7. PRP in burns

factors deposited in alpha granules of platelets and plasma proteins such as fibrin, fibronectin, and vitronectin [37, 46, 47]. While plasma proteins serve as a skeleton for the bone, connective tissue, and epithelial migration, cocktail of growth factors plays an important role in tissue repair and regeneration. Degradation of previously stored growth factors occurs after contact with coagulation triggers such as collagen and tissue thromboplastin. Platelet activation with exogenous thrombin is associated with massive thrombin release and may reduce biological activity. Ten minutes after platelet activation, platelets start to deliver growth factors and give 95% of these molecules to environment in an hour [21]. Therefore, platelets should be applied within 10 min after activation. After release growth factors attach to mesenchymal stem cells, osteoblasts, fibroblasts, endothelial cells, and transmembrane receptors expressed by epidermal cells. The best known growth factors are platelet-derived growth factor, fibroblast growth factor, transforming growth factor beta, epidermal growth factor, vascular endothelial growth factor, and insulin-like growth factor. This attachment triggers the internal signaling pathway and leads to the expression of gene sequences that increase the normal wound healing process, such as cell proliferation, matrix formation, osteoid production, and collagen synthesis. Topical application of PRP accelerates the reepithelialization process by upregulating regulatory proteins of cell cycle such as cyclin A and CDK4. PRP is a potent matrix metalloproteinase (MMP)-1 stimulator and, thus, allows the extracellular matrix to be reorganized during wound

PRP may also suppress inflammation by suppressing cytokine release and increases regeneration and reepithelization by triggering capillary angiogenesis. The involvement of macrophages in the wound healing process is also mediated by signal proteins released from platelets. PRP has also been reported to exhibit antimicrobial activity against microorganisms such as Escherichia coli, MRSA, Candida albicans, and Cryptococcus neoformans and to have analgesic effect. Additionally, the pH 6.5–6.7 of the PRP may explain its antibacterial property. Although it has been suggested that leukocytes in PRP accelerate the recovery of soft tissue injury by suppressing bacterial growth, it has been also claimed that PRP may cause local pain

and even suppress the healing process due to the inflammatory cytokines in it [50, 51].

In order for PRP therapy to be effective, it should contain 3–5 times the normal platelet level

suppress the wound healing with an opposite effect, because increase of the bioactive substances does not always mean a better effect. For example, at platelet concentrations higher

achieve the desired platelet concentration because of the large number of variable and poten-

A relation between growth factors in PRP with age and gender has not been detected. Since factors in PRP do not enter the cell or into the nucleus, it is assumed that there are no mitogenic

The use of PRP is contraindicated in coagulation defects (thrombocytopenia, anticoagulant use, hypofibrinogenemia), anemic situations, hemodynamic instability, and bovine thrombin

/μL). It is thought that, at very high platelet concentrations, it can

/μL, angiogenesis is suppressed. Eppley emphasizes that it is very difficult to

healing [48, 49].

94 Hot Topics in Burn Injuries

(approximately 0.8–<sup>1</sup> 106

tial interactions [24, 35, 52].

hypersensitivity [53, 54].

or carcinogenic properties of PRP [46].

than 1.5 106

Growth factors play a crucial role in normal wound healing as well as impaired wound healing. Growth factors, such as insulin-like growth factor-1 (IGF-1) and platelet-derived endothelial cell growth factor (PDGF), inhibit apoptosis pathways which provide a rapid cell turnover and, thus, catalyze the physiologic wound healing in different steps. It is also thought that direct or indirect effects of growth hormone on wound healing are related to IGF-1 expression [55].

PRP is a new therapeutic option that is increasingly used especially in the treatment of soft and bony tissue defects to increase the tissue formation capacity and in improvement of chronic wound healing process [56–59]. Platelet-rich plasma, a rich source of growth factors released by activated platelets, is obtained from centrifuged blood which is combined with calcium chloride and thrombin [57, 58, 60].

Platelets are critical in the wound healing process and migrate to the wound site immediately and initiate coagulation when any damage occurs. Platelets are good sources of growth factors and cytokines associated with wound healing. Multiple growth factors and cytokines, including platelet-derived endothelial cell growth factor (PDGF), transforming growth factor-b (TGF-b1 and TGF-b2), transforming growth factor-a (TGF-a), platelet thromboplastin, thrombospondin, platelet-activating growth factor-4, vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), coagulation factors, fibroblast growth factor (FGF), calcium, serotonin, histamine, and hydrolytic enzymes, with degranulation triggered by proteins such as thrombin are released by platelets [57, 58, 60].

Growth factors are key components of cellular activities related to wound repair. Growth factors mediate the migration of inflammatory cells into the wound site; they induce cell proliferation and differentiation and enhance extracellular matrix production and accumulation. Transforming growth factor beta is known to be an important mediator in tissue repair and has proven to be therapeutic in chronic nonhealing wounds [61, 62]. Platelet-derived endothelial cell growth factor promotes dermal regeneration, provokes protein and collagen synthesis that provides migration and angiogenesis, and increases TGF beta expression. Both transforming growth factor beta and platelet-derived endothelial cell growth factor are found at higher densities in PRP than platelet-poor plasma (PPP) [61].

Burn injury is a major reason of trauma that can result in death or disability, which requires a long recovery duration and high health care costs. In burn trauma, depth and size of burn injury, burn area, and patient age are the most important factors that affect the morbidity and mortality. Burn depth is also the most important parameter that determines the long-term appearance and functionality of the patient [63]. Conditions such as immunosuppression, extensive burn area, and malnutrition ensure an appropriate milieu for microorganisms, and unfortunately, infections are common and among the most important causes of morbidity and mortality in burn patients. Although the mortality rate is reduced with new treatment approaches in burn injuries, secondary infections and long recovery duration can still cause mortality. Early debridement and skin grafts can yield successful results, but inadequate graft donor area and unsuitable patient circumstances for surgery of burn patients are important obstacles for skin grafting [55, 62].

In these cases, using products that accelerate the wound healing process affects the morbidity and mortality of patients. Many different kinds of dressings or pharmacotherapies have been developed for this purpose, but these are very expensive, and mechanisms of action of these therapies are not fully documented [64–66]. Unfortunately, no optimal wound cover materials are currently available, but desired features of these materials include supporting increasing cells in wound healing, allowing vessel proliferation, keratinocyte adhesion, and differentiation and forming a barrier against fluid loss and microorganisms [62].

