sufficient bone to buttress the fracture and provide adequate healing, the surgeon may choose to use a smaller reconstruction plate.

The locking plate system 2.0 (large or extra-large profile) provides all the advantages of a locking reconstruction plate 2.4 but with a smaller profile. Many surgeons have successfully used the locking system 2.0 on edentulous fractures.

 

Plate design

The locking reconstruction plate combines all the advantages of a standard reconstruction plate with the locking principle.

The thread in the plate holes provides rigid anchorage for the 2.4 mm locking screw. This construction acts as an “internal fixator”. 3.0 mm screws are also available.
The conventional 2.4 mm nonlocking cortex screw can also be used with this plate. Wide angulation of the screw is possible which, in certain clinical situations, can be an advantage.

Other advantages of the locking principle are:

• The plate needs only limited adaptation

• It exerts no pressure on the bone

• The risk of screws loosening is reduced.

Click here for further details on the locking plate principles.

7. Plate bending

Templating

It is very common to use large reconstruction plates that span from angle to angle. By using a template the bending process is facilitated.

Bending

Clinical image shows the template and the reconstruction plate bent accordingly.

Pearl: reduction and temporary fixation

 

It can be very helpful to reduce and stabilize the fracture with adaptation plates to allow appropriate bending of the template and reconstruction plate. This is particularly applicable in fractures that are widely displaced, mobile, or unstable.

The adaptation plates are placed on the inferior border to allow excellent reconstruction plate adaption to the lateral surface of the mandible.

After the locking reconstruction plate has all planned screw holes used, the adaptation plates are removed.

Pearl: perfect adaptation

 

Perfect adaptation of the plate is not required as the locking reconstruction plate 2.4 acts as an “internal external fixator”.

8. Fixation

General considerations

The locking reconstruction plate 2.4 is fixed to the native mandible using either 2.4 mm or 3.0 mm screws. At least three screws must be present on either side of the fracture. In the atrophic edentulous mandible fracture, the screws are generally placed in the symphyseal region and the angular region. The bone in the symphysis is very often dense cortical bone which may require tapping of the screw hole.

Applying the plate

Apply the plate and stabilize it either with digital pressure or plate-holding forceps. One of the benefits of using a locking reconstruction plate is that perfect adaptation is not required and small discrepancies can be tolerated.

Placement of first screws

Place one screw on either side of fracture in the planned holes closest to the fracture.
A threaded drill guide must be used to allow for centric placement of the drill hole for use with the locking screw. Copious irrigation must be applied to cool the bone. A depth gauge is used to determine the appropriate screw length.

Additional screw placement

Once the screws are placed on either side of the fracture (on the first side) the surgeon has the option of completing all screws on that one side or placing one screw on either side of the fracture (on the opposite side) before completing all screws.

Clinical image shows the plate fixed to the mandible.

Harvesting of bone graft

Due to the poor healing quality of the bone, an autogenous bone graft is often used to facilitate bony union. Common sites of bone graft harvest include the iliac crest or tibia.

Clinical images show …

… the bone graft harvest site in the tibia.

Bone graft application

Autogenous cancellous bone grafts can be added to fracture sites and can be used to augment the native mandible to facilitate healing.

Completed osteosynthesis

X-ray shows the completed osteosynthesis.

9. Aftercare following treatment of an edentulous atrophic fracture with a reconstruction plate

If MMF screws are used intraoperatively in conjunction with the patient’s prostheses, they are usually removed at the conclusion of surgery if proper anatomic fracture reduction and fixation have been achieved.

Postoperative x-rays are taken within the first days after surgery. In an uneventful course, follow-up x-rays are taken after 4–6 weeks.

The patient is examined approximately 1 week postoperatively and periodically thereafter to assess the stability of the fracture and to check for infection of the surgical wound. During each visit, the surgeon must evaluate the patients ability to perform adequate oral hygiene and wound care, and provide additional instructions if necessary.

Follow-up appointments are at the discretion of the surgeon, and depend on the stability of the mandible on the first visit. Weekly appointments are recommended for the first 4 postoperative weeks.

Postoperatively, patients will have to follow three basic instructions:

1. Diet
Depending upon the stability of the internal fixation, the diet can vary between liquid and semi-liquid to “as tolerated”, at the discretion of the surgeon.

2. Oral hygiene
Patients having only extraoral approaches are not compromised in their routine oral hygiene measures and should continue with their daily schedule.
Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. A soft toothbrush (dipping in warm water makes it softer) should be used to clean the oral cavity. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris.

3. Physiotherapy
Physiotherapy can be prescribed at the first visit and opening and excursive exercises begun as soon as possible. Goals should be set, and, typically, 40 mm of maximum interincisal jaw opening should be attained by 4 weeks postoperatively. If the patient cannot fully open his mouth, additional passive physical therapy may be required such as Therabite or tongue-blade training.

Long-term dental rehabilitation
An existing dental prosthesis (denture) must often be remade. Dental implants may be placed in the anterior mandible after symphyseal screws have been removed. Implant reconstruction is undertaken when bony union of the mandible has been achieved.

Teeth in the line of fracture

1. General considerations

A common problem in managing mandibular fractures involves dealing with teeth in the line of fracture. Commonly, there are impacted wisdom teeth associated with mandibular angle fractures. However, any fracture involving the dentate areas of the jaw has the potential to involve erupted teeth in the fracture line.

The surgeon can either remove the offending tooth or leave it in place if it is thought not to compromise the result of fracture treatment.

Any fracture that involves the periodontal ligament space of an erupted tooth should be considered an open (contaminated) fracture, requiring administration of systemic antibiotics, at least until the fracture has been reduced and stabilized.

Because many fractures through the angle communicate with either the erupted third or second molars, most angle fractures are open. If the fracture extends only into the area of an unerupted third molar, and there is no break in the surface mucosa, such fractures are considered closed.

Closed fractures may not require the use of antibiotics prior to surgery but may be treated with prophylactic antibiotics in the perioperative period.

2. Indications

Indications for removal of teeth in the line of fracture

1.     Tooth luxated from its socket and/or interfering with reduction of the fracture.

2.     Tooth that is fractured (as illustrated).

3.     Tooth with advanced dental caries carrying a significant risk of abscess during treatment.

4.     Tooth with advanced periodontal disease with mobility which would not contribute to establishment of stable occlusion.

5.     Tooth with existing pathology such as cyst formation or pericoronitis.

Indications to leave teeth in the line of fracture

1.     Tooth that does not interfere with reduction and fixation of fracture.

2.     If tooth removal requires removal of excessive amount of bone so as to compromise the fracture site an possible plate/screw fixation.

3.     Tooth that is in good condition and assists in establishing occlusion and reducing the fracture.

3. Postoperative considerations

When an infection arises during the postoperative period, carefully evaluate teeth in the line of fracture as potential sources of the infection.

Involvement of alveolar area

1. Diagnosis

Routine diagnosis of alveolar fractures should include an OPG. Periapical and occlusal dental x-rays can be beneficial.

OPG showing a right body mandibular fracture with an associated alveolar component.

CT or digital volume tomography (DVT) imaging may be useful to delineate the fracture exactly.

The fragment of the alveolar process reaching from the canine to the first molar is clearly visible.

The oblique course of the fracture line across the inferior border is revealed.

In this representative slice from the sagittal series the fractured alveolar fragment is displayed.

2. Treatment options

Alveolar process fractures can usually be treated by reduction and fixation with an arch bar that must be maintained for approximately 6 weeks to provide time for the fracture to heal.

As an alternative, open reduction and internal fixation may be used in selected isolated alveolar fractures and mostly in those associated with more severe mandibular fractures. Sufficient size of the teeth-bearing bone fragments is required in order to position the miniplates and screws without damaging the dental roots.

Tooth luxations and fractures are commonly associated. The teeth in the fracture lines should be carefully assessed clinically and radiographically to determine the need of extraction. Click here for further information on treating teeth in the line of fracture.

3. Case example

In this case, it was possible to include the alveolar fragment using a miniplate plate fixed with monocortically inserted screws located adjacent to the tooth apices. The mandibular fracture was treated with a large profile locking plate 2.0 to give enough stability along the inferior mandibular border.

Infected fractures with or without bone loss

1. Diagnosis

Definition

Open fractures can generally be regarded as contaminated. Since fractures in the dentate area have communication with the oral cavity, these are considered open fractures.
Infections with clinical relevance show swelling, pain, fever, reddening, and secretion of pus. In the case of acute infection radiographic signs can be absent. Chronic cases exhibit the typical signs of osteomyelitis.

Special conditions influencing adequate internal fixation
Instability produces and maintains the infectious process.

Osteosynthesis of an acutely infected fracture or pseudarthrosis must be a safe procedure. Under these conditions, high rigidity (absolute immobility) is mandatory. Therefore the locking reconstruction system 2.4 is recommended. It is important not to place any screws into the infected bone area which must be spared from screw insertion. The reconstruction plate functions as a bridging device. Large areas of infected or necrotic bone require curettage and either immediate or delayed cancellous bone grafting. Antibiotic therapy alone does not eliminate the infection as long as the fracture is unstable.

Clinical findings
Fractures in the dentate area are regarded as open fractures because the gingiva is usually lacerated. These fractures are contaminated. An acute infection is not reflected in the x-ray examination. In chronic cases the bone becomes infected exhibiting the typical clinical and radiographic signs of osteomyelitis.

In addition there will be inflammatory signs such as swelling, pain, fever, reddening, and secretion of pus.

Clinical photograph showing an infected fracture between the first and second molar. The pericoronal gingiva of the second molar contains pus and the swelling fills the vestibular sulcus.

Imaging

OPG confirming the clinical diagnosis of an infected fracture site in the posterior mandibular body with radiolucency around the second molar and an extended fracture zone containing several bone sequestra.

PA view of the same case.

CT scans of the same patient detailing the condition of the fracture zone.

Additional considerations

Patients with infected fractures often present a constellation of problems:

• Noncompliance

• Alcohol addiction

• Drug abuse

• Self-neglect and social deprivation

• Imprisonment

• Dementia

Medical risk factors:

• Chronic corticoid medication

• Immune deficiency

• Diabetes mellitus

• Osteopathy

2. Principles

Formal pathogenesis

A predilection zone for infected fractures is the posterior mandibular body or the angle region. Contributing factors in this area are due to the occurrence of impacted or partially impacted wisdom teeth. The chronic infection leads to osteomyelitis with inflammatory resorption and sequestration of the bone in the proximity of the fracture line.

The current concept is that the infection and osteomyelitis are propagated by the instability and mobility of the fracture fragments.

When dealing with osteomyelitis, the infected fracture will be debrided and leave the patient with a defect fracture situation.

If the bony defect extends throughout the entire fracture, grafting will be necessary.

Choice of implant

Since the rigidity of large plates is defined by the number and diameter of the inserted screws, it is recommended to use reconstruction plates compatible with large diameter screws only, ie, 2.4 or 3.0 mm screws.

The span of the plate has to cover such a length that at least three screws on either side of the defect can be inserted into intact bone. Very often, with large span defects, it is advisable to have four or more screws on either side of the defect.

3. Sequestrectomy and debridement

Clearing of the infected area

After wide exposure of the outer bony surface the infected area must be cleared of any granulation tissue.
The extent of the exposure must anticipate the application of a large reconstruction plate allowing for the placement of at least three screws on either side away from the defect.

Sequestrectomy

Remove the dead bone (sequestra) and decorticate the bony surfaces of the fractured ends.

