Principles of burn reconstruction: Face, scalp, and neck

INTRODUCTION — The goals of reconstructive surgery for the burn patient are first to restore function, then to restore aesthetic appearance. Nowhere else in the body is it more important to achieve good functional reconstruction matched with perfect cosmetic appearance than in the head and neck, and specifically the face.

Cutaneous scarring following burn injury gives rise to characteristic post-burn physical and psychosocial morbidity. Modulation of the burn scar using physical and surgical techniques including pressure therapy, massage, exercise, intralesional steroids, laser therapy, and autologous fat transfer have all been used to modulate hypertrophic burn scar [1]. Laser and intense pulsed light therapy has become a valuable tool in scar modulation by decreasing scar erythema, reducing thickness, increasing pliability, reducing pain and pruritus, and improving scar color and texture [2]. Autologous fat transfer also improve burn scar pliability and objective appearance [3]. It can also be helpful for managing contour defects and irregularities.

Reconstruction of burns to the face, scalp, and neck areas is reviewed. An overview of the treatment of superficial (epiderma, superficial partial thickness) and deep burns (deep partial thickness, full thickness) (table 1), reconstructive procedures, and care of patients with moderate-to-severe burns are reviewed separately. (See "Overview of the management of the severely burned patient" and "Treatment of superficial burns requiring hospital admission" and "Treatment of deep burns" and "Overview of surgical procedures used in the management of burn injuries".)

GENERAL PRINCIPLES — Following resuscitation and stabilization, management of the burn wounds becomes the next priority. The later effects of burns, which are related to loss of normal tissue and scarring, include limitation of movement, pain, disfigurement, and social embarrassment [4].

The following are the basic tenets for reconstruction of burns to the face, scalp, and neck regions:

●Replace like tissue with like tissue (eg, the best replacement for scalp tissue is the scalp) when possible.

●Multidisciplinary, realistic, well-timed reconstructive plan discussed with the patient.

●Prioritize function over cosmesis but combine whenever possible.

●Reconstruct areas of paramount functional importance first, specifically those surrounded by sphincters, such as the mouth and lips to avoid microstomia and the eyelids to avoid exposure keratopathy and cicatricial ectropion.

●Consider early release and reconstruction of the neck with pliable tissue to avoid further secondary contracture.

●Respect the principle of cosmetic subunits in the face.

●Tissue expansion increases the amount of pliable autologous skin available for reconstruction. (See "Overview of surgical procedures used in the management of burn injuries", section on 'Tissue expansion'.)

●Meticulous attention must be paid to operative details. Awareness of important anatomical landmarks such as the facial nerve, the head and neck vasculature, and the aesthetic areas of eyelids, nose, and ears is fundamental.

Burn wound classification — Burns are classified according to the depth of tissue injury (table 1). Burns to the face, with the exception of a sunburn, are never considered minor given that even small burns affect function and/or cosmesis. (See "Assessment and classification of burn injury" and "Topical agents and dressings for local burn wound care".)

BURNS TO THE FACE — Burns to the face are particularly challenging because of the potential functional impairments and aesthetic disfigurements caused by deep burn injuries. Superficial burns to the face are potentially self-healing and are best managed initially by daily gentle washes, followed by the application of a topical cytoprotective or moisturizing agent. Excessive drying or desiccation of a potentially self-regenerating wound should be avoided to prevent conversion of a superficial burn to a deep burn injury. Dermal regeneration templates (biosynthetic skin substitutes) can be used to introduce a dermal component in intermediate partial-thickness or full-thickness wounds when dermal pliability may be compromised [5,6]. Evidence for reconstruction of the face and its components is based upon observational studies and the clinical setting.

Facial transplantation procedure, a controversial reconstructive technique, offers hope to patients with severe facial burns or other deformities. Facial transplantation remains predominantly an experimental technique [7]. Restrictions to this procedure include a limited availability of facial tissue allografts, inherent complexity of the technique, required presence of a skilled multidisciplinary surgical team, and a lifelong requirement for immunosuppression [8]. Postoperative sensory recovery is reported to occur between three and six months, and acceptable motor recovery occurs between 9 and 12 months [9]. In a review of 28 procedures performed worldwide, episodes of acute skin rejection have been able to be controlled with conventional immunosuppressive agents with no cases of chronic rejection reported [10]. Immunosensitization with the use of human allograft skin has been reported in the acute setting [11], which may have a negative impact of the results of subsequent composite tissue allotransplant [12]. Long-term outcomes of facial transplantation both from the physical and psychological point of view are not yet available.