> loss, as well as improve the take rate of the skin grafts by decreasing continued bleeding, functioning as a fibrin glue, as well as providing a well-vascularized bed for the meshed skin graft. Furthermore, the positive effects of PRP on wound healing, as seen in reports on PRP in in vitro models, chronic and acute wounds, could contribute to faster closure of mesh interstices, because PRP promotes vascular ingrowth and fibroblast proliferation and possibly reepithelialization. A deep dermal burn also could benefit from PRP through its hemostatic

analysis)

Application of PG No difference regarding reepithelialization

Application of PG on the

wound and 3 days later

PG accelerates reaching normal elasticity for splitthickness skin graft (no statistical analysis)

Platelet-Rich Plasma in Burn Treatment http://dx.doi.org/10.5772/intechopen.70835 97

PG accelerates complete healing (no statistical

skin graft

The addition of PRP to the graft site has been shown to accelerate wound healing and enhance epithelialization and angiogenesis in split-thickness skin grafts and donor sites. Klosová et al. reported that combination of split-thickness skin grafting (STSG) and autologous platelet concentrate reversed the viscoelastic properties of scars to the plateau state more rapidly than

In a recent study, it was demonstrated that PRP provided a quick repair of the extracellular matrix and its components in deep second-degree burn wounds in horses, and also, it was observed that two applications of PRP treatment accelerated formation of extracellular matrix during the first half of wound healing [80]. Additionally, Hao et al. reported that using PRP with acellular xenogeneic dermal matrix for treatment of deep second-degree burns decreased

On the other hand, it is ambiguous whether results obtained in chronic and acute wounds could be applicable in burn injury wounds because a burn wound has a distinct physiological features than these wounds, including an enhanced inflammatory response, both systemic and local; increased edema; and a reduced perfusion secondary to hypercoagulability and microthrombus formation [82–84]. Patients affected by burn trauma are in a changed systemic physiological status [82, 84] when compared with the other healthy subjects in whom PRP mostly has been used and studied so far. It is generally recommended to withdraw blood before surgery to avoid activation of the platelets, but apparently this is not possible in burn patients, in whom platelets are already massively activated. It is known that platelets of burn patients show a distinct course in time, with a nadir at postburn day 3 followed by a reactive peak at postburn day 15, with a gradual return to normal values around postburn day. Several factors such as burn surface area, age, and sepsis influence this time course. There is little data about how burns or other traumas affect platelet and platelet function. In patients who have been exposed to trauma, it has been demonstrated that platelets were activated at least 72 h after injury and had an increased functionality in the first 48 h. This might affect the quality of

antimicrobial abilities [73–76].

Klosova et al. Split-thickness skin

Henderson et al. Ultrapulse CO2 laser

Table 6. PRP in burns.

graft on deep burns

232 cm burns

Maciel et al. Burn with an iron Application of PG on the

areas treated with STSG alone [77–79].

infection rate and increased wound healing [62, 81].

Name Type of wound Method of use Results

PRP and the timing of its application in burn patients [76].

Platelet-rich plasma includes platelets, growth factors, cytokines, and clotting factors in high levels. Platelets in PRP initiate releasing these activated mediators in 10 min after clotting, and in the first hour, more than 95% of growth factors are released. Platelet-rich plasma stays stable, without losing its effectiveness, for approximately 8 h after preparation [57, 58]. PRP contain many different mediators, but TGF-b and PDGF are thought as the most important growth factors in PRP. They are involved in many stages of wound healing by triggering cell development and differentiation. Previous in vivo and in vitro studies have shown that cells which have roles in wound healing process are susceptible to growth factors [59]. Fibroblastatin is known to be sensitive to PDGFa, PDGFb, IGF, bFGF, and EGF [67]. Epidermal growth factor acts as a chemotactic factor for fibroblasts and, also, when administered topically enhances epidermal regeneration and strength of wound tension [59]. Endothelial cells are susceptible to VEGF and bFGF [68]. Growth factors such as VEGF, PDGF, and bFGF are triggers for vessel proliferation [69]. Fibroblast and smooth muscle cell migration and proliferation are induced by plateletderived endothelial cell growth factor; also it is shown that PDGF is a chemotactic factor for neutrophils and monocytes and increases collagen deposition [60]. Additionally, PDGF and bFGF promote chondrocyte, osteoblast, and periosteal cell proliferation [70]. Transforming growth factor-b1 acts as a regulator for cell differentiation, proliferation, chemotaxis, and synthesis of some extracellular matrix proteins [60]. The effects of enhancing collagen synthesis, granulation tissue, and strength of wound tension of TGF-b1 were observed in animal studies [59, 71]. Another effect of TGF-b is the promotion of suprabasal cell proliferation and epidermal regeneration. Furthermore, TGF-b stimulates glycosaminoglycan, collagen, and fibronectin synthesis from fibroblasts. Transforming growth factor-b induces collagen synthesis and accelerates collagen maturation in the early period of wound healing. In addition, it is shown that using TGF-b with PDGF increases collagen deposition effects of TGF-b [60].

PRP has been shown to improve wound healing process in acute trauma wounds, incisional wounds, and chronic nonhealing wounds and is a beneficial agent in reconstructions of soft and hard tissues. Furthermore, PRP enhances differentiation of epithelial cell and collagen bundle organization. In PRP-treated wounds, the inflammatory phase of wound healing is shortened, and prolonged inflammation process is not seen. These effects of PRP reduce bacterial infections and scar formation [56, 57, 59, 60, 62, 71].

Effects of growth factors in PRP on wound healing and successful results obtained with PRP treatment in other types of wound lead to the use of PRP for burn treatment. Despite the paucity of the literature on PRP in burns (Table 6) [72], in theory, a dermal burn could benefit from PRP in several ways. First, hemostatic qualities of PRP could reduce perioperative blood


Table 6. PRP in burns.

donor area and unsuitable patient circumstances for surgery of burn patients are important

In these cases, using products that accelerate the wound healing process affects the morbidity and mortality of patients. Many different kinds of dressings or pharmacotherapies have been developed for this purpose, but these are very expensive, and mechanisms of action of these therapies are not fully documented [64–66]. Unfortunately, no optimal wound cover materials are currently available, but desired features of these materials include supporting increasing cells in wound healing, allowing vessel proliferation, keratinocyte adhesion, and differentia-

Platelet-rich plasma includes platelets, growth factors, cytokines, and clotting factors in high levels. Platelets in PRP initiate releasing these activated mediators in 10 min after clotting, and in the first hour, more than 95% of growth factors are released. Platelet-rich plasma stays stable, without losing its effectiveness, for approximately 8 h after preparation [57, 58]. PRP contain many different mediators, but TGF-b and PDGF are thought as the most important growth factors in PRP. They are involved in many stages of wound healing by triggering cell development and differentiation. Previous in vivo and in vitro studies have shown that cells which have roles in wound healing process are susceptible to growth factors [59]. Fibroblastatin is known to be sensitive to PDGFa, PDGFb, IGF, bFGF, and EGF [67]. Epidermal growth factor acts as a chemotactic factor for fibroblasts and, also, when administered topically enhances epidermal regeneration and strength of wound tension [59]. Endothelial cells are susceptible to VEGF and bFGF [68]. Growth factors such as VEGF, PDGF, and bFGF are triggers for vessel proliferation [69]. Fibroblast and smooth muscle cell migration and proliferation are induced by plateletderived endothelial cell growth factor; also it is shown that PDGF is a chemotactic factor for neutrophils and monocytes and increases collagen deposition [60]. Additionally, PDGF and bFGF promote chondrocyte, osteoblast, and periosteal cell proliferation [70]. Transforming growth factor-b1 acts as a regulator for cell differentiation, proliferation, chemotaxis, and synthesis of some extracellular matrix proteins [60]. The effects of enhancing collagen synthesis, granulation tissue, and strength of wound tension of TGF-b1 were observed in animal studies [59, 71]. Another effect of TGF-b is the promotion of suprabasal cell proliferation and epidermal regeneration. Furthermore, TGF-b stimulates glycosaminoglycan, collagen, and fibronectin synthesis from fibroblasts. Transforming growth factor-b induces collagen synthesis and accelerates collagen maturation in the early period of wound healing. In addition, it is shown that using

tion and forming a barrier against fluid loss and microorganisms [62].