Smoothing bony edges

Sharp bony edges should be burred away. The remaining bone surfaces should have bleeding patches to make sure that the vascularization is maintained.
This will define the size of the eventual defect.

The mandibular nerve should be preserved, if not irreversibly damaged by the chronic infectious process.

Tooth and sequestra removed.

4. Load-bearing osteosynthesis

MMF and preliminary fragment fixation

The tooth bearing distal part of the fracture is secured via MMF. The condyle bearing part is positioned arbitrarily by pushing the condyle into the fossa and a small (adaptation) plate is applied onto the superior border of the defect in order to maintain the position of the fragments while the reconstruction plate is adapted and secured.

Contouring the plate

The load-bearing bridging plate is contoured to the lower border with the help of a malleable template.

The contour of the plate must match the template in all three dimensions.

Plate fixation

The bridging plate is firmly applied to the bone with plate forceps and the screws are inserted in the usual manner, starting with the screws closest to the defect zone.

Option: remove adaptation plate
After all screws are inserted, optionally, remove the adaptation plate at the superior border of the mandible.

Occlusion check

Load-bearing osteosynthesis is stable and cannot be influenced postoperatively using elastic tractions. Therefore, the occlusion must be checked after applying the plate. If it does not fit it must be decided whether the occlusion can be corrected by minimally grinding the teeth or repositioning of the bone and plate. The revision of the osteosynthesis may be difficult because of reduced quality of the bone and reduced bony buttressing.

Removal of arch bars
Usually, this type of fracture occurs in compromised or noncompliant patients. Therefore, one might consider removal of all MMF appliances prior to intraoral wound closure (at the tooth extraction site). This can facilitate oral hygiene.

5. Intraoral plastic soft-tissue coverage

 

The intraoral mucoperiosteum is closed using the envelope technique with a flap derived from the lateral vestibule.
This is done prior to any bone grafting in order to separate the defect from the oral cavity.

6. Same stage bone grafting

Bone harvesting

If immediate bone grafting is desired, bone is harvested from the anterior iliac crest or the tibial head according to preference and the amount of bone graft needed.

In this case a corticocancellous piece and cancellous chips were taken from the inner table of the iliac crest.

The corticocancellous piece was shaped approximately to the size of the defect. Holes were drilled to increase the bony surface in order to enhance revascularization.

Cancellous chips were harvested to augment and fill in the defect.

Applying the bone graft

All bone grafts are inserted through the external approach.
The shape of the corticocancellous bone graft is checked and introduced into the defect.

The remaining dead space is filled with cancellous chips which are further used to augment the area.

7. Extraoral wound closure

The use of suction drain is at the discretion of the surgeon. The external wound is closed in layers.

8. Completed osteosynthesis

Panoramic x-ray showing the plate osteosynthesis bridging the defect zone in the left posterior mandibular body.

Note: there are three screws on each side of the defect and these are placed away from the fracture. The defect zone appears opaque because of the bone graft.

A nasogastric tube is used to feed the patient to enhance intraoral hygiene.

9. Aftercare

If arch bars or MMF screws are used, they may be removed at the conclusion of surgery or may be maintained for several weeks at the discretion of the surgeon.
Postoperative x-rays are taken within the first days after surgery. In an uneventful course, follow-up x-rays are taken at the 4–6 week interval.
It will be necessary to see the patient after approximately 1 week to assess the stability of the occlusion. In an infected mandibular fracture, the aftercare has to include the observation of a number of factors including the special wound situation, the general health condition (nutritional status, diabetes, and particular medication), psychosocial status, economical situation and specific local regimens. The surgeon must also evaluate patient response to the current antibiotic regimens and check for systemic parameters (for example, CRP, white cell blood count, erythrocyte sedimentation rate). Patients will have to be re-examined periodically to rule out recurring signs of infection. At each visit, the surgeon must evaluate patient ability to perform adequate oral hygiene and wound care. It may be necessary to provide additional instruction to assure appropriate hygiene and wound care.

If a malocclusion is detected, the surgeon must ascertain the etiology of it (using the appropriate imaging technique). If the malocclusion is secondary to surgical edema or muscle splinting, training elastics may be beneficial. The lightest elastics possible are used for guidance, because active motion of the mandible is desirable. Patients should be shown how to place and remove the elastics using a hand mirror.

If the malocclusion is secondary to a bony problem due to inadequate reduction or hardware failure or displacement, elastic training will be of no benefit. The patient must return to the operating room for revision surgery.
Follow-up appointments are at the discretion of the surgeon, and will also depend on the stability of the occlusiooted on the first visit. If a malocclusion is noted and treatable by using training elastics, at weekly appointments to determine the progression are recommended.

Postoperatively, patients will have to follow three basic instructions:

1. Diet
Depending upon the stability of the internal fixation, the diet can vary between liquid and semi-liquid to “as tolerated”, at the discretion of the surgeon. Any elastics are removed during eating.

2. Oral hygiene
Patients having only extraoral approaches are not compromised in their routine oral hygiene measures and should continue with their daily schedule.
Patients with intraoral wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch-bars and any elastics makes this a more difficult procedure thaormal. A soft toothbrush (dipping in warm water makes it softer) should be used to clean the surfaces of the teeth and arch-bars. Any elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least three times each day to help sanitize the mouth. For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris. A Waterpik® is a very useful tool to help remove debris from the wires. If a Waterpik is used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence.

3. Physiotherapy
Physiotherapy can be prescribed at the first visit and opening and excursive exercises begun as soon as possible. Goals should be set, and, typically, 40 mm of maximum interincisal jaw opening should be attained by 4 weeks postoperatively. If the patient cannot fully open his mouth, additional passive physical therapy may be required such as Therabite or tongue-blade training.

Complications

1. General considerations

The mandible is the only facial bone that is movable. The results of mandibular fracture treatments are easily measurable. Unfortunately, there is a relatively high complication rate when dealing with mandible fractures.

2. Nonunion

General considerations

A nonunion occurs when the mandible does not heal in an appropriate time frame. The result is mobility of the fracture segments present after an adequate healing phase. Patients may also demonstrate malocclusion and infection at the site of fracture.

Note: no bony union is visible in fracture gap.

Clinical photograph reveals lack of bone at the fracture site.

Etiology

Nonunions are usually the result of one or more of the following factors:

• Fracture instability (mobility)

• Infection

• Inaccurate reduction

• No contact between fragments

Treatment

Treatment will consist of:

• Identifying the cause

• Controlling infection

• Surgical reconstruction: removing the existing hardware, debridement of devital bone and/or soft tissues, decortication of bone fragments at the fracture ends, reestablishing occlusion, stabilizing segments using a locking reconstruction plate 2.4, and autogenous bone graft to this area.

Case example

Panoramic x-ray 6 weeks after treatment of left angle fracture with single miniplate. The fracture is grossly mobile, infected, and the plate has become loose.

The fracture was debrided, the plate removed, the infection drained, and the patient placed on antibiotics to control infection.

Once infection has subsided, the patient was taken to surgery and the fracture exposed through a submandibular approach. The fibrous tissue between the fragments was debrided and the fragments decorticated.

Postoperative panoramic and …

… PA x-rays showing relationship of bone fragments and internal fixation hardware.

The occlusion was reestablished with MMF and a miniplate placed along the superior border to maintain the position of the proximal segment after pushing it posteriorly and superiorly to see the condyle. A reconstruction plate was then adapted and secured to provide load-bearing fixation across the fracture gap. Once the occlusion was verified by releasing MMF, the miniplate was removed.

Particulate autogenous bone was placed into the fracture gap and the incision closed in layers.

Photograph taken 10 months later showing reestablishment of normal occlusal relationship.

Panoramic x-ray taken 10 months postoperatively showing bone filling fracture gap.

3. Malunion/malocclusion

Etiology

Malunions occur for at least one of several reasons:

• Inadequate occlusal reduction during surgery

• Inadequate osseous reduction during surgery

• No osseous reduction (eg, condyle fractures)

• Imprecise application of internal fixation devices

• Inadequate stability (lack of rigidity)

Treatment

The treatment of a malunion must involve:

• Identification of the cause

• Orthodontic/orthopedic treatment if possible

• Osteotomies as necessary (re-fracture, standard osteotomies, combinations)

Case example

Frontal photograph of a patient who sustained right angle and left symphysis fractures but was never treated. Note a deviation of his chin to the left.

Intraoral photograph showing significant malocclusion resulting from malunion of fractures.

Panoramic x-ray showing malunion of right angle and left parasymphyseal fractures.

Photograph of dental models mounted on an articulator.

Photographs …

… of obtainable occlusion.

Interocclusal splint fabricated to be used during surgery to help position occlusal segments.

Intraoperative photograph showing malunion of right angle fracture.

Intraoperative photograph showing malunion of left parasymphyseal fracture.

Intraoperative photograph taken after right angle osteotomy and fixation with two miniplates.

Intraoperative photograph taken after left parasymphyseal osteotomy and fixation with a reconstruction plate.

Postoperative panoramic x-ray shows osteotomies and fixation devices.

Postoperative photograph showing that the facial asymmetry has been eliminated.

Postoperative occlusion showing elimination of the malocclusion.

4. Infection

Diagnosis

Infected fractures will usually demonstrate one or more of the following signs/symptoms:

• Swelling

• Erythema

• Rrismus

• Pain

• Purulent discharge

Etiology

Infection occurring in fractures usually results from one or more of the following:

• Microorganisms

• Fracture instability

• Devital tissues (teeth, bone, etc)

Treatment

The treatment of infected fractures involves:

• Incision and drainage of abscesses,

• Irrigations of the wounds as necessary

• Systemic antibiotics

• Removal of devital teeth/bone

• Removal of any loose internal fixation devices

• Re-stabilization of fracture

Case example

ORIF of posterior body and condyle fractures of the right mandible.

Note the consolidation at the body fracture and signs of bone resorption at the condylar fracture site.

Obvious infection of surgical site with wound dehiscence and purulent drainage.

The patient was taken to surgery and the internal fixation devices were removed along with loose bony fragments. The right mandibular condyle was found to be avascular and was therefore removed.

Panoramic x-ray showing removal of right mandibular condyle and mandibular body plates to treat infection of this surgical site. Good consolidation of the right mandibular body is evident.

The infection subsequently subsided and the soft tissues healed.

Patient will require secondary reconstruction of right mandibular condyle.

5. Ankylosis

Ankylosis is a process where the mandibular condyle fuses to the glenoid fossa. This generally occurs after prolonged immobilization (MMF) of a condylar fracture.

Patient demonstrating their maximum interincisal opening after treatment of multiple mandibular fractures and prolonged period of MMF.

Panoramic x-ray showing bilateral condyle fractures and a symphyseal fracture.

Note: lack of joint space in bilateral TMJ region.

CT scan showing bilateral TMJ ankylosis with bony fusion of mandibular condyle to the glenoid fossa on the left side.

The only option to remedy ankylosis in this case is additional surgery in the form of a gap arthroplasty or total alloplastic joint replacement.

6. Fixation failure

General consideration

Fixation failure results in fracture mobility that can subsequently lead to infection, nonunion and/or malunion.

Fixation fails by a number of mechanisms which include:

• Insufficient amount of fixation

• Fracture of the plate

• Loosening of the screws

• Devitalization of bone around screws

Insufficient amount of fixation

Left mandibular angle fracture was treated using a malleable miniplate 2.0 at the inferior border of the mandible. This is insufficient fixation for this fracture.