Ear — The skin covering the ear frame is firmly bound to the cartilage, as the ear lacks a subcutaneous layer and vascularity is dependent on the blood supply from branches of the superficial temporal, occipital, and posterior auricular arteries. Therefore, there is little protection or insulation of the cartilage from injury. Burn injury distorts the delicate cartilage, creating scars, deformities, and loss of elasticity. Reconstruction of ear burns is more difficult than other types of ear trauma. In a large retrospective review of reconstruction in 249 patients with traumatized ears, those with burned ears had worse results compared with other mechanisms of injury [13].

Superficial burns to the ear that do not damage or expose the cartilage are treated conservatively with topical antimicrobial ointments and dressing changes. This includes shaving the hair around the ear, assessing the burn depth, daily cleansing, and application of a topical ointment [14]. External pressure and overzealous debridement of the ear should be avoided to minimize tissue loss. Topical antimicrobial ointments (table 2), such as mafenide acetate, are advocated to prevent infection from converting a superficial partial-thickness to a deep partial-thickness burn. Mafenide acetate has a broad spectrum of activity and penetrates eschar. In a retrospective review of 76 patients with ear burns treated with conservative management and mafenide acetate, only two patients (2.6 percent) developed chondritis, a painful and destructive process of the cartilage [15]. (See "Topical agents and dressings for local burn wound care", section on 'Mafenide acetate'.)

Reconstruction of the burned ear is complex and depends mainly on the depth, not necessarily the extent, of the injury [16]. A number of classifications of the burned ear have been suggested [17,18]. Reconstruction should provide skin coverage and cartilage support if it is damaged or exposed. The following procedures are available to reconstruct the burned ear:

●Burns restricted to small areas of skin or cartilage loss are amenable to a primary direct closure, provided the closure will not alter the projection or shape of the ear.

●Deep burn injury that exposes or damages the cartilage is debrided to the level of healthy, unburned tissue and protected from desiccation and necrosis by coverage with vascularized tissue (eg, unburned full-thickness skin graft, temporoparietal fascial flap).

●For total or near-total destruction of the ear, reconstruction can be performed as a single procedure or as staged procedures with various local flaps, such as the temporoparietal fascial flap [19,20]. When unburned local or regional skin is not available for coverage, distant free flaps can be used [21]. When autologous tissue is limited, a bone-anchored prosthesis is an option [22].

●Conchal cartilage may be used for small defects, and autologous costal cartilage may be used for defects that involve more than 25 percent of the helical rim or more than two ear planes (helix, antihelix, and scapha) [23]. However, in a retrospective review of 25 burned ears reconstructed with a costal cartilage framework, only six ears had an excellent cosmetic result, and seven had a good result [13]. Successful outcome of reconstruction of the burned ear depended on the degree of damage to the surrounding tissues. Coverage of the cartilage framework by unburned mastoid skin was a critical factor for an acceptable outcome in this study.

●Defects of the helical rims can be covered by local helical advancement techniques (Antia-Buch flap) [24,25] or by tube pedicle flaps from the retroauricular skin. Local flaps and helical advancement flaps may provide sufficient coverage for defects that involve the upper or middle third of the ear, but autologous conchal or costal cartilage may be necessary to reconstruct the auricle. Skin cover can be provided by tube pedicles, or a combination of temporoparietal fascial flap and skin grafting.

●The ear can show a dramatic resilience to burn injury when basic principles of reconstruction are followed. In severe cases where burned ear cartilage is present, fashioning a retroauricular skin pocket to bury the underlying cartilage can provide salvage to the anatomical integrity of the ear with good cartilage memory and elasticity [26].

●Ultimately, each burned ear reconstruction is unique, requiring tailored individual reconstructive treatment. The quality of the adjacent tissue, the choice of framework, and the use of both autologous and emerging tissue engineering techniques, including three-dimensional printing of cartilage and the use of cell techniques, play important roles in the treatment plan [27].

Ocular — Burns to the eyelid, periorbital region, sclera, conjunctiva, and cornea are classified as ocular burns. The eyes must always be evaluated in burns to the face, and an ophthalmologist should be consulted, and a fluorescein test should be performed to assess the presence of corneal damage. Thermal and chemical ocular burns may result in exposure keratopathy, infection, and loss of central and/or peripheral vision [28,29]. Other non-burn ocular injuries may be present in those who suffer concomitant traumatic injury. (See "Overview of eye injuries in the emergency department".)