TGF-b with PDGF increases collagen deposition effects of TGF-b [60].

bacterial infections and scar formation [56, 57, 59, 60, 62, 71].

PRP has been shown to improve wound healing process in acute trauma wounds, incisional wounds, and chronic nonhealing wounds and is a beneficial agent in reconstructions of soft and hard tissues. Furthermore, PRP enhances differentiation of epithelial cell and collagen bundle organization. In PRP-treated wounds, the inflammatory phase of wound healing is shortened, and prolonged inflammation process is not seen. These effects of PRP reduce

Effects of growth factors in PRP on wound healing and successful results obtained with PRP treatment in other types of wound lead to the use of PRP for burn treatment. Despite the paucity of the literature on PRP in burns (Table 6) [72], in theory, a dermal burn could benefit from PRP in several ways. First, hemostatic qualities of PRP could reduce perioperative blood

obstacles for skin grafting [55, 62].

96 Hot Topics in Burn Injuries

loss, as well as improve the take rate of the skin grafts by decreasing continued bleeding, functioning as a fibrin glue, as well as providing a well-vascularized bed for the meshed skin graft. Furthermore, the positive effects of PRP on wound healing, as seen in reports on PRP in in vitro models, chronic and acute wounds, could contribute to faster closure of mesh interstices, because PRP promotes vascular ingrowth and fibroblast proliferation and possibly reepithelialization. A deep dermal burn also could benefit from PRP through its hemostatic antimicrobial abilities [73–76].

The addition of PRP to the graft site has been shown to accelerate wound healing and enhance epithelialization and angiogenesis in split-thickness skin grafts and donor sites. Klosová et al. reported that combination of split-thickness skin grafting (STSG) and autologous platelet concentrate reversed the viscoelastic properties of scars to the plateau state more rapidly than areas treated with STSG alone [77–79].

In a recent study, it was demonstrated that PRP provided a quick repair of the extracellular matrix and its components in deep second-degree burn wounds in horses, and also, it was observed that two applications of PRP treatment accelerated formation of extracellular matrix during the first half of wound healing [80]. Additionally, Hao et al. reported that using PRP with acellular xenogeneic dermal matrix for treatment of deep second-degree burns decreased infection rate and increased wound healing [62, 81].

On the other hand, it is ambiguous whether results obtained in chronic and acute wounds could be applicable in burn injury wounds because a burn wound has a distinct physiological features than these wounds, including an enhanced inflammatory response, both systemic and local; increased edema; and a reduced perfusion secondary to hypercoagulability and microthrombus formation [82–84]. Patients affected by burn trauma are in a changed systemic physiological status [82, 84] when compared with the other healthy subjects in whom PRP mostly has been used and studied so far. It is generally recommended to withdraw blood before surgery to avoid activation of the platelets, but apparently this is not possible in burn patients, in whom platelets are already massively activated. It is known that platelets of burn patients show a distinct course in time, with a nadir at postburn day 3 followed by a reactive peak at postburn day 15, with a gradual return to normal values around postburn day. Several factors such as burn surface area, age, and sepsis influence this time course. There is little data about how burns or other traumas affect platelet and platelet function. In patients who have been exposed to trauma, it has been demonstrated that platelets were activated at least 72 h after injury and had an increased functionality in the first 48 h. This might affect the quality of PRP and the timing of its application in burn patients [76].

The long term effect of PRP on scar formation after burn injury is another important consideration and has not yet been evaluated comprehensively. There are plenty of growth factors released from the platelets and leukocytes in PRP, and some of these growth factors are chemotactic in recruiting inflammatory cells and a prolonged inflammation which could cause hypertrophic scar [85]. Furthermore, scar formation consists of series of complex events, and the effects of single growth factors in this process are still being unraveled. Among the growth factors, TGF-β1, TGF-β2, and platelet-derived growth factor are especially remarkable, because these factors are associated with hypertrophic and keloid scarring of normal skin wounds as well as in burn wounds. On the other hand, how PRP, a cocktail of many different growth factors, might influence scar formation remains to be seen. There are a limited number of publications on the development of hypertrophic scarring after the use of PRP in wound healing until now, and most of these publications are not related to burn trauma [76]. One of these studies is authored by Prochazka et al. They reported that while in burn patients treated with PRP combination, the rate of reepithelialization may not have been higher or faster than traditionally observed, the inflammatory markers normalized faster, providing the reepithelialized wound more stable. Because patients treated with PRP combination showed minimal cicatrization, they had high quality of healing without evidence of scar hypertrophy or contractures [76]. Additionally, recently some reports were published with positive results of PRP in combination with adipose cells for scar treatment; therefore, there might be an indication for PRP in the reconstructive aspect of burn treatment. On the other hand, in another study, long-term follow-up results did not show significant differences in scar quality in patients treated with PRP combination [86].

[3] Schapiro JM, Arber N, Sidi Y. Platelet hyperreactivity and prognosis in survivors of

Platelet-Rich Plasma in Burn Treatment http://dx.doi.org/10.5772/intechopen.70835 99

[4] Dean WL, Lee MJ, Cummins TD, Schultz DJ, Powell DW. Proteomic and functional characterisation of platelet microparticle size classes. Thrombosis and Haemostasis. 2009;102:711

[6] Oprea WE, Karp JM, Hosseini MM, Davies JE. Effect of platelet releasate on bone cell migration and recruitment in vitro. The Journal of Craniofacial Surgery. 2003;14:292-300 [7] Schober A, Manka D, von Hundelshausen P, et al. Deposition of platelet RANTES triggering monocyte recruitment requires P-selectin and is involved in neointima formation

[9] Epply BL, Pietrzak WS, Blanton M. Platelet-rich plasma. A review of biology and applications in plastic surgery. Plastic and Reconstructive Surgery. 2006;118:147e-159e [10] Conley CL. Hemostasis. In: Mountcastle VB, editor. Medical Physiology. St. Louis:

[11] Welsh WJ. Autologous platelet gel: Clinical function and usage in plastic surgery. Cos-

[12] Caro CD, Pedley TJ, Schroter RC, et al. The Mechanics of the Circulation. Oxford: Oxford

[13] Guyton AC. Physiology of the Human Body. Philadelphia: Saunders College Publishing; 1979 [14] Marx RE. Platelet-rich plasma (PRP): What is PRP and what is not PRP? Implant Den-

[15] Tischler M. Platelet rich plasma: The use of autologous growth factors to enhance bone

[16] Bhanot S, Alex JC. Current applications of platelet gels in facial plastic surgery. Facial

[17] Buckwalter JA, Einhorn TA, Bolander ME, et al. Healing of musculoskeletal tissues. In: Rockwood CA Jr, Bucholz RW, Green DP, editors. Fractures in Adults. Philadelphia:

[18] Anderson JM. The cellular cascades of wound healing. In: Davies JE, editor. Bone Engi-

[19] Szpaderska AM, Egozi EI, Gamelli RL, et al. The effect of thrombocytopenia on dermal

[20] Froum SJ, Wallace SS, Tarnow DP, et al. Effect of platelet-rich plasma on bone growth and osseointegration in human maxillary sinus grafts: Three bilateral case reports. The Inter-

wound healing. The Journal of Investigative Dermatology. 2003;120:1130

national Journal of Periodontics & Restorative Dentistry. 2002;22:45

and soft tissue grafts. The New York State Dental Journal. 2002;68:22

myocardial infarction. The New England Journal of Medicine. 1990;323:1707

[5] White JG, Michelson A. Platelet structure. Platelets. 2007;3:117-144

[8] Harrison P, Cramer EM. Platelet alpha-granules. Blood Reviews. 1993;7:52

after arterial injury. Circulation. 2002;106:1523-1529

Mosby; 2004. p. 1137-1146

University Press; 1978

tistry. 2001;10:225

Plastic Surgery. 2002;18:27

Lippincott-Raven; 1996. p. 261-304

neering. Toronto: EM Squared Inc.; 2000. p. 81-93

metic Dermatology. 2000;11:13

Furthermore, PRP treatment provides less pain and pruritus during the wound healing in burn trauma. And, one of the most important benefits of PRP in burn therapy is the costeffectiveness of the therapy. The cost of hospital stay is lower (approximately 25% less) than that of patients who did not receive PRP combination treatment [87, 88].