Illustration demonstrating biomechanics of an angle fracture. A small plate applied at the inferior border provides insufficient stability in such a fracture. It cannot prevent a gap from opening at the superior surface of the mandible under function.

The patient developed infection of left angle fracture site 2 weeks later. They were taken back to the operation room and stable fixation was applied. Subsequently, the fracture healed.

Fracture of the plate

X-ray shows a superior border miniplate.

It is obvious, that this clinical situation (edentulous mandible at fracture site, impacted third molar) is biomechanically demanding and not suitable for one miniplate osteosynthesis.

X-ray shows plate fractured. Segments were mobile which required treatment consisting of ORIF with locking reconstruction plate 2.4.

Loosening of screws

Four weeks after two miniplate fixation of a right angle fracture, the patient presents with a draining sinus tract through the skin.

X-ray shows at least one loose screw and loss of fixation.

The patient was taken back to surgery where a reconstruction plate was applied.

Devitalization of bone around screws

6 weeks after treatment of right angle fracture and left body fracture with two compression plates, the patient presents with swelling. Panoramic x-ray shows loose hardware in the right side.

The fracture was opened and the hardware was found to be still attached to portions of the buccal cortex which had become devitalized and sequestered.

Fortunately, the lingual cortex had healed and the occlusion was normal. Thus, no further treatment was necessary.

 

 

 

 

 

 

 

Maxillofacial burn is a frequent anatomic site to incur thermal injuries, and the treatment modalities are ones that oral and maxillofacial surgeons use routinely with other surgical procedures. This article reviews the pathophysiology, current therapy of management and role of oral and maxillofacial surgeon in burn management of maxillofacial burn.

Introduction

Burns can be thermal, radiation, chemical, or electrical. The most common causes are child play fires, scalding water, curlers, ovens/ranges, microwaves, fire works, electric outlets, and various chemicals. Legislation, health promotion and appliance design have reduced the incidence of burns, with regulations regarding flame retardant clothes and furniture, the promotion of smoke alarms, the design of cookers and gas fires, the almost universal use of cordlers kettles, and the education of parents to keep their hot water thermostat to 60°C all playing their part.¹ The management of the major burn injury represents a significant challenge to every member at the burn team burn doctors, anesthetists, oral and maxillofacial surgeons, ward and theatre nurses, physiotherapists occupational therapists, dietitians, bacteriologists physicians, psychiatrists, psychologists and the many ancillary staff whose cleaning and supply services are vital to the successful running of burns unit.²

Advertisement

The patho-physiology of burns

Burns cause damage iumber of different way, but before the most common organ affected the skin. It occurs when these structures absorb more heat than their capacity to dissipate. Children and the elderly, by virtue of their thinner skin, sustain more severe burns at lower temperatures and in less time than a young adult. Exposure for just 3 seconds to water at 140°F can result in full thickness or third degree burn. At temperatures between 44°C and 51°C, the rate of cellular destruction doubles with each degree of increase in temperature.³

Degree of Burn⁴:

1.  First degree burn: It can be caused by sun burn, scaled or flash flame. The appearance is dry and without blisters with a pink color that is usually painful. Healing occurs over 5 to 10 days with pealing when hair follicle and sweat glands are not destroyed. Usually, no permanent scar occurs but the tissue may discolor.

2.  Second degree burn : It can be caused by contact with hot liquids or solids, flash flame, or chemicals. The appearance is hypermic, but may be pale, moist with blisters, and is painful. A superficial partial thickness burn heals in 10 to 14 days and no grafting is needed. The skin is thin, hairless, and very delicate. A deeper partial thickness burns may take more than 30 days to heal and can convert to full thickness injury or the deeper partial thickness burn usually results in hypertrophic scarring.

3.  Third degree burn: It can be caused by contact with hot liquids/solids, flames, chemicals or electricity. The surface is dry and leathery until removed and charred blood vessels are visible under the skin. The deeper wound may appear while waxy, pearly, dark khaki, mahogany, or charred. The patient may have no cutaneous pain. These wounds will need grafting and take months to heal.

Overall, burn severity is a measurement of the depth of burning and the size of the burn. Measuring the size of a burn is difficult because every person is different in size, shape and weight. It’s impossible to simply choose what universal size of burn is significant. A square foot of burned surface area is much worse to a person who weighs 130 pounds than it is to someone who weighs 200 pounds.

To account for inequities in size and shape, burned surface area is calculated as a percentage of total body area. Of course, we don’t actually know how many square inches of skin covers any single person, but we do know about how much of our skin it takes to cover our arms and legs, for example.

The Rule of Nines

To approximate the percentage of burned surface area, the body has been divided into eleven sections:

·                     Head

·                     Right arm

·                     Left arm

·                     Chest

·                     Abdomen

·                     Upper back

·                     Lower back

·                     Right thigh

·                     Left thigh

·                     Right leg (below the knee)

·                     Left leg (below the knee)

Each of these sections takes about nine percent of the body’s skin to cover it. Added all together, these sections account for 99 percent. The genitals make up the last one percent.

To apply the rule of nines, add up all the areas of the body that are burned deep enough to cause blisters or worse (2^nd or 3^rd degree burns). For example, the entire left arm and the chest covered in blisters would be 18 percent. Partial areas are approximated. For example, the face is only the front half of the head and would be considered 4.5 percent.

Since kids are shaped so much different than adults, there are adjustments made to the rule of nines, which of course ruins the point of making this tool the rule of nines. So many variations exist that it would be fruitless to go into them here.

The most important thing to remember about the rule of nines is that it is intended to be used in the field to quickly determine if victims need to go to a specialty burn center. Once the victim is in a burn center, more advanced techniques will be used to determine the exact burned surface area.

There are several factors used to determine if a burn is critical enough to necessitate a specialty burn center. Any burn that matches these criteria warrants a call to 911. In many areas, ground ambulances or helicopters are able to take burn victims directly from the scene to a burn unit.

Burns that cover more than 10 percent of the body’s surface area are generally considered to be critical in most locations, but be sure to follow your local protocols. To determine the total burned surface area in the field, use the Rule of Nines. Remember to only count second-degree burns or worse. First-degree burns do not need specialty treatment.

Specific Critical Burns

Most burns are determined to be critical by the depth and the size of the burn. However, burns on important parts of the body are critical regardless of the overall size of the burn itself. Burns still must be second-degree or worse to be considered critical. First-degree burns are not counted.

Burns to these areas are considered critical:

·                     Face

·                     Burns that completely encircle the hands or feet

·                     Genitals

Treatment of Critical Burns

Treating burns is the same regardless of how critical they are. Complications of critical burns include infection, hypothermia, and dehydration. The most important step a lay rescuer can take for a critical burn is to call 911.

 

 

Effect of burn on maxillofacial anatomy

Eye

Anatomic sites need to be addressed as part of the whole injury, but also individually. With eye injuries, early closure and/or grafting must be considered. The eyelid skin is thinnest on the face, and early contracture can lead to exposure keratitis and rapidly destroy vision. An ophthalmology consult should be obtained because corneal abrasion is the most common injury. Protection of cornea with ointment or early tarsorrhaphies may be initially indicated. Ectropion may develop if secondary healing occurs with scarring or if tension occurs with primary closure. A graft of sufficient thickness should be used to help prevent lid contractures and globe exposure⁵. Multiple surgical reconstructions may be anticipated until adequate function is achieved.

Mouth: Injuries around the mouth can be cause considerable deformities. Microstomia can be limited with the use of internal or external mouth spreaders upper and lower lip grafts can be placed to reconstruct the vermilion. Mucosal advancement flaps can also be used. Secondary reconstruction may be necessary, including scar releasing procedures.

Nasal: The skin is often preserved over the lower portion where the skin is thicker and the sebaceous glands are deeper. Flattening of the alar region is often encountered secondary to contracture.⁴

Ear: Ear injuries may need local debridement or resection. If a choridritis occurs, it can be managed by removal of the affected cartilage. Attempts to salvage visible cartrilage may be made by burying in soft tissue pockets and later performing secondary graft reconstruction. Some patients may require local regional temporalis facial flaps for coverage. Pressure should be kept off the pinna with a doughnut dressing to reduce the possibility of pressure necrosis.⁵

Tongue: It may produce coagulatioecrosis of superficial tissue that appears whitish. In some cases, there may be frank ulceration and stripping of mucosa. Red area is tender to painful; it may blanch on pressure and there is bleeding on manipulation. It can be manage by systemic analgesics and topical hydrocarbon in emollient base.⁶

Lip: There is persistent swelling and redness. It occurs due to prolonged contact of ice cream and other frozen confectionaries or very cold metal, glass object, with child’s lip.⁷

Current therapy for management of burn

Carbon dioxide, carbon monoxide and other foreign bodies

It must be determined if gases inhalation occurred. Signs suggesting inhalation injury are as follows: history of confinement at a burning building, exposure to an explosion, decreased level of consciousness, carbon deposits around the mouth or oropharynx, coughing, signed facial hair and respiratory distress. Assessment for carbon monoxide (CO) poising is imperative because this is most common cause of death in fires. The signs and symptoms of CO poising correlate with concentration. The symptoms is mild, throbbing headache, excitement, reckless behaviour, nausea, vomiting and fainting in exertion are observed. If the CO level rises above 50 percent, coma, convulsions or death may occur. One way observe the “cherry red” mucous membrane with increased CO, but this is not an absolute sign. The definitive test for CO poising is a spectrophotometric determination. Treatment is administration of 100 percent O2. If upper airway injuries are expected, one must consider the need for a controlled airway. Edema may increase over the first 24 to 36 hours and nasotracheal intubation or tracheostomy may need to be performed. The status of immunization must be noted and tetanus toxoid is not needed if the patient has been immunized within the past 5 years. Estimation of total surface area burned to helpful for fluid replacement. Wallace’s rule of 9 is a reliable method for estimating the total body surface area burnt.

Management of first degree and minor second degree consists of suntan lotions, topical anesthetic, anti-inflammatory agents and oral antihistamines. Management of second degree of 15% or less or third degree of less than 2% of the body surface may be treated on an outpatient basis if all other circumstances are favorable.⁹ Second degree and third degree burns of greater than 15 percent should be treated as in patients because plasma loss will be great enough to cause hypovolemic shock if not prevented by intravenous infusion. Burn greater than 30 percent should be treated at burn facility. Fluid replacement is estimated by the parkland formula.¹⁰ To avoid overhydration and pulmonary edema, patients with inhalation injury should have their urinary output monitored closely. Deep second degree and third degree burns require surgical intervention unless the wound is small enough to heal by contracture. Initially, the wound is treated with either the exposure method or closed method.⁹ Topical antimicrobial agents such as mafenide, silver sulfadiazine and 0.5 percent silver nitrate solution may be used to limit proliferation of bacteria. Systemic antibiotics may not reach the wound well and are not routinely used. Once patient is diagnosed with deep second degree or third degree injury, definite treatment must be considered. Numerous methods are available for wound reconstruction including; healing by granulation, freeskin grafts, primary closure, and local, regional or distant skin flaps.¹¹

For most oral and maxillofacial injuries, a sequential excision consisting of removing thin layers as injured tissue is performed until viable tissue is identified. A facial excision consists of removal of all tissue to the depth of underling muscle. This may be performed with a surgical blade or dermatome. After removal of non viable tissue, a graft must be placed and autogenous skin grafts are accepted as the treatment of choice. Donor sights of good quality of for the face are the scalp, neck, supraclavicular region, and inner thigh / arm. The autograph thickness can be variable, but a graft of 0.010 to 0.0025 inches in sheets seems to give good cosmetic and functional results.¹² Currently, a skin substitute called interga is available. It is a bilayer of pseudodermis with an overlying silastic cover. It contains no living components but supplies a protective covering and pliable scaffold onto which the patient’s own skin cells “regenerate” the lower dermal layer that was destroyed by burn¹³. Another material much like integra is alloderm. This material skin is produced by removing from cadaver skin all cell components that cause rejection. Similar to derm provides a scaffold for new derm’s to form.¹⁴ Other techniques to limit scar contracture are exercise, traction, oral appliances, nasal vestibule inserts, silicone sheeting and steriod injections.