Immediate and copious irrigation with sterile saline solution (or water if no other option is available) should be performed for chemical burns. Other options of neutralization include the use of amphoteric and buffer solutions [30]. A topical ophthalmologic anesthetic can be used in the eyes to facilitate irrigation, and a non-steroid-containing topical antimicrobial ointment can be applied to the eyes.

Burned eyelashes and eschar should be debrided. An eye patch may be needed in the case of a thermal injury or lid retraction from a splash injury. Artificial tears are used if the lacrimal ducts are burned. For pain relief, oral or systemic analgesics are effective, and cool saline compresses can be applied to the eyelids.

Eyelid — Eyelid burns occur in approximately 10 percent of all thermal injuries [31]. There is no consensus on the best reconstructive procedures for eyelid burns short of providing the best anatomical and cosmetic result combined with adequate protection to the cornea. Ultimately the aim is to replace like with like.

The eyelid is composed of an anterior and a posterior lamella. The anterior lamella consists of skin, subcutaneous tissues, and the striated orbicularis muscle. The posterior lamella includes the tarsal plate, a layer of smooth muscle (Müller palpebral muscle), and the bulbar conjunctiva. Reconstruction of the eyelid multilamellar structures present formidable challenges due to the lack of pliable tissue for cover, mucosal tissue for lining, and support tissue for mechanical integrity, and delayed scar maturation. Because of the complexity of the anatomy and the inflammatory response to the burn, reconstruction may be delayed following the injury, provided appropriate eye protection can be achieved, otherwise, urgent reconstruction will be necessary [31,32]. While awaiting reconstruction, the eye is protected from trauma using topical antibiotics. (see "Blepharitis", section on 'Topical antibiotics')

Reconstruction of the anterior lamella with tarsal involvement may be performed with split- or full-thickness graft; however, multiple procedures to release recurrent contractures may be required. Reconstruction of anterior lamellar defects without tarsal involvement includes direct closure of small burns, full-thickness or partial-thickness skin grafts, and local flaps. Reconstruction of full-thickness defects involving both lamellae depends on the size of the defect. Defects involving one-third to one-half of the upper lids can be reconstructed with direct closure or myocutaneous flaps with canthal release. For more extensive defects, the options include bridging techniques (occlusive or eyelid-sharing) or non-bridging techniques with lamellar flaps and posterior lamellar graft (hard palate, nasal or buccal mucosa) or bilamellar grafts with orbicularis mobilization [33,34]. Free tissue transfer (eg, radial forearm flap, anterolateral thigh flap) is an option to reconstruct upper and lower eyelids [35].

Reconstruction of the eyelid depends on the depth of the burn and the amount of unburned pliable tissue available. Any eyelid burn, with the exception of a very superficial burn, will create eyelid retraction and cicatricial ectropion. The following illustrates our algorithm for reconstructing eyelid burns:

●For burn scars involving only the anterior lamellar structures, the reconstruction involves simple release of the contracture and full-thickness skin grafting. Hooding of the medial canthus is usually addressed with a 5-flap plasty or a V-M plasty, which combines the principles of the V-Y plasty and the Z-plasty [36].

●For deep or more extensive defects of the anterior lamellar structures, tissue from the lower lid (if it is available and unburned) can be utilized with or without skin grafts to provide support if the tarsal plate is missing.

•The main concern to take into account is to provide cover for the cornea to avoid exposure keratopathy and desiccation.

•The main problem faced is to replicate the delicate, thin, mobile structure represented by the eyelid lamellae.

•If no local tissue is available, distant reconstruction with regional flaps (eg, temporoparietal flap, forehead flap) or free flap (eg, posterior auricular chondrocutaneous, anterior lateral thigh, radial forearm flap) may be necessary.

Ultimately, the site of injury (upper eyelid versus lower eyelid) and the size of the defect (up to 25 percent, 25 to 50 percent, larger than 50 percent) dictates reconstruction principles like in any other form of trauma-related eyelid tissue loss [32].