### Author details

#### Mehmet Unal

Address all correspondence to: dr.munal1101@gmail.com

Department of Dermatology and Venerology, Faculty of Medicine, Selcuk University, Konya, Turkey

#### References


The long term effect of PRP on scar formation after burn injury is another important consideration and has not yet been evaluated comprehensively. There are plenty of growth factors released from the platelets and leukocytes in PRP, and some of these growth factors are chemotactic in recruiting inflammatory cells and a prolonged inflammation which could cause hypertrophic scar [85]. Furthermore, scar formation consists of series of complex events, and the effects of single growth factors in this process are still being unraveled. Among the growth factors, TGF-β1, TGF-β2, and platelet-derived growth factor are especially remarkable, because these factors are associated with hypertrophic and keloid scarring of normal skin wounds as well as in burn wounds. On the other hand, how PRP, a cocktail of many different growth factors, might influence scar formation remains to be seen. There are a limited number of publications on the development of hypertrophic scarring after the use of PRP in wound healing until now, and most of these publications are not related to burn trauma [76]. One of these studies is authored by Prochazka et al. They reported that while in burn patients treated with PRP combination, the rate of reepithelialization may not have been higher or faster than traditionally observed, the inflammatory markers normalized faster, providing the reepithelialized wound more stable. Because patients treated with PRP combination showed minimal cicatrization, they had high quality of healing without evidence of scar hypertrophy or contractures [76]. Additionally, recently some reports were published with positive results of PRP in combination with adipose cells for scar treatment; therefore, there might be an indication for PRP in the reconstructive aspect of burn treatment. On the other hand, in another study, long-term follow-up results did not show

significant differences in scar quality in patients treated with PRP combination [86].

that of patients who did not receive PRP combination treatment [87, 88].

Address all correspondence to: dr.munal1101@gmail.com

Author details

98 Hot Topics in Burn Injuries

Mehmet Unal

References

Turkey

Furthermore, PRP treatment provides less pain and pruritus during the wound healing in burn trauma. And, one of the most important benefits of PRP in burn therapy is the costeffectiveness of the therapy. The cost of hospital stay is lower (approximately 25% less) than

Department of Dermatology and Venerology, Faculty of Medicine, Selcuk University, Konya,

[1] Fernandez-Moure JS, Van Eps JL, Cabrera FJ, Barbosa Z, Medrano Del Rosal G, Weiner BK, Ellsworth WA 4th, Tasciotti E. Platelet-rich plasma: A biomimetic approach to enhancement

[2] Marcus AJ. Platelet function. The New England Journal of Medicine. 1969;280:1278-1284

of surgical wound healing. The Journal of Surgical Research. 2017 Jan;207:33-44


[21] Marx RE. Platelet-rich plasma: Evidence to support its use. Journal of Oral and Maxillofacial Surgery. 2004;62:489

[34] Marx RE, Carlson ER, Eichstaedt RM, et al. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and

Platelet-Rich Plasma in Burn Treatment http://dx.doi.org/10.5772/intechopen.70835 101

[35] Eppley BL, Woodell JE, Higgins J. Platelet quantification and growth factor analysis from platelet-rich plasma: Implications for wound healing. Plastic and Reconstructive Surgery.

[36] Weibrich G, Kleis WK, Kunz-Kostomanolakis M, et al. Correlation of platelet concentration in platelet-rich plasma to the extraction method, age, sex, and platelet count of the

[37] Steed DL. The role of growth factors in wound healing. The Surgical Clinics of North

[38] Zimmermann R, Jakubietz R, Jakubietz M, Strasser E, Schlegel A, Wiltfang J, et al. Different preparation methods to obtain platelet component as a source of growth factors for

[39] Man D, Plosker H, Winland-Brown JE. The use of autologous platelet-rich plasma (platelet gel) and autologous platelet-poor plasma (fibrin glue) in cosmetic surgery. Plastic and

[40] Marlovits S, Mousavi M, Gabler C, et al. A new simplified technique for producing platelet-rich plasma: A short technical note. European Spine Journal. 2004;13(Suppl. 1):

[41] Lozada JL, Caplanis N, Proussaefs P, et al. Platelet-rich plasma application in sinus graft surgery: Part I. Background and processing techniques. The Journal of Oral Implantology.

[42] Arm DM. Autologous platelet-based therapies for orthopaedic tissue regeneration.

[43] Slater M, Patava J, Kingham K, et al. Involvement of platelets in stimulating osteogenic

[44] Anderson NA, Pamphilon DH, Tandy NJ, et al. Comparison of platelet-rich plasma collection using the Haemonetics PCS and Baxter Autopheresis C. Vox Sanguinis.

[45] Robiony M, Polini F, Costa F, et al. Osteogenesis distraction and platelet-rich plasma for bone restoration of the severely atrophic mandible: Preliminary results. Journal of Oral

[46] Schmitz JP, Hollinger JO. The biology of platelet-rich plasma. Journal of Oral and Maxil-

[47] Bulbul Baskan E. Platelet rich plasma therapy in chronic wound healing. Turkiye

Klinikleri Journal of Cosmetic Dermatology Special Topics. 2014;7(3):13-19

donor. The International Journal of Oral & Maxillofacial Implants. 2001;16:693

Endodontics. 1998;85:638

America. 1997;77(3):575-586

local application. Transfusion. 2001;41:1217-1224

activity. Journal of Orthopaedic Research. 1995;13:655

and Maxillofacial Surgery. 2002;60:630

lofacial Surgery. 2001;59(9):1119-1121

Reconstructive Surgery. 2001;107:229

2004;114:1502

S102

2001;27:38

1991;60:155

Orthopedics. 2002;25:169


[34] Marx RE, Carlson ER, Eichstaedt RM, et al. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 1998;85:638

[21] Marx RE. Platelet-rich plasma: Evidence to support its use. Journal of Oral and Maxillo-

[22] Lowe HC, Rafty LA, Collins T, et al. Biology of platelet-derived growth factor. In: Canalis E, editor. Skeletal Growth Factors. Philadelphia: Lippincott Williams & Wilkins; 2000. p.