Conclusion

The oral maxillofacial surgeon may not treat burn routinely and understanding the principles of the injury and possible treatment options should be in armamentarium of each surgeon. It must be remembered that burn injuries may take the skills of multiple specialties in burn center, and long term treatment may be staged. The consequences of maxillofacial burns can be devastating to the patient and acceptable results challenging to the surgeon.

Management of Burns

The burns patient has the same priorities as all  other trauma patients.

• Assess:

– Airway

– Breathing: beware of inhalation and rapid airway compromise

– Circulation: fluid replacement

– Disability: compartment syndrome

– Exposure: percentage area of burn.

 

• Essential management points:

– Stop the burning

– ABCDE

– Determine the percentage area of burn (Rule of 9’s)

– Good IV access and early fluid replacement.

 • The severity of the burn is determined by:

– Burned surface area

– Depth of burn

– Other considerations.

 

• Morbidity and mortality rises with increasing burned surface area. It also rises with increasing age so that even small burns may be fatal in elderly people.

Burn Management in Adults

• The “Rule of 9’s” is commonly used to estimate the  burned surface area in adults.

 • The body is divided into anatomical regions that represent 9% (or multiples of 9%) of the total body surface (Figure 7). The outstretched palm and fingers approximates to 1% of the body surface area.

 • If the burned area is small, assess how many times your hand covers the area.

 • Morbidity and mortality rises with increasing burned surface area. It also rises with increasing age so that even small burns may be fatal in elderly people.

Burn Management in Children

• The ‘Rule of 9’s’ method is too imprecise for estimating the burned surface area in children because the infant or young child’s head and lower extremities represent different proportions of surface area than in an adult (see Figure 8).

 

• Burns greater than 15% in an adult, greater than 10% in a child, or any burn occurring in the very young or elderly are serious.

Depth of burn

• It is important to estimate the depth of the burn to assess its severity and to plan future wound care. Burns can be divided into three types, as shown below.

 

• It is common to find all three types within the same burn wound and the depth may change with time, especially if infection occurs. Any full thickness burn is considered serious.

Serious burn requiring hospitalization

– Greater than 15% burns in an adult

– Greater than 10% burns in a child

– Any burn in the very young, the elderly or the infirm

– Any full thickness burn

– Burns of special regions: face, hands, feet, perineum

– Circumferential burns

– Inhalation injury

– Associated trauma or significant pre-burn illness: e.g. diabetes

Wound care

Most minor burns will heal on their own, and home treatment is usually all that is needed to relieve your symptoms and promote healing. But if you suspect you may have a more severe injury, use first-aid measures while you arrange for an evaluation by your doctor.

Immediate first aid for burns

·                     First, stop the burning to prevent a more severe burn.

o                  Heat burns (thermal burns): Smother any flames by covering them with a blanket or water. If your clothing catches fire, do not run: stop, drop, and rollon the ground to smother the flames.

o                  Cold temperature burns: Try first aid measures to warm the areas. Small areas of your body (ears, face, nose, fingers, toes) that are really cold or frozen can be warmed by blowing warm air on them, tucking them inside your clothing or putting them in warm water.

o                  Liquid scald burns (thermal burns): Run cool tap water over the burn for 10 to 20 minutes. Do not use ice.

o                  Electrical burns: After the person has been separated from the electrical source, check for breathing and a heartbeat. If the person is not breathing or does not have a heartbeat, call 911.

o                  Chemical burns: Natural foods such as chili peppers, which contain a substance irritating to the skin, can cause a burning sensation. When a chemical burn occurs, find out what chemical caused the burn. Call your localPoison Control Center or the National Poison Control Hotline (1-800-222-1222) for more information about how to treat the burn.

o                  Tar or hot plastic burns: Immediately run cold water over the hot tar or hot plastic to cool the tar or plastic.

·                     Next, look for other injuries. The burn may not be the only injury.

·                     Remove any jewelry or clothing at the site of the burn. If clothing is stuck to the burn, do not remove it. Carefully cut around the stuck fabric to remove loose fabric. Remove all jewelry, because it may be hard to remove it later if swelling occurs.

Prepare for an evaluation by a doctor

If you are going to see your doctor soon:

·                     Cover the burn with a clean, dry cloth to reduce the risk of infection.

·                     Do not put any salve or medicine on the burned area, so your doctor can properly assess your burn.

·                     Do not put ice or butter on the burned area, because these measures do not help and can damage the skin tissue.

Home treatment for minor burns

·                     For home treatment of first-degree burns and sunburns:

o                  Use cool cloths on burned areas.

o                  Take frequent cool showers or baths.

o                  Apply soothing lotions that contain aloe vera to burned areas to relieve pain and swelling. Applying 0.5% hydrocortisone cream to the burned area also may help. Note: Do not use the cream on children younger than age 2 unless your doctor tells you to. Do not use in the rectal or vaginal area of children younger than age 12 unless your doctor tells you to.

·                     There isn’t much you can do to stop skin from peeling after a sunburn-it is part of the healing process. Lotion may help relieve the itching.

·                     Other home treatment measures, such as chamomile, may help relieve your sunburn symptoms.

You may be able to treat second-degree burns at home.

First-degree burns and minor second-degree burns can be painful. Try the following to help relieve your pain:

 

Lotions

Some doctors suggest using skin lotions, such as Vaseline Intensive Care or Lubriderm, on first-degree burns or second-degree burns that have unbroken healing skin. These skin lotions can be used to relieve itching but should not be used if the burns have fluid weeping from them or have fresh scabs. An antihistamine, such asBenadryl or Chlor-Trimeton, can also help stop the itching. Read and follow any warning on the label.

When a first-degree burn or minor second-degree burn is 2 to 3 days old, using the juice from an aloe leaf can help the burn heal and feel better. Applying the aloe juice may sting at first contact.

It is important to protect a burn while it is healing.

·                     Newly healed burns can be sensitive to temperature. Healing burns need to be protected from the cold, because the burned area is more likely to developfrostbite.

·                     A newly burned area can sunburn easily. Sunscreen with a high sun protective factor (SPF at least 30) should be used for the first year after a burn to protect the new skin.

Do not smoke. Smoking slows healing because it decreases blood supply and delays tissue repair. For more information, see the topic Quitting Smoking.

Symptoms to watch for during home treatment

Call your doctor if any of the following occur during home treatment:

·                     Pain, limited movement, or numbness develops.

·                     Difficulty breathing develops.

·                     Signs of infection develop.

·                     Symptoms become more severe or frequent.

·                      

 

First aid

• If the patient arrives at the health facility without first aid having been given, drench the burn thoroughly with cool water to prevent further damage and remove all burned clothing.

 

• If the burn area is limited, immerse the site in cold water for 30 minutes to reduce pain and oedema and to minimize tissue damage.

 

• If the area of the burn is large, after it has been doused with cool water, apply clean wraps about the burned area (or the whole patient) to prevent systemic heat loss and hypothermia.

 

• Hypothermia is a particular risk in young children.

 

• First 6 hours following injury are critical; transport the patient with severe burns to a hospital as soon as possible.

 

Initial treatment

• Initially, burns are sterile. Focus the treatment on speedy healing and prevention of infection.

 

• In all cases, administer tetanus prophylaxis.

 

• Except in very small burns, debride all bullae. Excise adherent necrotic (dead) tissue initially and debride all necrotic tissue over the first several days.

 

• After debridement, gently cleanse the burn with 0.25% (2.5 g/litre) chlorhexidine solution, 0.1% (1 g/litre) cetrimide solution, or another mild water-based antiseptic.

 

• Do not use alcohol-based solutions.

 

• Gentle scrubbing will remove the loose necrotic tissue. Apply a thin layer of antibiotic cream (silver sulfadiazine).

 

• Dress the burn with petroleum gauze and dry gauze thick enough to prevent seepage to the outer layers.

Daily treatment

• Change the dressing daily (twice daily if possible) or as often as necessary to prevent seepage through the dressing. On each dressing change, remove any loose tissue.

 

• Inspect the wounds for discoloration or haemorrhage, which indicate developing infection.

 

• Fever is not a useful sign as it may persist until the burn wound is closed.

 

• Cellulitis in the surrounding tissue is a better indicator of infection.

 

• Give systemic antibiotics in cases of haemolytic streptococcal wound infection or septicaemia.

 

• Pseudomonas aeruginosa infection often results in septicaemia and death.

 

Treat with systemic aminoglycosides.

 

• Administer topical antibiotic chemotherapy daily. Silver nitrate (0.5% aqueous) is the cheapest, is applied with occlusive dressings but does not penetrate eschar. It depletes electrolytes and stains the local environment.

 

• Use silver sulfadiazine (1% miscible ointment) with a single layer dressing. It has limited eschar penetration and may cause neutropenia.

 

• Mafenide acetate (11% in a miscible ointment) is used without dressings. It penetrates eschar but causes acidosis. Alternating these agents is an appropriate strategy.

 

• Treat burned hands with special care to preserve function.

− Cover the hands with silver sulfadiazine and place them in loose polythene gloves or bags secured at the wrist with a crepe bandage;

− Elevate the hands for the first 48 hours, and then start hand exercises;

− At least once a day, remove the gloves, bathe the hands, inspect the burn and then reapply silver sulfadiazine and the gloves;

− If skin grafting is necessary, consider treatment by a specialist after healthy granulation tissue appears.

Healing phase

• The depth of the burn and the surface involved influence the duration of the healing phase. Without infection, superficial burns heal rapidly.

 

• Apply split thickness skin grafts to full-thickness burns after wound excision or the appearance of healthy granulation tissue.

 

• Plan to provide long term care to the patient.

 

• Burn scars undergo maturation, at first being red, raised and uncomfortable. They frequently become hypertrophic and form keloids. They flatten, soften and fade with time, but the process is unpredictable and can take up to two years.

 

• In children

 

– The scars cannot expand to keep pace with the growth of the child and may lead to contractures.

– Arrange for early surgical release of contractures before they interfere with growth.

 

• Burn scars on the face lead to cosmetic deformity, ectropion and contractures about the lips. Ectropion can lead to exposure keratitis and blindness and lip deformity restricts eating and mouth care.

 

• Consider specialized care for these patients as skin grafting is ofteot sufficient to correct facial deformity.

Nutrition

• Patient’s energy and protein requirements will be extremely high due to the catabolism of trauma, heat loss, infection and demands of tissue regeneration. If necessary, feed the patient through a nasogastric tube to ensure an adequate energy intake (up to 6000 kcal a day).

 

• Anaemia and malnutrition prevent burn wound healing and result in failure of skin grafts. Eggs and peanut oil and locally available supplements are good.