Eyebrow — Burns to the eyebrow destroy the hair-bearing potential of this skin. Reconstruction is complicated due to the non-uniform hair growth of the eyebrow that is difficult to replicate. The eyebrow can be reconstructed using a superficial temporal artery island flap, a composite, mini, or micrograft from scalp [37], or local advancement flaps [38]. In our practice, we use mainly strip grafts with the occasional use of micrografts, as these offer minimal morbidity with good outcomes.

Eyelashes — Hair follicular unit transplantation offers the most delicate and cosmetically pleasing outcomes for reconstruction of burned eyelashes [39,40]. The techniques that we use are similar to the hair-bearing options discussed in eyebrow reconstruction. The eyebrow can be used as a composite graft for reconstruction of the eyelashes [41].

Lip — Reconstruction of the burned lip is performed to improve functional and aesthetic outcomes once conservative scar therapy approaches have been tried and exhausted. Microstomia is a complication of burn injury to the mouth area and causes limitations of speech, jaw movement, tongue movement, oral intake, oral continence, and oral hygiene as well as facial distortion.

Upper- and lower-lip scar contracture resulting in deformity or impaired function can usually be addressed using simple methods such as Z-plasty or local flap transposition for linear or narrow scar bands. Persistent larger and more extensive contractures affecting significant portions of the upper or lower lip are often best dealt with by scar excision and resurfacing of cosmetic units using full-thickness skin grafts.

Injury to the commissures is particularly debilitating. No ideal method of reconstruction has been identified [42].

In a similar priority to reconstruction for burns to the eyelid, microstomia represents a potential urgent need for reconstruction, as early surgical intervention before scar maturation may be necessary to reestablish oral competence. There are a number of non-operative options that can be used (eg, splints, dental appliances) which need to be explored prior to potential surgery [43]. In a retrospective review of 18 patients suffering with microstomia from facial burns, an acceptable aesthetic appearance and good functional recovery was achieved in all patients with reconstruction of the oral commissures performed by scar excision and local mucosal flap advancement, wound closure with full-thickness or partial-thickness skin grafts, or rhomboid mucosal flaps resulted [44]. Mucosal advancement flaps provided better aesthetic and functional results compared with skin grafts. The use of a trapeze-flap plasty has been reported to achieve a normal-size oral opening [45].

Other innovative options include the use of cervical tubed flaps [46], pre-expanded scalp tissue [47], or procedures based on oncologic techniques. All local advancement procedures are limited by availability of perioral unburned skin. Free flap reconstruction can be used when no unburned skin or oral mucosa is available. (See "Overview of surgical procedures used in the management of burn injuries", section on 'Burn wound coverage'.)

Nose — The nose is a central, prominent, and frequently deformed structure in the burned face. Cosmetic and functional embarrassment for the patient is considerable. The secondary reconstruction starts only when scars are mature, usually after two years. The nose is a tridimensional tissue pyramid consisting of three tissue layers: inner lining, framework support, and soft tissue cover. Depending on the depth of the burn, all three layers may require reconstruction. There is no consensus on the best reconstructive or aesthetic procedure to use to reconstruct the burned nose.

Full-thickness or partial-thickness skin grafts or a combination of grafts and a dermal substitute may be used for partial-thickness defects with intact framework and lining. Local flaps (eg, bilateral nasolabial) or regional flaps can be used for larger defects. Regional flaps include forehead flap [48], deltopectoral flaps [49], cervical tube pedicle flap [46], flaps based in the temporal artery territory [50], or complex options such as a pre-expanded scalp skin [51].

Framework reconstruction is mandatory for deep burn defects with loss of the tridimensional projection. Full reconstruction is needed to support, augment, or enhance the nasal projection. Reconstructive options include costal cartilage, bone grafts from the radius or ulna, and split calvarial bone graft [52]. Alloplastic materials can be used to increase the nasal projection; however, extrusion, infection, and/or prosthesis displacement are complications of this technique.

The classic aesthetic rhinoplasty procedures are applicable to burns involving the nose [53]. In a retrospective review of 13 patients with complete or subtotal nasal burns and severely burned or grafted skin, there was no necrosis of the tissues following aesthetic procedures. The use of free flaps (eg, prelaminated osteocutaneous radial forearm flap) combines tissue for lining, support, and coverage of the burn defect [54]. Scar contractures occluding the nostrils are usually managed with a combination of release, local flaps, and full-thickness skin grafts [55].