[23] Petrungaro PS. Using platelet-rich plasma to accelerate soft tissue maturation in esthetic periodontal surgery. The Compendium of Continuing Education in Dentistry. 2001;22:729

[24] Weibrich G, Kleis WK, Hafner G, et al. Growth factor levels in platelet-rich plasma and correlations with donor age, sex, and platelet count. Journal of Cranio-Maxillo-Facial

[25] Dohan Ehrenfest DM, Bielecki T, Del Corso M, Inchingolo F, Sammartino G. Shedding light in the controversial terminology for platelet-rich products: Platelet-rich plasma (PRP), platelet-rich fibrin (PRF), platelet-leukocyte gel (PLG), preparation rich in growth factors (PRGF), classification and commercialism. Journal of Biomedical Materials

[26] Dohan Ehrenfest DM, Rasmusson L, Albrektsson T. Classification of platelet concentrates: From pure platelet-rich plasma (P-PRP) to leucocyte- and platelet-rich fibrin

[27] Everts PA, van Zundert A, Schönberger JP, Devilee RJ, Knape JT. What do we use: Platelet-rich plasma or plateletleukocyte gel? Journal of Biomedical Materials Research.

[28] Anitua E, Sánchez M, Orive G. The importance of understanding what is platelet-rich growth factor (PRGF) and what is not. Journal of Shoulder and Elbow Surgery. 2011;20:

[29] Marx RE. Platelet concentrate: A strategy for accelerating and improving bone regeneration. In: Davies JE, editor. Bone Engineering. Toronto: University of Toronto; 2000. p. 447-

[30] Kevy SV, Jacobson MS. Comparison of methods for point of care preparation of autolo-

[31] Gonshor A. Technique for producing platelet-rich plasma and platelet concentrate: Background and process. The International Journal of Periodontics & Restorative Dentistry.

[32] Marck RE, Gardien KL, Stekelenburg CM, Vehmeijer M, Baas D, Tuinebreijer WE, Breederveld RS, Middelkoop E. The application of platelet-rich plasma in the treatment of deep dermal burns: A randomized, double-blind, intra-patient controlled study.

[33] Waters JH, Roberts KC. Database review of possible factors influencing point-of-care platelet gel manufacture. The Journal of Extra-Corporeal Technology. 2004;36:250

gous platelet gel. The Journal of Extra-Corporeal Technology. 2004;36:28

Wound Repair and Regeneration. 2016 Jul;24(4):712-720

facial Surgery. 2004;62:489

Surgery. 2002;30:97

Research. Part A. 2010;95:1280-1282

Part A. 2008;85:1135-1136

e23-e24 author reply e24

453

2002;22:547

(L-PRF). Trends in Biotechnology. 2009;27:158-167

129-151

100 Hot Topics in Burn Injuries


[48] Kim SA, Ryu HW, Lee KS, Cho JW. Application of platelet-rich plasma accelerates the wound healing process in acute and chronic ulcers through rapid migration and upregulation of cyclin A and CDK4 in HaCaT cells. Molecular Medicine Reports. 2013;7(2):476-480

[63] Monstrey S, Hoeksema H, Verbelen J, et al. Assessment of burn depth and burn wound

Platelet-Rich Plasma in Burn Treatment http://dx.doi.org/10.5772/intechopen.70835 103

[64] Fathke C, Wilson L, Hutter J, et al. Contribution of bone marrow-derived cells to skin:

[65] Ichioka S, Kouraba S, Sekiya N, et al. Bone marrow-impregnated collagen matrix for wound healing: Experimental evaluation in a microcirculatory model of angiogenesis,

[66] Shakespeare PG. The role of skin substitutes in the treatment of burn injuries. Clinics in

[67] Loot MA, Kenter SB, Au FL, et al. Fibroblasts derived from chronic diabetic ulcers differ in their response to stimulation with EGF, IGF-I, bFGF and PDGF-AB compared to

[68] Pintucci G, Froum S, Pinnell J, et al. Trophic effects of platelets on cultured endothelial cells are mediated by platelet-associated fibroblast growth factor-2 (FGF-2) and vascular endothelial growth factor (VEGF). Thrombosis and Haemostasis. 2002;88(5):834-842 [69] Go RS, Ritman EL, Owen WG. Angiogenesis in rat aortic rings stimulated by very low

[70] Kaps C, Loch A, Haisch A, et al. Human platelet supernatant promotes proliferation but not differentiation of articular chondrocytes. Medical & Biological Engineering & Com-

[71] Ostvar O, Shadvar S, Yahaghi E, et al. Effect of platelet-rich plasma on the healing of cutaneous defects exposed to acute to chronic wounds: A clinico-histopathologic study in

[72] Picard F, Hersant B, Bosc R, Meningaud JP. Should we use platelet-rich plasma as an adjunct therapy to treat "acute wounds," "burns," and "laser therapies": A review and a proposal of a quality criteria checklist for further studies. Wound Repair and Regenera-

[73] Kim DH, Je YJ, Kim CD, et al. Can platelet-rich plasma be used for skin rejuvenation? Evaluation of effects of platelet-rich plasma on human dermal fibroblast. Annals of

[74] Graziani F, Ivanovski S, Cei S, Ducci F, Tonetti M, Gabriele M. The in vitro effect of different PRP concentrations on osteoblasts and fibroblasts. Clinical Oral Implants

[75] Carter MJ, Fylling CP, Parnell LK. Use of platelet rich plasma gel on wound healing: A

[76] Marck RE, Middelkoop E, Breederveld RS. Considerations on the use of platelet-rich plasma, specifically for burn treatment. Journal of Burn Care & Research. 2014 May-

systematic review and meta-analysis. Eplasty. 2011;11:e38

and clinical experience. British Journal of Plastic Surgery. 2005;58(8):1124-1130

Collagen deposition and wound repair. Stem Cells. 2004;22(5):812-822

controls. European Journal of Cell Biology. 2002;81(3):153-160

concentrations of serum and plasma. Angiogenesis. 2003;6(1):25-29

healing potential. Burns. 2008;34(6):761-769

Dermatology. 2005;23(4):413-418

puting. 2002;40(4):485-490

rabbits. Diagnostic Pathology. 2015;10:85

tion. 2015 Mar-Apr;23(2):163-170

Dermatology. 2011;23:424-431

Research. 2006;17:212-219

Jun;35(3):219-227


[63] Monstrey S, Hoeksema H, Verbelen J, et al. Assessment of burn depth and burn wound healing potential. Burns. 2008;34(6):761-769

[48] Kim SA, Ryu HW, Lee KS, Cho JW. Application of platelet-rich plasma accelerates the wound healing process in acute and chronic ulcers through rapid migration and upregulation of

[49] Shin MK, Lee JW, Kim YII, Kim YO, Seok H, Kim NI. The effects of platelet rich clot releasate on the expression of MMP-1 and type I collagen in human adult dermal fibroblasts: PRP is a stronger MMP-1 stimulator. Molecular Biology Reports. 2014;41(1):3-8 [50] Edelblute CM, Donate AL, Hargrave BY, Heller LC. Human platelet gel supernatant inactivates opportunistic wound pathogens on skin. Platelets. 2015;26(1):13-16

[51] Mei-Dan O, Mann G, Maffulli N. Platelet-rich plasma: Any substance to it? British Journal

[52] Sundman EA, Cole BJ, Fortier LA. Growth factor and catabolic cytokine concentrations are influenced by the cellular composition of platelet rich plasma. The American Journal

[53] Kumaran MS. Platelet rich plasma in dermatology: Boon or bane? Indian Journal of

[54] Smith SE, Roukis T. Bone and wound healing augmentation with platelet rich plasma.