Appropriate timing of surgical intervention is essential to a successful outcome. Establishing priorities, placing functional concerns before cosmetic concerns, and rationing potential donor sites are key elements of this operative strategy. Allow the patient (rather than the surgeon) to prioritize reconstructive procedures, with the surgeon providing counseling regarding expected benefits and appropriate timing of procedures. Together, an overall master plan may be developed that may need modification as treatment progresses and patient status changes. Whenever possible, reduce anesthetic events by combining complementary procedures and coordinating the various surgical disciplines involved.

Generally, surgical intervention may be categorized as early or delayed; but, in reality, patient treatment is a continuum beginning at the time of injury. The earliest essential concern is to achieve a closed wound. This is necessary before entertaining any thoughts of reconstruction.

Techniques

General

Certain aesthetic principles are important when approaching reconstruction of the burned face. Reconstruction should proceed within facial aesthetic units. Treat each region (ie, forehead, eyes, nose, cheeks, ears, upper lip, lower lip and chin, neck) as an individual entity. Place scars at the boundaries of 2 aesthetic units. Often, sacrificing normal skin and replacing an entire aesthetic unit is better than replacing part of an aesthetic unit and having a scar coursing across that unit. Orientation of scars parallel to relaxed skin-tension lines (RSTLs) is also important. Some authors even stress symmetry to the point of recommending the same procedure for each side of the face. This may seem reasonable if the entire face were involved but is unnecessary if only part of the face is burned.

Primary repair is elected over waiting for scar maturation and secondary release of contractures that always results in a patchlike appearance on the applied grafts.^[6]Hypertrophic scarring seems to occur in wounds that take longer than 2-3 weeks to heal. Scar revision or staged excision may still be necessary later, and the patient should understand this at the outset.

Preoperative treatment includes daily antiseptic bath with chlorhexidine 0.05% and antibiotic ointment applied daily. Continue until day 10 and address those wounds that are not likely to heal within 2 weeks of injury. Once diagnosed with a deep injury, definitive treatment must be considered. Options include healing by granulation, primary closure, free skin grafts, local regional, or distant skin flaps. Burns that are clearly full-thickness are scheduled for excision and grafting within the next 7-10 days.

A careful operative technique is essential for a successful outcome. Perioperative antibiotics are administered. Use ocular lubricating ointments or corneal protectors prior to starting the procedure. After administering an appropriate level of anesthesia, prepare the wound for reconstruction. Start with wound cleansing with saline or dilute Betadine, judicious debridement, and achievement of meticulous hemostasis. Good hemostatic control can be gained with ligation, gentle pressure, application of a topical vasoconstrictor (eg, epinephrine), or bipolar electrocautery. Minimize electrocautery, as it creates devitalized tissue. Use of topical or injected epinephrine at the donor or recipient sites does not compromise outcome or tissue survival.

Early excision and grafting is the treatment of choice, it may be a 1-2 stage technique.^{[7, 8]} Other options include AlloDerm (from cadaver skin, removing all cell components that cause rejection), TransCyte (human fibroblast-derived temporary skin substitute), or Integra (a temporary silicone epidermal substitute and an artificial dermal layer. If Integra is used, the neo-dermis forms in 2-4 weeks. The silicone layer is then removed and replaced with an ultrathin split-thickness skin graft (0.004 in).^[9] For larger burn defects, one might consider regional flaps, free flaps, and tissue expansion in addition to skin grafting.

Prioritized Specific Procedures

Skin grafting

Grafting is frequently the preferred choice when large full-thickness or deep partial thickness defects are involved. The propensity of split-thickness grafts for contracture is attributable to their limited content of dermal tissue.

Skin grafting is the simplest way to replace burned facial skin. Setting aside the face’s donor site before all donor sites are used to resurface other body parts is important. Although even the best full-thickness graft loses some of its innate skin qualities, and although textural and pigmentary changes may persist, skin grafts advantageously lack bulk; therefore, they do not mask facial expression. Donor sites for full-thickness grafts are limited, and preoperative planning must consider the most efficient use of these donor sites. Match thickness, texture, pigmentation, and hair coverage as closely as possible. When grafting in children, remember that donor sites (eg, groin, axilla, thigh, chest) sprout hair at puberty, and this hair growth may be undesirable at the new location.

Full-thickness grafts

Choose donor sites for full-thickness grafts that are inconspicuous and that are easily closed primarily. Full-thickness grafts may be harvested from the upper eyelid, nasolabial fold, preauricular and postauricular regions, and the supraclavicular fossae. These donor sites are most often used to close facial or neck wounds or to resurface an existing scarred region.

When harvesting from the face, harvesting bilaterally to maintain facial symmetry is often aesthetically preferable, even if more skin thaecessary is removed to cover the defect. Full-thickness donor sites used less frequently include hairless groin skin, dorsum of the foot, wrist-flexion creases, and elbow creases. Scars from skin grafts harvested from the wrist-flexion crease may resemble those seen with suicide attempts and should probably be avoided. Darker-pigmented grafts may be obtained from the prepuce, scrotum, and labia minora. Locations with avulsed or surgically removed skin are potential donor sites that are often overlooked.

Split-thickness grafts

Only use split-thickness grafts if harvested very thick with a significant portion of dermis included. This is because secondary contraction often occurs after split-thickness skin grafting, and the amount of secondary contraction is inversely proportional to the amount of dermis included in the graft. The scalp is a great donor site. For split-thickness grafts 0.018-0.025 inch, the scalp is then shaved. After complete hemostasis is achieved, the autografts are placed in aesthetic units.

Regional flaps

Regional and transpositional flaps introduce neighboring tissue with organic blood supply to the defect and have the advantage of providing skin of similar quality and pigmentation as the burned site. Transposition flaps are generally thin and pliable, although not as thin as skin grafts.

Free-tissue flaps

Free-tissue transfer may be required to cover exposed bone or cartilage or to introduce extra tissue when local tissues or skin grafts are inadequate or contraindicated. Defects greater than two-thirds of the anterior neck require distant tissue and are usually not amenable to local flaps. The most commonly used free-tissue flaps for facial reconstruction include latissimus dorsi, temporoparietal fascia, omentum, rectus abdominis, groin, radial forearm, dorsalis pedis, and parascapular flaps. These flaps require microvascular anastomosis and often subsequent debulking because of their large size. Free-tissue transfer for head and neck burn flap does have a success rate of 94%.

A total-face reconstruction was performed with a bilateral free scapula megaflap, but did result in the appearance of facial masking. Advances such as flap prefabrication, prelamination pre-expansion, chimeric flaps, and super-thin flaps have increased the quality of freeflaps.^[10] Prefabrication has resulted in thin flaps not requiring debunking in 64% of patients.^[11] In addition to the extra tissue, the radial forearm free flaps can be made sensate by incorporating the lateral ante brachial cutaneous nerve and attaching it to a branch of the trigeminal nerve.^[12]The free flap is not usually a first-line treatment option with the inherent disadvantages such as the complexity of the surgery with microvascular anastomose but is a valuable adjunct when required.

Tissue expansion

Another reconstruction option is recruitment of additional skin by tissue expansion. Benefits of this technique include generation of tissue that is similar to the defect in color, texture, and thickness. Furthermore, no donor site is created. In addition to standard tissue expansion techniques, tissue expansion has been used to expand the donor sites for full-thickness skin grafts. This allows harvesting of large full-thickness grafts from a relatively small donor area that subsequently may be closed primarily. Grafts produced in this manner behave like smaller, nonexpanded full-thickness grafts. Tissue expansion and free-tissue transfer are commonly used together in reconstructive facial plastic surgery. Tissue expanders are placed under the subcutaneous place between the deep fascia and the muscle layer. Disadvantages of pre-expansion are the need for 2 operations and a significant time period for the progressive expansion.^[13]

Delayed or Secondary Treatments

Scar revision

Hypertrophic scarring, keloid formation, and contracture leading to disability and deformity continue to be challenging late complications of burn injuries and other traumas. Contractures can lead to permanent skeletal deformities and functional deficits. Methods of release include alphabet plasties (eg, Z, W, Y-V), skin grafts, skin expansion, or regional or free musculocutaneous or fasciocutaneous flaps to achieve adequate functional improvement.

Nonoperative treatments include massage, pressure garments, and cosmetic camouflage. Secondary skin grafting is simple, reliable and safe. Full-thickness skin grafts (groin, thighs, abdomen, postauricular, supraclavicular, upper eyelid, shoulder, cubital fossa) are preferred to split-thickness skin grafts (thigh, arms, buttocks) in postburn contracture releases.^[14]

Another option is using Integra, which may reduce the number of operations and the time period of treatment required by conventional procedures of multistage scar contracture release. With this technique, allografts were applied to control wound colonization and 48 hours later, the allografts were removed and Integra was applied to the wounds. Eighteen days after Integra application, ultrathin split thickness skin grafts were applied over the Integra dermal layer.^[9] Dermabrasionis a useful technique for revising old burn scars.^[15] The ultimate goal for delayed scar revision is symmetry and a relatively normal appearance.

Human partial face allograft (face transplant)

The first of several human partial face allograft transplants occurred in 2005. After 18 months, the surgeons reported the outcome, stating that the patient has sensitivity to light touch and to heat and cold, which returned to normal at 6 months after transplantation. Motor recovery was slower, and labial contact allowing complete mouth closure was achieved at 10 months. Psychological acceptance of the graft progressed as function improved. Rejection episodes occurred twice after transplantation and were reversed. Face transplants still have long-term rejection risks and require immunosuppressants that have inherent risks, such as developing a carcinoma.^[16] Potentially, someday this procedure could be of benefit for some severely disfigured burn patients.

Specific Anatomic Sites

Eyelid

Eyelid reconstruction has highest priority because the lid functions to protect the cornea. Initiate reconstruction even in the presence of an immature scar. Scar release and subsequent grafting is the procedure of choice. Split-thickness grafts are a better match for the upper eyelid, and the optimal donor site is the contralateral upper lid if uninvolved with injury. Full-thickness grafts better approximate lower lid thickness, and decreased tendency for secondary contraction minimizes chances of postoperative ectropion. Generally, surgeons are recommended to release upper and lower eyelids in separate operative sessions.

Lip and chin region

This region is second in priority. Complications of burns in this region include drooling, microstomia, eating and communication difficulties, lip eversion, and oral hygiene inadequacy. General anesthesia administration in these patients can be difficult and dangerous. This region is not only important but is also one of the most difficult regions to reconstruct adequately. If at all possible, allow scars to fully mature with continuous pressure application so that tissues are soft and supple.

Often, patience yields equivalent or better results than might be expected with surgery. If operative intervention is necessary, thorough scar release with sufficient skin and soft tissue should be added to the lip and chin area, and this frequently requires a multiple-step operation. Full-thickness grafting is the procedure of choice. Reconstruction of very large defects of the lower lip is difficult. Consider cheek advancement flaps, rotation flaps using the residual lip, doublecross-lip flaps, or nasolabial flaps.

Large flaps that cover the chin and upper neck usually obscure the cervicomental angle and add to the appearance of pseudomicrogenia. Free flaps, such as the free radial forearm flap, are also a consideration, but the thickness of the flap should be reduced to cover the defect of the lower lip and chin area. To improve the cervicomental angle the lower border of the flap can be fixed with space of 1 finger-width from the hyoid bone. To form the labiomental sulcus, a space between the epidermis of the flap and muscle of the defective area was adhered.^[12] The addition of an alloplastic chin implant often improves the contour and provides better chin definition. Many authors place a feeding tube at the time of surgery and forbid eating, drinking, or speaking for a week postoperatively.