Cheek — Burns to the cheek are generally treated conservatively with local topical agents; however, if conservative management will result in early scarring or distortion of surrounding sphincter structures (eg, nose, eye canthi) because the burn is deep, or if the burn is not healed in three weeks, primary reconstruction can be performed with skin grafts from the scalp [56].

For those that are conservatively managed, scars in the cheek area can be treated as soon as the burns are healed. Laser techniques are effective in dealing with all abnormal functional and cosmetic features of scarring, including pigmentation, vascularity, pliability, and thickness. Ablative and non-ablative techniques including pulse dye (hypervascularity) and CO₂ lasers (hypertrophy and thickness reduction) are used. There is growing evidence that laser therapy should be included in burn scar treatment protocol before surgery and also as an adjuvant therapy to traditional interventions [57-59]. The use of pulse dye laser (PDL) for hypervascularity and CO₂ laser to modulate the thickness and contracture of scars are useful methods to improve function and cosmetic appearance in facial burn scarring. In the authors' practice, more than 300 patients have been treated with these techniques to improve outcomes [60,61]. In our burn unit, we treat scars with three to five treatments of pulse dye lasers and CO₂ laser separated by six to eight weeks prior to any surgical intervention. Burn scars mature between 12 and 24 months following the injury. Secondary reconstruction is planned following full scar management and/or laser therapy to obtain as much supple tissue as possible.

Most cheek defects to be addressed with primary closure, local flaps, or locoregional flaps. Key points of cheek reconstruction include the following [62]:

●Attention to symmetry, contour, color, and texture of the contralateral cheek.

●Awareness of orientation of relaxed skin tension lines, lines of maximum extensibility, surface contour, subcutaneous anatomy, patient age, comorbidities, prior surgery or radiation, wound size, depth, and location relative to central face subunits.

Full-thickness scalp graft provides the best match in terms of texture and color for the cheek. The size of the graft from the donor site is limited due to excessive scarring and alopecia. Donor full-thickness skin from the supraclavicular area, postauricular area, the medial skin of the upper arm, and the lateral thoracic skin are suitable sources of matching reconstructive grafts for the face [52].

Small local flaps based on the Z-plasty transposition principle relocate scars and redirect contractures. These procedures are particularly important for treating contracture deformities affecting the eyes, mouth, or nose. (See "Z-plasty".)

While aesthetic results of using skin substitutes for facial burns are variable, they provide an acceptable alternative to autografts [63-65]. No randomized trials have been performed to determine the role of skin substitutes in reconstruction of burns to the face. However, skin substitutes cannot be used without subsequent autografting. Early reconstruction does not offer results that are any better than full-thickness grafting. In a retrospective review of 12 patients with deep facial burns, the use of skin substitutes resulted in excellent color, minimal visible skin graft junctures, and good texture but less pliability when compared with thick autografts [65]. In other studies, skin substitutes resulted in acceptable aesthetic and functional outcomes [63,64]. (See "Skin substitutes".)

Regional pedicled flaps (eg, chest, deltopectoral) from unburned skin can match the color and texture of the recipient site and provide pliability with the presence of healthy dermis [47,49,50,53,66-69]. Flaps can be used with or without tissue expansion. The expanded cervicofacial flap reconstructive technique provides staged coverage of the burned face [67]. The first stage involves placing a single rectangular tissue into a subcutaneous pocket created in the anterior neck and the port in the infraclavicular area. The expander is inflated intraoperatively. The second stage involves inflating the expander. Once maximum insertion is achieved, the expander is removed, the burn defect is excised, and the tissue flap is advanced to cover the defect. The use of osmotic tissue expanders introduces a port-free option of reconstruction, even though careful surveillance is necessary to prevent infection and early extrusion. Expanders can be inserted endoscopically, with the potential advantages of lower risk of dehiscence, less disruption of normal tissue, smaller and remote incisions for insertion of the expander, and lower risk of infection [70]. (See "Overview of surgical procedures used in the management of burn injuries", section on 'Tissue expansion'.)

Free flap surgery (eg, radial forearm or anterolateral thigh fasciocutaneous flaps) is the most complicated reconstructive option and is reserved for situations when there is no other option of pliable skin or when deep structures (eg, frontal sinuses) must be covered.