[55] Poffenbarger PL, Haberal MA. Role of serum nonsuppressible insulin-like activity (NSILA) in wound healing. I. Influence of thyroparathyroidectomy on serum NSILA

[56] Iesari S, Lai Q, Rughetti A, Dell'Orso L, Clemente K, Famulari A, Pisani F, Favi E. Infected nonhealing wound in a kidney transplant recipient: Successful treatment with topical homologous platelet-rich gel. Experimental and Clinical Transplantation. 2017 Apr;15(2):

[57] Pallua N, Wolter T, Markowicz M. Platelet-rich plasma in burns. Burns. 2010;36(1):4-8

[58] Yol S, Tekin A, Yilmaz H, et al. Effects of platelet rich plasma on colonic anastomosis. The

[59] Kazakos K, Lyras DN, Verettas D, et al. The use of autologous PRP gel as an aid in the

[60] Carter CA, Jolly DG, Worden CE Sr, et al. Platelet-rich plasma gel promotes differentiation and regeneration during equine wound healing. Experimental and Molecular Pathol-

[61] Knighton DR, Ciresi K, Fiegel VD, et al. Stimulation of repair in chronic, nonhealing, cutaneous ulcers using platelet-derived wound healing formula. Surgery, Gynecology &

[62] Ozcelik U, Ekici Y, Bircan HY, Aydogan C, Turkoglu S, Ozen O, Moray G, Haberal M. Effect of topical platelet-rich plasma on burn healing after partial-thickness burn injury.

of Sports Medicine. 2010;44(9):618-619

of Sports Medicine. 2011;39(10):2135-2140

222-225

102 Hot Topics in Burn Injuries

ogy. 2003;74(3):244-255

Obstetrics. 1990;170(1):56-60

Dermatology, Venereology and Leprology. 2014;80(1):5-14

and wound healing in the rat. Surgery. 1976;80(5):608-616

Journal of Surgical Research. 2008;146(2):190-194

Medical Science Monitor. 2016 Jun 5;22:1903-1909

management of acute trauma wounds. Injury. 2009;40(8):801-805

Clinics in Podiatric Medicine and Surgery. 2009;26(4):559-588

cyclin A and CDK4 in HaCaT cells. Molecular Medicine Reports. 2013;7(2):476-480


[77] Achora S, Muliira JK, Thanka AN. Strategies to promote healing of split thickness skin grafts: An integrative review. Journal of Wound, Ostomy, and Continence Nursing. 2014;41(4):335-339

**Chapter 7**

**Provisional chapter**

**Surgical Treatment of Burn Scars**

**Surgical Treatment of Burn Scars**

DOI: 10.5772/intechopen.72303

The relationship between a burns patient and a reconstructive surgeon is normally long lasting and continues lifelong. Patients not only require a surgeon's professional expertise, but also time, optimism and compassion. Scar management relates to the physical and aesthetic components as well as the psychosocial implications of scarring. Hypertrophic scar formation which can cause debilitating deficiencies and poor aesthetic outcomes might be a result of burn injuries. Although nonsurgical treatment modalities in the early phase of scar maturation are critical to decrease hypertrophic scar formation, surgical management is often indicated to restore function. Operative scar management releases the tension and can often be achieved through local tissue arrangement.

Today, a lot of patients survive burn injuries, but they will not escape the burden of severe scar formation. The scarred tissue leaves contractures at joints, and this causes functional limitations. Surgical treatment is an indication to treat the burn scars [1]. In this chapter we

Superficial burn wounds usually heal without complications. Deep partial and full-thickness burns have an increased risk for hypertrophic scar formation [2]. In the burns that include epidermis, the dermis remains intact and re-epithelization occurs by keratinocytes. Superficial partial-thickness burns involve epidermis and superficial dermis which results in blisters. Superficial injuries may require careful monitoring only. In deep partial-thickness burns, prolonged time for re-epithelialization is needed [3]. Assessing the depth of burn earlier is

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Emel Erdal Çalıkoğlu and Serap Maden

http://dx.doi.org/10.5772/intechopen.72303

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

**Keywords:** surgery, burn, scar, treatment

explain the surgical treatment of burn scars.

Pertevniyal Bodamyalızade, Emel Erdal Çalıkoğlu

Pertevniyal Bodamyalızade,

and Serap Maden

**Abstract**

**1. Introduction**


**Chapter 7 Provisional chapter**

#### **Surgical Treatment of Burn Scars Surgical Treatment of Burn Scars**

Pertevniyal Bodamyalızade, Emel Erdal Çalıkoğlu and Serap Maden Pertevniyal Bodamyalızade, Emel Erdal Çalıkoğlu and Serap Maden

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72303

#### **Abstract**

[77] Achora S, Muliira JK, Thanka AN. Strategies to promote healing of split thickness skin grafts: An integrative review. Journal of Wound, Ostomy, and Continence Nursing.

[78] Kakudo N, Kushida S, Minakata T, et al. Platelet-rich plasma promotes epithelialization and angiogenesis in a split-thickness skin graft donor site. Medical Molecular Morphol-

[79] Klosová H, Stětinský J, Bryjová I, et al. Objective evaluation of the effect of autologous platelet concentrate on post-operative scarring in deep burns. Burns. 2013;39(6):1263-1276

[80] Maciel FB, DeRossi R, Módolo TJ, et al. Scanning electron microscopy and microbiological evaluation of equine burn wound repair after platelet-rich plasma gel treatment.

[81] Hao T, Zhu J, Hu W, et al. Autogenous platelet-rich plasma gel with acellular xenogeneic dermal matrix for treatment of deep II degree burns. Zhongguo Xiu Fu Chong Jian Wai

[82] Shupp JW, Nasabzadeh TJ, Rosenthal DS, Jordan MH, Fidler P, Jeng JC. A review of the local pathophysiologic bases of burn wound progression. Journal of Burn Care &

[83] van de Goot F, Krijnen PA, Begieneman MP, et al. Acute inflammation is persistent locally in burn wounds: A pivotal role for complement and C-reactive protein. Journal

[84] Evers LH, Bhavsar D, Mailänder P. The biology of burn injury. Experimental Dermatol-

[85] van der Veer WM, Bloemen MC, Ulrich MM, et al. Potential cellular and molecular causes

[86] Prochazka V, Klosova H, Stetinsky J, Gumulec J, Vitkova K, Salounova D, Dvorackova J, Bielnikova H, Klement P, Levakova V, Ocelka T, Pavliska L, Kovanic P, Klement GL. Addition of platelet concentrate to dermo-epidermal skin graft in deep burn trauma reduces scarring and need for revision surgeries. Biomedical Papers of the Medical Faculty of the University Palacky, Olomouc, Czech Republic. 2014 Jun;158(2):242-258 [87] Cervelli V, Nicoli F, Spallone D, et al. Treatment of traumatic scars using fat grafts mixed with platelet-rich plasma, and resurfacing of skin with the 1540 nm nonablative laser.

[88] Cervelli V, Palla L, Pascali M, De Angelis B, Curcio BC, Gentile P. Autologous plateletrich plasma mixed with purified fat graft in aesthetic plastic surgery. Aesthetic Plastic

2014;41(4):335-339

104 Hot Topics in Burn Injuries

ogy. 2011;44(4):233-236

Burns. 2012;38(7):1058-1065

Ke Za Zhi. 2010;24(6):647-649

Research. 2010;31:849-873

ogy. 2010;19:777-783

Surgery. 2009;33:716-721

of Burn Care & Research. 2009;30:274-280

of hypertrophic scar formation. Burns. 2009;35:15-19

Clinical and Experimental Dermatology. 2012;37:55-51

The relationship between a burns patient and a reconstructive surgeon is normally long lasting and continues lifelong. Patients not only require a surgeon's professional expertise, but also time, optimism and compassion. Scar management relates to the physical and aesthetic components as well as the psychosocial implications of scarring. Hypertrophic scar formation which can cause debilitating deficiencies and poor aesthetic outcomes might be a result of burn injuries. Although nonsurgical treatment modalities in the early phase of scar maturation are critical to decrease hypertrophic scar formation, surgical management is often indicated to restore function. Operative scar management releases the tension and can often be achieved through local tissue arrangement.