These are considered major procedures, and patients must receive long-term postoperative care. A modified dynamic mouth splint to minimize microstomia contractures is an important aspect of continued facial burn treatment. Also, compression therapy, scar massage, contact media, exercise, patient education, and neck splinting are used. The prevention and treatment of microstomia is difficult because of the aggressiveness of the contracting tissues and poor patient compliance.^[17]

Neck

Neck flexion contractures can result in significant posture alteration and in difficulty eating, communicating, and seeing. As with oral burns, general anesthesia administration in these patients may be difficult and dangerous. Splint the neck in patients suffering burns in the cervical region to prevent contracture and to make subsequent surgical intervention easier. Splints should be worn almost continuously. Refit and reapply splints promptly following each surgical intervention for at least 6 months.

Since correction of neck contractures generally requires multiple interventions, these procedures are usually begun early in the reconstructive plan. They are often complimentary procedures performed in tandem with other procedures.

In general, completely excise and resurface hypertrophic or widely restrictive scars. If less than a third of the neck is involved, local tissue transposition, Z-plasty, or W-plasty may be performed to reorient scars from vertical to transverse. For relatively minor burns involving less than two thirds of the neck, tissue expansion may provide an opportunity to replace all scarred tissue. When more than two thirds of the neck is involved, consider regional flaps, free flaps, and grafts. Skin grafts work well but require longer postoperative splinting and are not as aesthetically pleasing.

Cheek

Treat the burned cheek with a facial-pressure garment to assist in scar maturation. This is unnecessary, however, if the entire aesthetic unit is to be excised and grafted. Other options include tissue expansion of unburned cervical skin and local flaps. Postoperatively, a mask should be worn for 6 months if skin grafts have been applied.

Upper lip

The upper lip actually consists of 3 aesthetic units: the 2 lateral lip elements and the central philtral ridge. Usually, an incision is placed transversely at the root of the nose, allowing the upper lip to fall back into its normal position and maintain fullness. The secondary defect is subsequently skin-grafted. The philtral ridge may be augmented with dermal or cartilage grafts that otherwise might be discarded. Patients agreeable to permanent moustache wear might consider moustache reconstruction. This is performed with a free or islandized scalp flap based on the superficial temporal vessels. Achieving the correct downward-growth orientation of hair follicles is a crucial consideration.

Nose

Nasal reconstruction is of intermediate priority. Airway obstruction may require early intervention with scar release and skin grafting. Cosmetic nose reconstruction is better postponed until scar maturation is complete, but total resurfacing with a skin graft may be performed rather early. Since the nose is the central point of the face, many patients derive significant psychological benefit from satisfactory nasal reconstruction. Nasal reconstruction often restores a sense of humanity to individuals. Alar deformities may be treated with a local turndown flap resurfaced with a full-thickness skin graft or a composite graft from the ear.

Total nasal reconstruction may be performed with a forehead flap; however, many patients reject a forehead flap if the forehead is perceived as the only remaining normal region of the face. In these instances, a dorsalis pedis free flap or a Tagliacozzi tubed pedicled flap may be better alternatives.

Forehead

The forehead may be resurfaced completely as an aesthetic unit with a full-thickness skin graft. Tissue expansion is an alternative for a forehead burned on less than half its area. Exposed bone requires introduction of vascularized tissue (eg, temporoparietal fascial flaps) to accept a skin graft.

Generally, perform scalp reconstruction late in the sequence of events. If extensive bone is exposed early, the entire cranium may be resurfaced with a free flap that subsequently may be skin grafted. Scalp flaps may be used for less extensive injuries. Apply scalp flaps for specific indications and design them carefully, as they often leave donor sites as large as the covered defect. Temporoparietal fascial flaps may also be used as a vascularized surface for skin grafting, as with forehead defects. Punch grafts or hair transplants generally do not survive in previously burned or grafted skin that has a less-than-optimal blood supply. Tissue expansion is optimal if enough unburned hair-bearing skin remains. Advantages of tissue expansion include (1) no donor site creation; (2) donor skin of very similar color, thickness, and texture; and (3) high hair follicle survival rate. Patients who reject these procedures may wear hairpieces or wigs.

Eyebrow reconstruction may proceed with strips of hair-bearing scalp transplanted as free grafts. Delicately handle and minimally defat these grafts because significant follicle loss may accompany this technique. Another option for bushier eyebrows is transference of a hair-bearing scalp segment as an island flap based on the superficial temporal vessels, as in upper-lip moustache reconstruction.

Ear

Ear reconstruction is generally performed last because the first choice for reconstruction uses available local tissue that should be allowed to achieve mature scarring. Indications for early intervention include cartilage exposure, in which case a turnover temporoparietal fascial flap may be used as a vascularized surface over which to apply a full-thickness skin graft.

Reconstructive options include local skin and fascial flaps with/without tissue expansion, ipsilateral axial temporoparietal fascial flap, contralateral temporoparietal, or an ipsilateral random fascial flaps. If the entire skin of the temporoauriculomastoid region is lost or badly scared with poor axial vascularity, a bilobed cervical flap or fascial free flap is an option.^[18] Rib cartilages are harvested from the right side and sculptured to create an ear frame. Another solution is the osseointegrated auricular prostheses, but it has a high cost and risk of potential complications over the long term.

Postoperative care

After wound closure, scar hypertrophy may begin within 3 weeks. Scar hypertrophy is most exuberant over the next 3 months and is characterized by raised, red, itchy, tight scars. These scars then slowly regress during the following 12-24 months. At completion of this process, a mature scar remains that is characteristically white, soft, and flat. If possible, depending on clinical condition and patient insistence, exercise an observation protocol and patience until scars mature.

Postoperative care includes the continuous use of pressure garments or masks fitted early after injury. Regularly reassess, remold, and, as necessary, replace these garments to ensure continuous uniform pressure over the entire scarred area. Silicone pads are also sometimes used. No pressure should be placed on the auricle. These pressure devices lead to softer, less exuberant scars. Application of splints (Hartford or Larson device) to oral commissures and the neck may help prevent contracture development. Appropriate early measures may render subsequent procedures unnecessary or less difficult. Triamcinolone may be injected if hypertrophic scarring begins to develop.

The patient should begin scar massage as soon as wounds heal. Instruction in use of camouflage makeup may make a substantial impact on the lifestyle of these patients and their willingness to appear in public. Finally, instruct patients to wear moisturizing sunscreen and avoid direct sun exposure for the first 12 months following burn scar healing and skin grafting. These precautions avoid potential hyperpigmentation complications.

Chemical Burns Overview

A chemical burn is irritation and destruction of human tissue caused by exposure to a chemical, usually by direct contact with the chemical or its fumes. Chemicalburns can occur in the home, at work or school, or as a result of accident or assault. Although few people in the United States die after contact with chemicals in the home, many substances common in both living and storage areas can do serious harm.

Many chemical burns occur accidentally through misuse of products such as those for hair, skin, and nail care. Although injuries do occur at home, the risk of sustaining a chemical burn is much greater in the workplace, especially in businesses and manufacturing plants that use large quantities of chemicals.

Most chemical burns are caused by either strong acids or strong bases (for example, hydrochloric acid or sodium hydroxide). Acids damage and kill cells by coagulating cells while bases liquefy cells. Prolonged exposure can severely damage human tissues and, if the patient survives, leads to scarring and disability. Other chemicals like oxidants and certain metals may also produce similar chemical burns. Limiting the time of exposure to any of these chemicals can greatly reduce their damaging effects.

Unfortunately, some chemical burn agents are designed to harm people (chemical agents used in wars and in terrorist attacks). It is not the scope of this article to cover these agents.

Chemical Burn Causes

Most chemicals that cause burns are either strong acids or bases. A glance at the medical information on the labels of dangerous chemicals usually confirms the expected toxicity. Common sense precautions and consumer education can reduce the risk of injury. A variety of common household products that may cause chemical burns are as follows:

·                     Bleach

·                     Concrete mix

·                     Drain or toilet bowl cleaners

·                     Metal cleaners

·                     Pool chlorinators

This is just a sample list. Many other products used in the home and at work may contain some amount of chemicals that may cause burns. it is important to keep the labels on the containers in case of an exposure so the medical personnel can know what the patient has been exposed to.

All of these should only be stored in the appropriate containers to prevent accidental ingestion.

Chemical Burn Symptoms

All chemical burns should be considered potential medical emergencies.

Most chemical burns occur on the face, eyes, hands, arms, and legs. Usually a chemical burn will be relatively small and will require only outpatient treatment. Chemical burns can be deceiving, however. Some agents can cause deep tissue damage that is not not readily apparent when people first look at it.

·                     Tissue damage from chemical burns depends on several factors.

o                  The strength or concentration of the agent

o                  The site of contact (eye, skin, mucous membrane)

o                  Whether swallowed or inhaled

o                  Whether or not skin is intact

o                  With the quantity of the chemical

o                  The duration of exposure

o                  How the chemical works

o                  The length of time to washing (decontamination)

 

·                     Signs and symptoms of chemical burns include the following:

o                  Redness, irritation, or burning at the site of contact

o                  Pain or numbness at the site of contact

o                  Formation of blisters or black dead skin at the contact site

o                  Vision changes if the chemical gets into the eyes

o                  Cough or shortness of breath

o                  Vomiting

 

·                     In severe cases, a person may develop any of the following symptoms:

o                  Low blood pressure

o                  Faintness, weakness, dizziness

o                  Shortness of breath or severe cough

o                  Headache

o                  Muscle twitching or seizures

o                  Cardiac arrest or irregular heartbeat

 

Chemical burns can be very unpredictable. Death from a chemical injury, although rare, can occur.

Chemical Burn Diagnosis

In the emergency department, a person can expect the following:

·                     Initial evaluation and stabilization

·                     Rapid evaluation of the chemical’s ability to damage tissue

·                     Determination of the extent of injury

·                     Blood tests and other studies to determine if the patient should be admitted to the hospital

·                     Determination of additional injuries and treatment

Chemical Burn Medical Treatment

Specific medical treatment depends on the chemical that the patient was exposed to. Some of the general steps taken to medically treat chemical burns are as follows:

·                     IV fluids may be needed to normalize blood pressure and heart rate as any type of burn (fire, chemical, sun exposure) often results in dehydration of the patient.

·                     The IV access may also be used for any medications needed to treat pain or protect against infection.

·                     Decontamination will begin (likely water irrigation).

·                     Some people may be an antidote to counteract the chemical, if appropriate.

·                     Antibiotics often are not needed for minor chemical burns.

·                     Wounds will be cleaned and bandaged with medicated creams and sterile wraps as needed.

·                     Consultation with other medical specialists may be done if indicated.

·                     Pain in a burn can often be severe. Adequate pain control will be addressed by the doctor.

·                     If there is any indication of breathing problems, a breathing tube may be placed in the patient’s airway to help maintain the airway and provide adequate ventilation.

Electrical injuries have become a more common form of trauma with a unique pathophysiology and with high morbidity and mortality. They encompass several types, as follows: lightning injury, high-voltage injury, and low-voltage injury. Clinical manifestations range from transient unpleasant sensations without apparent injury to massive tissue damage. Some electrocutions are instantly fatal. Familiarity with the mechanisms of injury and the principles of therapy improves patient care

Pathophysiology

Three electrical factors determine the severity of the damage caused by electrical burns: voltage, current, and resistance. The severity of the burn also depends on the pathway the current takes through the body. Generally, the pathway of the current will follow the course the least resistant tissues: firstly blood vessels, nerves, and muscle, then skin, tendon, fat, and bone. Most commonly, electric injuries primarily damage the outer limbs, but more critical portions of the body may be affected as well causing severe complications.