BURNS TO THE SCALP — Burns to the scalp should be carefully cleansed and debrided to remove loose, devitalized, and necrotic tissue. Topical antimicrobial agents and dressings are applied as the burn wound is being prepared for grafting or another type of tissue or biologic substitute coverage. Evidence for reconstruction of the scalp is based upon observational studies and the clinical setting. (See "Topical agents and dressings for local burn wound care" and "Overview of surgical procedures used in the management of burn injuries".)

Goals — The goals of scalp reconstruction are to provide full coverage of the calvarium to prevent desiccation, sequestration, and infection, and to cover the defect with hair-bearing skin. The type of reconstruction depends on several factors, including [71]:

●Size, depth, and location of the defect in the scalp

●Presence or absence of periosteum

●Quality of surrounding scalp tissue

●Presence or absence of hair

●Location of the hairline

●Patient comorbidities

Reconstruction options — Burns to the scalp are best covered by skin from the scalp, if at all possible. Other reconstruction options depend on tissue availability, extensiveness of the burn, and location [72-74]. (See "Z-plasty".)

Anterior — The principle goal of reconstruction of burns in the anterior portion of the scalp is restoration of hair-bearing skin to recreate the anterior hairline. A rotational flap should be designed to avoid distortion of the anterior or temporal hairline.

●Small defects – For small defects (<2 cm²), the best surgical option is a primary closure. Redundant forehead skin is an excellent option. Advancement flaps based on a pedicle are also an option [75].

●Moderate defects – For moderate defects (2 to 25 cm²), successful coverage of the burn requires adjacent tissue transfer from rotation or advancement flaps, such as V-Y flaps, pedicled flaps, or rotation flaps.

●Large defects – For large defects (>25 cm²), a temporoparietal-occipital flap or an Orticochea flap are used to recreate the anterior hairline [76-78]. Large rotation flaps may restore hair anteriorly but require grafting of the donor site. If tissue expansion is an option, this is preferable to the Orticochea flap for a better cosmetic result.

Parietal — Burns to the parietal scalp are amenable to local tissue rearrangement [72]. The tissue of the parietal scalp is more mobile than other scalp tissue because the temporoparietal fascia, the lateral continuation of the galea aponeurosis, overlies the deep temporal fascia instead of the periosteum.

●Small defects – For small defects (<2 cm²), the burns can be closed primarily or by V-Y flaps, pedicled flaps, or rhomboid flaps [79]. The redirected hair follicles of the rhomboid flap serve as an excellent match for the burned hair-bearing pattern.

●Moderate defects – For moderate defects (2 to 25 cm²), rotation advancement flaps are the preferred coverage. Bilobed flaps also provide excellent coverage in this area [80].

●Large defects – For large defects (≥25 cm²), skin grafts may be applied if bone is not exposed. Tissue expansion is the only technique that provides satisfactory coverage of a large parietal burn defect. An Orticochea flap is not used in this area because tissue advancement from the contralateral parietal scalp is often inadequate for tissue coverage. Large bipedicled fronto-occipital flaps have been used but require skin grafts to the donor site, with unfavorable cosmetic results [81].

Occipital — Burns to the occipital scalp are amenable to local tissue transfer because of the moderate skin mobility in this area [72]. Depending on the size of the burn, the occipital hairline may be restored, but this area is not as cosmetically sensitive as the anterior scalp.

●Small defects – For small defects (<2 cm²), the best option is a primary closure.

●Moderate defects – For moderate defects (2 to 25 cm²), rotation advancement flaps are used. Dissection can be carried over the neck in order to obtain tissue to cover the burn, but care must be taken to preserve the posterior hairline. Islanded pedicled V-Y advancement flaps are based on the ipsilateral occipital artery. The donor site can be closed primarily and the operation performed in a single stage [82].

●Large defects – For large defects (>25 cm²), larger rotation flaps (eg, Orticochea flap) are used. Tissue expansion of adjacent skin also provides satisfactory coverage.

Vertex — The vertex of the scalp has limited mobility and requires extensive undermining and recruitment of tissue from the more mobile anterior, parietal, and occipital areas of the scalp [72]. If at all possible, the whorl pattern of hair at the vertex should be preserved.

●Small defects – For small defects (<2 cm²), subgaleal dissection and primary closure may be possible. An alternative repair to a primary closure is a local flap, such as a rhomboid flap. This is preferred if tension is present on the primary closure.

●Moderate defects – For moderate defects (2 to 25 cm²), double opposing rotation flaps are an excellent option for coverage. Another alternative is a rotation flap from the occipital region, with skin grafting to the donor site. Pinwheel and rhomboid flaps are less useful in the moderate-sized defects of the vertex.