DOI: 10.5772/intechopen.72303

**Keywords:** surgery, burn, scar, treatment

#### **1. Introduction**

Today, a lot of patients survive burn injuries, but they will not escape the burden of severe scar formation. The scarred tissue leaves contractures at joints, and this causes functional limitations. Surgical treatment is an indication to treat the burn scars [1]. In this chapter we explain the surgical treatment of burn scars.

Superficial burn wounds usually heal without complications. Deep partial and full-thickness burns have an increased risk for hypertrophic scar formation [2]. In the burns that include epidermis, the dermis remains intact and re-epithelization occurs by keratinocytes. Superficial partial-thickness burns involve epidermis and superficial dermis which results in blisters. Superficial injuries may require careful monitoring only. In deep partial-thickness burns, prolonged time for re-epithelialization is needed [3]. Assessing the depth of burn earlier is

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

important to administer optimal treatment and prevent hypertrophic scar formation. Wound healing has three phases: inflammation, proliferation and remodeling [4, 5]. The dorsal area of the hands is thin and susceptible to hypertrophic scar formation. Dorsal scarring of the hands may not only inhibit passive flexion at the metacarpophalangeal joint but in some severe cases further result in hyperextension and subluxation of the joint [6].

A healed burn patient may have varying degrees of scars with functional and aesthetic components. Depending on the depth of the burn injury, post-burn scars are inevitable even with the best treatment. Second-degree deep dermal and full-thickness burns heal by scarring. The post-burn scars may be immature/mature, atrophic/hypertrophic/keloid, stable/ unstable, depigmented (vitiligo)/hyperpigmented. They can turn into malignancy as well [7]. Unfortunately, the head and neck area are the most frequently affected area involved in burn injuries [8]. Especially, the neck with its ability to develop severe contractures and its aesthetic importance, deserves more attention [9]. Achieving long-term results with patient satisfaction remains a challenge [10]. Pre-expansion of free and regional axial island flap have all contributed to achieve this goal [11, 12]. The color match of skin grafts might be poor and also not as elastic as face and neck skin [13, 14]. Pre-expansion of tissue is valuable when large areas need to be resurfaced. This helps to cover more surfaces enabling the closure of the donor site. Studies showed that pre-expansion increases vascularization, reliability and the amount of tissue needed to be transferred [15–17]. Pre-expansion also causes atrophy of all expanded tissue layers except the epidermis that makes the flaps become thinner [18]. If there is no scar formation and the donor site can be closed primarily, then local options should be preferred. Supraclavicular flaps are preferred to infraclavicular flaps because they have greater proximity as well as better skin and tissue match to the affected areas when compared with infraclavicular flaps. Pre-expanded groin flaps show thinner dermis, expand easily and can be harvested without patient repositioning. If locoregional options cannot be used, in comparison to scapular and parascapular flaps, pre-expanded groin flaps are preferred (**Figure 1**).

**1.1. Skin graft**

spontaneously.

**1.2. Skin flaps**

**1.3. Donor sites**

When we use the grafts sheet, grafts are preferred and expansion should not be preferred [13, 19, 20]. The junction line of the grafts' sheets should be parallel to the joint motion axis. After immediately release, the skin grafts are applied. Generally, contractures are treated with split skin grafts of intermediate or thick variety. This helps the donor site to heal up

Surgical Treatment of Burn Scars

107

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If the contracture release is likely to open up the joint of the hands and feet or tendon nerve, surgery is planned at a later date, for example, for old healed electrical burns, the skin flap is a must. The surgeon must provide a flap cover after release of contracture. If the defect is located in a cosmetic area and the reconstruction with a flap is thought to give a better cosmetic result, then covering a flap should be considered. For example, to repair upper lip ectropion of a male patient, the flap can be provided from scalp or upper neck. If it is a female

For the split-skin grafts, thighs are usually used for harvesting. In a patient with severe burn and extensive scar formation, the grafts may be harvested from legs, abdomen and upper

patient, a graft cover is needed to repair upper lip ectropion.

**Figure 1.** Post-burn treatment algorithm for head and neck contractures.

As a rule, surgical treatment for post-burn contractures should not be undertaken during healing and scarring which usually takes 1 year. The surgical management of any post-burn contracture involves complete release of contracture. To decrease the requirement for skin cover, incision can be performed. To have a relatively bloodless field, incision line can be infiltrated with 1:200.000 adrenaline solution. The limb contractures can be released under tourniquet which should be deflated after complete release and hemostasis is achieved. Generally, for the patients who have received pre-operative physical therapy and their scars have become soft, incision rather than excision is applied to release the contracture. For example, in a case of post-burn contracture of neck, the scars may extend from chin, neck onto the chest and even abdomen. In this case, partial excision of hypertrophic scars may sometimes be done. If there is a contracture, it should be completely released. In severe long-standing contractures, the musculotendinous units and neurovascular structures can be shortened. Hence, complete release might be impossible. For example, if the joints are subluxated or dislocated, complete release might be impossible. In this case, the possible release is done, and then, full correction is achieved by serial splintage, skin/skeletal traction or by using the modern distractor systems. After the full correction is performed, then the skin is covered over the area. After releasing the contracture, the defect must be covered by using skin grafts or a skin flap [7].

**Figure 1.** Post-burn treatment algorithm for head and neck contractures.

#### **1.1. Skin graft**

important to administer optimal treatment and prevent hypertrophic scar formation. Wound healing has three phases: inflammation, proliferation and remodeling [4, 5]. The dorsal area of the hands is thin and susceptible to hypertrophic scar formation. Dorsal scarring of the hands may not only inhibit passive flexion at the metacarpophalangeal joint but in some severe cases