As the body comes into contact with an electrical source, it becomes part of the electrical current. As such, the current has a point of entry and an exit at two different points on the body. The point of entry tends to be depressed and leathery whereas the exit wound is typically more extensive and explosive. It is hard to accurately diagnose an electrical burn because only the entry and exit wounds are visible and the internal damage is not.

Causes and classification

Electrical burns can be caused by a variety of ways such as touching or grasping electrically live objects, short-circuiting, inserting fingers into electrical sockets, and falling into electrified water.Lightning strikes are also a cause of electrical burns, but this is a less common event. With the advances in technology, electrical injuries are becoming more common and are the fourth leading cause of work-related traumatic death. One third of all electrical traumas and most high-voltage injuries are job related, and more than 50% of these injures result from power line contact.

Electrical burns can be classified into six categories, and any combination of these categories may be present on an electrical burn victim:

·                    Low-voltage burn. A burn produced by contact with a power source of 500 volts or less is classified as a low-voltage burn. The current at this voltage is not enough to cause tissue damage along its path except at the contact site. This type of burn may be mild, superficial, or severe depending on the contact time.

·                    High voltage burn. This burn is very severe as the victim makes direct contact with the high voltage supply and the damage runs its course throughout the body. Exterior injuries are misleading as most of the damage occurs underneath the skin. In this case, subdermal tissues are severely damaged.

·                    Arc burn. This type of burn occurs when electrical energy passes from a high-resistance area to a low-resistance area.^[7] No contact is required with an arc burn as the electricity ionizes air particles to complete the circuit. The heat generated can be as high as 4,000 degrees Celsius – hot enough to vaporize metal and ignite a victim’s clothing. A form of explosion dissipates excess energy from the arc. In addition, a high-amperage arc can produce a pressure wave blast in excess of 1000 pounds per square inch of pressure. This can throw the victim and cause severe injuries.

·                    Flash burn. Flash burns are caused by electrical arcs that pass over the skin. The intense heat and light of an arc flash can cause severe burns. Although the burns on the skin are largely superficial and cover a large area, tissues beneath the skin are generally undamaged and unaffected.

·                    Flame burn. Associated with flash and arc burns, flame burns are caused by contact to objects that were ignited by an electrical source.

·                    Oral burns. This is caused by biting or sucking on electrical cords, and it most commonly happens to children. Electrical current typically passes from one side of the child’s mouth to the other, possibly causing deformity.

Treatment

First aid

An electrically burned patient should not be touched or treated until the source of electricity has been removed. Electrical injuries often extend beyond burns and include cardiac arrhythmia, such as ventricular fibrillation. First aid treatments include assessment of consciousness of the victim, evaluation of pulse and circulation, and treatment of burns.

Hospitalization

Typically, an electrical burn patient has a lower affected body surface area than other burn patients, yet complication risks are much higher due to internal injury. Often, the damaged internal tissue demands hospitalization. If not treated, this damaged tissue can cause complications (such as gaseous gangrene from dead tissue or loss of blood flow to limbs) and the damaged body parts may need to be amputated.  Repeated removal of the damaged tissue and extensive rehabilitation are common while limb amputation rates for victims who experience direct electrical contact can be as high as 75%. Burn treatment for severe wounds may require skin grafting, debridement, excision of dead tissue, and repair of damaged organs.

Rehabilitation

Electrical burning has an effect on most vital body functions and is accompanied by several other electrical related injuries:

·                    Damage to the veins and arteries which can cause ischaemic necrosis.

·                    Involuntary contraction of muscles due to electrical interference which can cause bone fractures and dislocations.

·                    Interference with the electrical conductivity of organs such as the heart and nerves. This can lead to seizures, lung injury due to severe central nervous system damage, and cardiac arrest.

·                    Forceful propulsion of the body, producing such injuries as spinal and limb fractures.

These injuries must be treated in addition to the burns themselves.

 Burn Shock 

Definition

Shock is a medical emergency in which the organs and tissues of the body are not receiving an adequate flow of blood. This deprives the organs and tissues of oxygen (carried in the blood) and allows the buildup of waste products. Shock can result in serious damage or evendeath.

Description

There are three stages of shock: Stage I (also called compensated, or nonprogressive), Stage II (also called decompensated or progressive), and Stage III (also called irreversible).

In Stage I of shock, when low blood flow (perfusion) is first detected, a number of systems are activated in order to maintain/restore perfusion. The result is that the heart beats faster, the blood vessels throughout the body become slightly smaller in diameter, and the kidney works to retain fluid in the circulatory system. All this serves to maximize blood flow to the most important organs and systems in the body. The patient in this stage of shock has very few symptoms, and treatment can completely halt any progression.

In Stage II of shock, these methods of compensation begin to fail. The systems of the body are unable to improve perfusion any longer, and the patient’s symptoms reflect that fact. Oxygen deprivation in the brain causes the patient to become confused and disoriented, while oxygen deprivation in the heart may cause chest pain. With quick and appropriate treatment, this stage of shock can be reversed.

In Stage III of shock, the length of time that poor perfusion has existed begins to take a permanent toll on the body’s organs and tissues. The heart’s functioning continues to spiral downward, and the kidneys usually shut down completely. Cells in organs and tissues throughout the body are injured and dying. The endpoint of Stage III shock is the patient’s death.

Causes and symptoms

Shock is caused by three major categories of problems: cardiogenic (meaning problems associated with the heart’s functioning); hypovolemic (meaning that the total volume of blood available to circulate is low); and septic shock (caused by overwhelming infection, usually by bacteria).

Cardiogenic shock can be caused by any disease, or event, which prevents the heart muscle from pumping strongly and consistently enough to circulate the blood normally. Heart attack, conditions which cause inflammation of the heart muscle (myocarditis), disturbances of the electrical rhythm of the heart, any kind of mass or fluid accumulation and/or blood clot which interferes with flow out of the heart can all significantly affect the heart’s ability to adequately pump a normal quantity of blood.

Hypovolemic shock occurs when the total volume of blood in the body falls well below normal. This can occur when there is excess fluid loss, as in dehydration due to severe vomiting or diarrhea, diseases which cause excess urination (diabetes insipidus, diabetes mellitus, and kidney failure), extensive burns, blockage in the intestine, inflammation of the pancreas (pancreatitis), or severe bleeding of any kind.

Septic shock can occur when an untreated or inadequately treated infection (usually bacterial) is allowed to progress. Bacteria often produce poisonous chemicals (toxins) which can cause injury throughout the body. When large quantities of these bacteria, and their toxins, begin circulating in the bloodstream, every organ and tissue in the body is at risk of their damaging effects. The most damaging consequences of these bacteria and toxins include poor functioning of the heart muscle; widening of the diameter of the blood vessels; a drop in blood pressure; activation of the blood clotting system, causing blood clots, followed by a risk of uncontrollable bleeding; damage to the lungs, causing acute respiratory distress syndrome; liver failure; kidney failure; and coma.

Initial symptoms of shock include cold, clammy hands and feet; pale or blue-tinged skin tone; weak, fast pulse rate; fast rate of breathing; low blood pressure. A variety of other symptoms may be present, but they are dependent on the underlying cause of shock.

Diagnosis

Diagnosis of shock is based on the patient’s symptoms, as well as criteria including a significant drop in blood pressure, extremely low urine output, and blood tests that reveal overly acidic blood with a low circulating concentration of carbon dioxide. Other tests are performed, as appropriate, to try to determine the underlying condition responsible for the patient’s state of shock.

Treatment

The most important goals in the treatment of shock include: quickly diagnosing the patient’s state of shock; quickly intervening to halt the underlying condition (stopping bleeding, re-starting the heart, giving antibiotics to combat an infection, etc.); treating the effects of shock (low oxygen, increased acid in the blood, activation of the blood clotting system); and supporting vital functions (blood pressure, urine flow, heart function).

Treatment includes keeping the patient warm, with legs raised and head down to improve blood flow to the brain, putting a needle in a vein in order to give fluids or blood transfusions, as necessary; giving the patient extra oxygen to breathe and medications to improve the heart’s functioning; and treating the underlying condition which led to shock.

Prognosis

The prognosis of an individual patient in shock depends on the stage of shock when treatment was begun, the underlying condition causing shock, and the general medical state of the patient.

Prevention

The most preventable type of shock is caused by dehydration during illnesses with severe vomiting or diarrhea. Shock can be avoided by recognizing that a patient who is unable to drink in order to replace lost fluids needs to be given fluids intravenously (through a needle in a vein). Other types of shock are only preventable insofar as one can prevent their underlying conditions, or can monitor and manage those conditions well enough so that they never progress to the point of shock.

Plastic surgery is a medical specialty concerned with the “correction” or restoration of form and function. Though cosmetic or aesthetic surgery is the best-known kind of plastic surgery, most plastic surgery is not cosmetic; plastic surgery includes many types of reconstructive surgery, hand surgery, microsurgery, and the treatment of burns.

History

Walter Yeo, a British sailor, is often cited as the first known person to have benefited from plastic surgery. The photograph shows him before the procedure (left) and after (right) receiving a skin flap performed by SirHarold Gillies in 1917.

Reconstructive surgery techniques were being carried out in India by 800 BC.^[4] Sushruta, the father of Surgery,^[5] made important contributions to the field of plastic and cataract surgery in 6th century BC.^[5] The medical works of both Sushruta and Charak originally in Sanskrit were translated into theArabic language during the Abbasid Caliphate in 750 AD.^[6] The Arabic translations made their way into Europe via intermediaries.^[6] In Italy the Branca family^[7] of Sicily and Gaspare Tagliacozzi (Bologna) became familiar with the techniques of Sushruta.^[6]

British physicians traveled to India to see rhinoplasties being performed by native methods.^[8] Reports on Indian rhinoplasty performed by a Kumharvaidya were published in the Gentleman’s Magazine by 1794.^[8] Joseph Constantine Carpue spent 20 years in India studying local plastic surgery methods.^[8] Carpue was able to perform the first major surgery in the Western world by 1815.^[9] Instruments described in the Sushruta Samhita were further modified in the Western world.^[9]

Aulus Cornelius Celsus, who lived in the first century AD, described plastic surgery of the face, using skin from other parts of the body

The ancient Egyptians and Romans also performed plastic cosmetic surgery. The Romans were able to perform simple techniques, such as repairing damaged ears from around the 1st century BC. For religious reasons, they did not dissect either human beings or animals, thus their knowledge was based in its entirety on the texts of their Greekpredecessors. Notwithstanding, Aulus Cornelius Celsus left some surprisingly accurate anatomical descriptions,^[10]some of which — for instance, his studies on the genitalia and the skeleton — are of special interest to plastic surgery.^[11]

In 1465, Sabuncu’s book, description, and classification of hypospadias was more informative and up to date. Localization of urethral meatus^{[disambiguation needed]} was described in detail. Sabuncuoglu also detailed the description and classification of ambiguous genitalia.^{[citatioeeded]} In mid-15th-century Europe, Heinrich von Pfolspeundt described a process “to make a new nose for one who lacks it entirely, and the dogs have devoured it” by removing skin from the back of the arm and suturing it in place. However, because of the dangers associated with surgery in any form, especially that involving the head or face, it was not until the 19th and 20th centuries that such surgery became common.