●Large defects – For large defects (>25 cm²), the only alternative for coverage is a very large rotation flap with skin grafts to the donor site. Tissue expansion offers the best result for coverage in this area.

Total or nearly total defects — The best technique to cover a total loss of skin is a free flap [72]. Free tissue transfer allows for complete skin reconstruction and can be performed in one stage. If the superficial temporal vessels are damaged, arterial branches of the external carotid artery and internal jugular vein may be used. The latissimus dorsi musculocutaneous flap has a long pedicle and provides the best coverage. However, muscle flap atrophy can result in delayed exposure of the calvarium. Other options for coverage of the near-total defect of the scalp include radial forearm flap, parascapular and anterolateral thigh perforator flaps, and omentum.

Exposed calvarium — An exposed calvarium can by covered with either a free flap [83,84] or tissue expansion [85,86]. If the integrity of the calvarium is compromised by damage to the bone tables of the skull leaving exposed meningeal or neural tissue content, neurosurgical consultation is necessary prior to burn reconstruction. If only the outer table is compromised, the area can be induced to granulate with the use of carefully performed burring of the outer table to the diploe, with or without postoperative topical negative pressure therapy (see "Negative pressure wound therapy"). A skin graft is subsequently placed.

Exposed dura — A full-thickness scalp defect with exposed dura can be reconstructed with dermal regeneration templates [87]. Exposed dura presents an additional risk to patient recovery, and a neurosurgical consultation is necessary prior to burn reconstruction. Secondary reconstruction can be performed with tissue expansion and local flaps based in the transposition, advancement, or rotation principles [88]. (See "Overview of surgical procedures used in the management of burn injuries", section on 'Use of skin substitutes' and "Skin substitutes".)

The use of tissue expansion for secondary scalp reconstruction requires careful planning and patient selection. The availability of sizes, shapes, and mechanisms of expansion with this technique is vast. Patient participation is fundamental to ensure success of this procedure, as multiple sessions of expansion may be necessary [89,90]. (See "Overview of surgical procedures used in the management of burn injuries", section on 'Tissue expansion'.)

BURNS TO THE NECK — Burns to the neck can result in significant functional and aesthetic complications. Secondary reconstruction of the burned neck aims to import pliable tissue to this delicate area. Burns can result in contractures that foreshorten the mentocervical distance, decrease cervical movement, and fix the head and neck in the flexion position. In severe cases, the dense scars can lead to complete fusion of the chin and the chest skin. The inferior pull of the contracture on the chin and adjacent tissues leads to an open-mouth appearance, with redundant lower lip and gum showing. This rigid deformity complicates oral continence, the ability to eat, and an intubation. Evidence for reconstruction of the neck is based upon observational studies and the clinical setting.

Laser techniques are applicable to scars in the neck, as they can improve abnormal features of scarring both in function and cosmesis. Laser therapy can be started from the very immediate period of wound healing and be repeated every six to eight weeks for at least five treatments [57-59]. Scar maturation occurs in approximately 12 to 24 months. Once scars have undergone non-surgical modalities of treatment including physical therapy and/or laser techniques, management of the scar is completed through secondary reconstruction of cervical contractures. The choice of reconstruction procedures should be based on tissue availability, degree of restriction of movement, and neck zones involved [91].

Small linear contracture bands can be released with Z-plasty-type procedures to realign or release scars. Transposition flaps will cover small-to-moderate neck burn defects satisfactorily, provided that the neck fascia and the platysma muscle are incorporated into the design. Postburn neck contractures can be lengthened 100 to 200 percent using the trapeze-flap plasty technique, described as the opposite transposition of trapezoid scar and fascial flaps [92]. Both flaps include scars, adipose tissue, platysma muscle, and deep cervical fascia. This procedure can eliminate the contracture and restore the mentocervical angle and head movement. In one small series, functional results were good in 24 of 26 patients [92].

Other options for releasing burn scar neck contractures include split-thickness skin grafts (STSGs), full-thickness skin grafts (FTSGs), and skin substitutes. STSGs are not the ideal option, as contractures can recur due to the lack of dermal elements that provide pliability. In patients with extensive burns, the availability of FTSGs may be limited. When available, FTSGs are an ideal option, as they are more pliable and develop fewer contractures in comparison with STSGs. Dermal regeneration templates provide improved pliability and better cosmetic results than STSGs. In a retrospective multicenter review of 89 burn patients with 127 contracture release procedures, a skin substitute resulted in favorable functional outcomes and a high rate of patient satisfaction, similar to those of full-thickness grafts without the donor-site morbidity [93]. Negative pressure wound therapy dressings provide an excellent option to control graft position and reduce the formation of hematomas. Grafted areas can also be bolstered with tie-over dressings consisting of nanocrystalline silver to provide local infection control. (See "Skin autografting" and "Skin substitutes".)

Regional flaps based on a pedicle or perforator, with or without a tissue expander, can cover the released neck burn defect with vascularized tissue. A complex algorithm was described for reconstruction of cervical burn defects by classifying the neck into different territories and applying a free flap option to each territory [91]. The reconstructive territories were classified as central above, central below, central above and below, and lateral. Reconstruction based on an undamaged superficial cervical artery with tissue expansion and the superficial transverse cervical artery combined with the bilobed flap principle resulted in a significant improvement in neck range of motion. The functional outcome of improved range of motion was best in the central above territory, while etiology of the burn and time between injury and reconstruction had no impact on the functional outcome.

Free flaps (eg, inguinal region, scapula, anterolateral thigh) can be used to resurface wide contractures in the neck [91,94]. Optimal neck contouring is difficult to obtain because of the bulkiness and the limitations in the size of the flaps. To improve aesthetic and functional results, free flap donor sites in the groin and scapular regions were prepared by controlled tissue expansion prior to transfer to the neck in eight patients [94]. All eight patients demonstrated full neck extension and a good aesthetic result; five required minor secondary flap revisions. The advantages of the pre-expansion of the donor site include an increase in tissue for reconstruction; an increase in vascularity, pliability, and elasticity of the donor flap; and minimal donor site scarring. The disadvantages are that this is a two-stage procedure, and there are risks associated with tissue expansion. (See "Overview of surgical procedures used in the management of burn injuries", section on 'Tissue expansion'.)

CO₂ and pulse dye lasers can be used to modulate the abnormal behavior of burn scars in the neck both for cosmetic and functional appearance [60,61].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)

SUMMARY AND RECOMMENDATIONS

●General principles – The goals of reconstructive surgery for the burn patient are first to restore function, then to restore aesthetic appearance. Following resuscitation and stabilization, management of burn wounds becomes the next priority. The later effects of burns, which are related to loss of normal tissue and scarring, include limitation of movement, pain, disfigurement, and social embarrassment. (See 'Introduction' above and 'General principles' above.)

●Burn reconstruction – The type of reconstruction procedure selected depends on the location of the burn, the extensiveness of the injury, and the availability of donor skin and tissue. The optimal reconstructive procedure will vary from patient to patient.

•Face – Areas of functional importance are reconstructed first, specifically those surrounded by sphincters, such as the mouth and lips to avoid microstomia and the eyelids to avoid exposure keratopathy and cicatricial ectropion. (See 'Burns to the face' above.)

•Ears – For superficial burns to the ears, gentle debridement is performed to preserve normal anatomic structures. The wounds are typically managed with antimicrobial ointments and dressings. For deep burns to the ears that expose or damage the cartilage, cautious debridement to healthy tissue is performed. Reconstruction with coverage from vascularized tissue is preferred. (See 'Ear' above.)

•Eyes – For burns to the eyes, a fluorescein test is performed to evaluate the cornea, an ophthalmologist is consulted, and topical ophthalmologic anesthetic and non-steroid-containing topical antimicrobial ointments are used. (See 'Ocular' above.)

•Scalp – For burns to the scalp, skin coverage from other areas of the scalp is preferred, if unburned scalp is available. If minimal healthy scalp skin is available, tissue expansion with implants is the reconstructive option of choice. Other reconstruction options include full-thickness skin grafts; tissue expansion; and/or advancement, rotation, or transposition flaps. (See 'Burns to the scalp' above.)

•Neck – For small linear contractures resulting from burns to the neck, a Z-plasty procedure to realign or release the scar can be performed. For more extensive scarring of the neck, full-thickness skin grafts, split-thickness skin grafts with a dermal regeneration template, tissue expansion, advancement flaps, rotational flaps, or free flaps are reconstructive options depending on tissue availability. (See 'Burns to the neck' above.)