Up until the techniques of anesthesia became established, surgeries involving healthy tissues involved great pain. Infection from surgery was reduced by the introduction of sterile techniques and disinfectants. The invention and use of antibiotics, beginning with sulfonamide and penicillin, was another step in makingelective surgery possible.

In 1793, Chopart performed operative procedure on a lip using a flap from the neck. In 1814, Joseph Carpue successfully performed operative procedure on a British military officer who had lost his nose to the toxic effects of mercury treatments. In 1818, German surgeon Carl Ferdinand von Graefe published his major work entitled Rhinoplastik. Von Graefe modified the Italian method using a free skin graft from the arm instead of the original delayed pedicle flap.

The first American plastic surgeon was John Peter Mettauer, who, in 1827, performed the first cleft palate operation with instruments that he designed himself. In 1845, Johann Friedrich Dieffenbach wrote a comprehensive text on rhinoplasty, entitled Operative Chirurgie, and introduced the concept of reoperation to improve the cosmetic appearance of the reconstructed nose.

In 1891, American otorhinolaryngologist John Roe presented an example of his work, a young woman on whom he reduced a dorsal nasal hump for cosmetic indications. In 1892, Robert Weir experimented unsuccessfully with xenografts (duck sternum) in the reconstruction of sunkeoses. In 1896, James Israel, a urological surgeon from Germany, and in 1889 George Monks of the United States each described the successful use of heterogeneous free-bone grafting to reconstruct saddle nose defects. In 1898, Jacques Joseph, the German orthopaedic-trained surgeon, published his first account of reduction rhinoplasty. In 1928, Jacques Joseph published Nasenplastik und Sonstige Gesichtsplastik.

20th century

In World War I, a New Zealand otolaryngologist working in London, Harold Gillies, developed many of the techniques of modern facial surgery in caring for soldiers suffering from disfiguring facial injuries. Varaztad Kazanjian and Blair, two men hired for plastic surgery by the United States army, learned from Gillies in England.^[12] His work was expanded upon during World War II by his cousin and former student Archibald McIndoe, who pioneered treatments for RAF aircrew suffering from severe burns. McIndoe’s radical, experimental treatments, led to the formation of theGuinea Pig Club. In 1946, Gillies carried out the first female-to-male sex reassignment surgery.

Techniques and procedures

In plastic surgery, the transfer of skin tissue (skin grafting) is a very common procedure. Skin grafts can be taken from the recipient or donors:

·                    Autografts are taken from the recipient. If absent or deficient of natural tissue, alternatives can be cultured sheets of epithelial cells in vitro or synthetic compounds, such as integra, which consists of silicone and bovine tendon collagen with glycosaminoglycans.

·                    Allografts are taken from a donor of the same species.

·                    Xenografts are taken from a donor of a different species.

Usually, good results are expected from plastic surgery that emphasizes careful planning of incisions so that they fall in the line of natural skin folds or lines, appropriate choice of wound closure, use of best available suture materials, and early removal of exposed sutures so that the wound is held closed by buried sutures.

Reconstructive surgery

Navy doctors perform reconstructive surgery on a 21-year-old patient

“Reconstructive” redirects here. For other uses, see Reconstructive plastic surgery.

Reconstructive plastic surgery is performed to correct functional impairments caused by burns; traumatic injuries, such as facial bone fractures and breaks; congenital abnormalities, such as cleft palates or cleft lips; developmental abnormalities; infection and disease; and cancer or tumors. Reconstructive plastic surgery is usually performed to improve function, but it may be done to approximate a normal appearance.

The most common reconstructive procedures are tumor removal, laceration repair, scar repair, hand surgery, and breast reduction plasty. According to the American Society of Plastic Surgeons, the number of reconstructive breast reductions for women increased in 2007 by 2 percent from the year before. Breast reduction in men also increased in 2007 by 7 percent. Some other common reconstructive surgical procedures include breast reconstruction after a mastectomy, cleft lip and palate surgery, contracture surgery for burn survivors, and creating a new outer ear when one is congenitally absent.

Plastic surgeons use microsurgery to transfer tissue for coverage of a defect wheo local tissue is available. Free flaps of skin, muscle, bone, fat, or a combination may be removed from the body, moved to another site on the body, and reconnected to a blood supply by suturing arteries and veins as small as 1 to 2 millimeters in diameter.

Cosmetic surgery[edit]

Cosmetic surgery is an optional procedure that is performed oormal parts of the body with the only purpose of improving a person’s appearance and/or removing signs of aging, studies prove that this type of surgery play an important role in a person’s self-esteem because the physical appearance is an important status equivalent to gender or race and by making changes to the body it contributes not only to the patient’s physical appearance but also to the mental health of the patient.

In 2006, nearly 11 million cosmetic procedures were performed in the United States alone. The number of cosmetic procedures performed in the United States has increased over 50 percent since the start of the century. Nearly 12 million cosmetic procedures were performed in 2007, with the five most common surgeries being breast augmentation, liposuction, nasal surgery, eyelid surgery and abdominoplasty. The American Society for Aesthetic Plastic Surgery looks at the statistics for thirty-four different cosmetic procedures. Nineteen of the procedures are surgical, such as rhinoplasty or facelift. The nonsurgical procedures include Botox and laser hair removal. In 2010, their survey revealed that there were 9,336,814 total procedures in the United States. Of those, 1,622,290 procedures were surgical (p. 5). They also found that a large majority, 81%, of the procedures were done on Caucasian people (p. 12).^[13] The increased use of cosmetic procedures crosses racial and ethnic lines in the U.S., with increases seen among African-Americans and Hispanic Americans as well as Caucasian Americans. In Europe, the second largest market for cosmetic procedures, cosmetic surgery is a $2.2 billion business.^[14] Cosmetic surgery is now very common in countries such as the United Kingdom, France, and Germany. In Asia, cosmetic surgery has become an accepted practice, and countries such as China and India has become Asia’s biggest cosmetic surgery markets.^[15] Thailand is also one of the main cosmetic surgery markets in Asia, in particular for affordable breast augmentation and sex reassignment surgery, with international patients coming from Australia, Europe and neighboring Asian countries.^[16]

The most prevalent aesthetic/cosmetic procedures include:

·                    Abdominoplasty (“tummy tuck”): reshaping and firming of the abdomen

·                    Blepharoplasty (“eyelid surgery”): reshaping of the eyelids or the application of permanent eyeliner, including Asian blepharoplasty

·                    Phalloplasty (“penile liposuction”) : construction (or reconstruction) of a penis or, sometimes, artificial modification of the penis by surgery, often for cosmetic purposes

·                    Mammoplasty:

·                                Breast augmentations (“breast implant” or “boob job”): augmentation of the breasts by means of fat grafting, saline, or silicone gel prosthetics, which was initially performed to women withmicromastia

·                                Reduction mammoplasty (“breast reduction”): removal of skin and glandular tissue, which is done to reduce back and shoulder pain in women with gigantomastia and/or for psychological benefit men with gynecomastia

·                                Mastopexy (“breast lift”): Lifting or reshaping of breasts to make them less saggy, often after weight loss (after a pregnancy, for example). It involves removal of breast skin as opposed to glandular tissue

·                    Buttock augmentation (“butt implant”): enhancement of the buttocks using silicone implants or fat grafting (“Brazilian butt lift”) and transfer from other areas of the body

·                                Buttock lift: lifting, and tightening of the buttocks by excision of redundant skin

·                    Chemical peel: minimizing the appearance of acne, chicken pox, and other scars as well as wrinkles (depending on concentration and type of agent used, except for deep furrows), solar lentigines (age spots, freckles), and photodamage in general. Chemical peels commonly involve carbolic acid (Phenol), trichloroacetic acid (TCA), glycolic acid (AHA), or salicylic acid (BHA) as the active agent.

·                    Labiaplasty: surgical reduction and reshaping of the labia

·                    Lip enhancement: surgical improvement of lips’ fullness through enlargement

·                    Rhinoplasty (“nose job”): reshaping of the nose

·                    Otoplasty (“ear surgery”/”ear pinning”): reshaping of the ear, most often done by pinning the protruding ear closer to the head.

·                    Rhytidectomy (“face lift”): removal of wrinkles and signs of aging from the face

·                                Browplasty (“brow lift” or “forehead lift”): elevates eyebrows, smooths forehead skin

·                                Midface lift (“cheek lift”): tightening of the cheeks

·                    Chin augmentation (“chin implant”): augmentation of the chin with an implant, usually silicone, by sliding genioplasty of the jawbone or by suture of the soft tissue

·                    Cheek augmentation (“cheek implant”): implants to the cheek

·                    Orthognathic Surgery: manipulation of the facial bones through controlled fracturing

·                    Fillers injections: collagen, fat, and other tissue filler injections, such as hyaluronic acid

·                    Brachioplasty (“Arm lift”): reducing excess skin and fat between the underarm and the elbow^[17]

·                    Laser Skin Rejuvenation or Resurfacing:The lessening of depth in pores of the face

·                    Liposuction (“suction lipectomy”): removal of fat deposits by traditional suction technique or ultrasonic energy to aid fat removal

·                    Keloid removal – The keloid forms when the body fails to stop producing new tissue during healing. This leads to an overabundance of fibrous protein and collagen.^[18]

Sub-specialties

Plastic surgery is a broad field, and may be subdivided further. In the United States, plastic surgeons are board certified by American Board of Plastic Surgery and the American Osteopathic Board of Surgery.^[19][20] Subdisciplines of plastic surgery may include:

Burn

Burn surgery generally takes place in two phases. Acute burn surgery is the treatment immediately after a burn. Reconstructive burn surgery takes place after the burn wounds have healed.

Cosmetic

Aesthetic surgery is an essential component of plastic surgery. Plastic surgeons use cosmetic surgical principles in all reconstructive surgical procedures as well as isolated operations to improve overall appearance.^[21]

Craniofacial

Craniofacial surgery is divided into pediatric and adult craniofacial surgery. Pediatric craniofacial surgery mostly revolves around the treatment of congenital anomalies of the craniofacial skeleton and soft tissues, such as cleft lip and palate, craniosynostosis, and pediatric fractures. Adult craniofacial surgery deals mostly with fractures and secondary surgeries (such as orbital reconstruction) along with orthognathic surgery. Craniofacial surgery is an important part of all plastic surgery training programs, further training and subspecialisation is obtained via a craniofacial fellowship.

Hand

Hand surgery is concerned with acute injuries and chronic diseases of the hand and wrist, correction of congenital malformations of the upper extremities, and peripheral nerve problems (such as brachial plexus injuries or carpal tunnel syndrome). Hand surgery is an important part of training in plastic surgery, as well as microsurgery, which is necessary to replant an amputated extremity. The Hand surgery field is also practiced by orthopedic surgeons and general surgeons (see Hand surgeon). Scar tissue formation after surgery can be problematic on the delicate hand, causing loss of dexterity and digit function if severe enough.

Micro

Microsurgery is generally concerned with the reconstruction of missing tissues by transferring a piece of tissue to the reconstruction site and reconnecting blood vessels. Popular subspecialty areas are breast reconstruction, head and neck reconstruction, hand surgery/replantation, and brachial plexus surgery.

Pediatric

Children often face medical issues very different from the experiences of an adult patient. Many birth defects or syndromes present at birth are best treated in childhood, and pediatric plastic surgeons specialize in treating these conditions in children. Conditions commonly treated by pediatric plastic surgeons include craniofacial anomalies, cleft lip and palate and congenital hand deformities.