A healed burn patient may have varying degrees of scars with functional and aesthetic components. Depending on the depth of the burn injury, post-burn scars are inevitable even with the best treatment. Second-degree deep dermal and full-thickness burns heal by scarring. The post-burn scars may be immature/mature, atrophic/hypertrophic/keloid, stable/ unstable, depigmented (vitiligo)/hyperpigmented. They can turn into malignancy as well [7]. Unfortunately, the head and neck area are the most frequently affected area involved in burn injuries [8]. Especially, the neck with its ability to develop severe contractures and its aesthetic importance, deserves more attention [9]. Achieving long-term results with patient satisfaction remains a challenge [10]. Pre-expansion of free and regional axial island flap have all contributed to achieve this goal [11, 12]. The color match of skin grafts might be poor and also not as elastic as face and neck skin [13, 14]. Pre-expansion of tissue is valuable when large areas need to be resurfaced. This helps to cover more surfaces enabling the closure of the donor site. Studies showed that pre-expansion increases vascularization, reliability and the amount of tissue needed to be transferred [15–17]. Pre-expansion also causes atrophy of all expanded tissue layers except the epidermis that makes the flaps become thinner [18]. If there is no scar formation and the donor site can be closed primarily, then local options should be preferred. Supraclavicular flaps are preferred to infraclavicular flaps because they have greater proximity as well as better skin and tissue match to the affected areas when compared with infraclavicular flaps. Pre-expanded groin flaps show thinner dermis, expand easily and can be harvested without patient repositioning. If locoregional options cannot be used, in comparison to scapular and parascapular flaps, pre-expanded groin flaps are preferred (**Figure 1**). As a rule, surgical treatment for post-burn contractures should not be undertaken during healing and scarring which usually takes 1 year. The surgical management of any post-burn contracture involves complete release of contracture. To decrease the requirement for skin cover, incision can be performed. To have a relatively bloodless field, incision line can be infiltrated with 1:200.000 adrenaline solution. The limb contractures can be released under tourniquet which should be deflated after complete release and hemostasis is achieved. Generally, for the patients who have received pre-operative physical therapy and their scars have become soft, incision rather than excision is applied to release the contracture. For example, in a case of post-burn contracture of neck, the scars may extend from chin, neck onto the chest and even abdomen. In this case, partial excision of hypertrophic scars may sometimes be done. If there is a contracture, it should be completely released. In severe long-standing contractures, the musculotendinous units and neurovascular structures can be shortened. Hence, complete release might be impossible. For example, if the joints are subluxated or dislocated, complete release might be impossible. In this case, the possible release is done, and then, full correction is achieved by serial splintage, skin/skeletal traction or by using the modern distractor systems. After the full correction is performed, then the skin is covered over the area. After releasing the contracture, the defect must be covered by using skin grafts or a skin flap [7].

further result in hyperextension and subluxation of the joint [6].

106 Hot Topics in Burn Injuries

When we use the grafts sheet, grafts are preferred and expansion should not be preferred [13, 19, 20]. The junction line of the grafts' sheets should be parallel to the joint motion axis. After immediately release, the skin grafts are applied. Generally, contractures are treated with split skin grafts of intermediate or thick variety. This helps the donor site to heal up spontaneously.

#### **1.2. Skin flaps**

If the contracture release is likely to open up the joint of the hands and feet or tendon nerve, surgery is planned at a later date, for example, for old healed electrical burns, the skin flap is a must. The surgeon must provide a flap cover after release of contracture. If the defect is located in a cosmetic area and the reconstruction with a flap is thought to give a better cosmetic result, then covering a flap should be considered. For example, to repair upper lip ectropion of a male patient, the flap can be provided from scalp or upper neck. If it is a female patient, a graft cover is needed to repair upper lip ectropion.

#### **1.3. Donor sites**

For the split-skin grafts, thighs are usually used for harvesting. In a patient with severe burn and extensive scar formation, the grafts may be harvested from legs, abdomen and upper limb, scalp or back. In cases with multiple and massive contractures, the donor sites should be checked and plan charted out for "which donor site for which contracture." For neck, axilla and facial resurfacing, large sheets are important to be required while comparatively smaller pieces of graft are adequate for eyelid or finger contractures [7].

sequence of z-plasties. If it is a severe contracture, release of the scar may be required leaving a large defect. Full-thickness skin graft can be used to fill this defect. Full-thickness skin grafts are preferred over split-thickness graft because they have a decreased effect of secondary contraction to minimize scarring. If the contracture release leads to exposed tendon or

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1. Proximal joint contractures should be released before distal contractures. For example, if the shoulder and elbow have limited range of movement, then there is a little value to have

**2.** If there are multiple joints requiring release, each joint should be considered separately and each contracture should be fully released. The Y-V plasty technique simultaneously

**3.** Function is always prior over cosmesis; it is better to have a functioning joint with an albeit disappointing cosmesis than to have a cosmetically perfect joint without mobility. This does not mean cosmesis is not important but it should not take precedence over function. **4.** When split-thickness graft is applied over a wound, it will again contract with the potential for recurrent contracture formation. To prevent this, physiotherapy is a method to mobilize the joint. A flap is much more preferred than a split-skin graft. It has its own blood

supply and also supplies bulk, which might lead to better cosmetic appearance.

**5.** Sometimes, the important underlying structures may be exposed and require release. For example, a dorsal release of the ankle joint may leave extensor tendons exposed. In a longstanding contracture, ligaments and tendons may have permanently shortened, and ten-

Burn contracture release is undertaken once it is deemed "mature." Interfering with an active scar leads further contracture formation. Contracture and hypertrophic scar formation increases in the first 6 months, and full scar maturation will occur after 2 years. When the scar

To reconstruct the contracture, surgical treatment should be combined with release and splitskin grafting. This recently is called conventional waiting approach. For example, in the acute lower lid treatment, some studies showed that full-thickness grafts reduce the incidence of subsequent ectropion release [33]. It is important that, when flap cover of the defect is planned, this timing restriction is not applicable. Some authors support waiting for 2 or 3 weeks acutely, prior to undertaking release and free flap cover, and have reported success rates of 94% [34].

bone, local flaps may be used [31].

a mobile wrist.

**2.1. General principles of contracture release**

leads to release of multiple joints.

don lengthening may be necessary for dorsiflexion.

is active, it is pliable and amenable to stretching by physiotherapy [32].

**2.2. Time for surgical contracture release**

**2.3. How to treat the burn scar contractures**

**2.** Local plastic surgical procedures

1. Split-skin grafting

#### **1.4. Postoperative care**

The grafts become stable usually in 3 weeks time. Daily physical therapeutic exercises are required to keep the joints in range of motion. These exercises are continued till the grafts mature and range of motion is achieved. Care of the grafted areas is done till the graft loses its tendency to contract and can be pinched and moved over the recipient area [7]. According to Burn Association Repositories' data, it has been found that 500,000 burn victims seek medical treatment every year, and 39% of these injuries involve upper extremity and hand [2, 21, 22]. There are several risk factors for the formation of hypertrophic scars like young age, infection, skin stretch and anatomic location (axilla, neck) [23].

### **2. Operative burn scar management**

In the acute phase of the thermal injury and during initial scar maturation, scar management can ameliorate hypertrophic scar formation and prevent scar banding. Timing of the operative procedure should allow enough time for complete scar maturation, as premature intervention can result in increased inflammation and additional scarring. Reconstructive procedures usually start 6 months after injury. For the correction of mild and moderate hypertrophic scar contractures, local skin flaps are commonly used to avoid more complex procedures [24]. Simple linear scar bands which can be seen across joints can be treated best with a scar-lengthening Z-plasty. The classic Z-plasty is designed with its central limb along the hypertrophic scar band and with a 60° angle of the lateral limbs. By making the corner 90° before extending the Z-plasty to 60°, perfusion to the tip of the Z-plasty is improved [25]. The flaps can be raised in scar tissue if maintained thick and involving underlying adipose tissue to achieve active lengthening of 75%. Creating the angle to 90° results in lengthening of 125%, however, involves larger limbs. To modify this approach, a series of smaller z-plasties along a scar can be performed. This helps to achieve similar lengthening but avoiding donor site morbidity with larger flaps. While larger flaps are used for axillary contractures, smaller flaps are used for palms and digits [26]. In web space contractures, modifications of plasties and a variety of local flaps are commonly devised [27, 28]. Because of its geometric design, the 5-flap Z-plasty is frequently used to create concavity and lengthening within the web space. Another option is the V-Y advancement flaps that use the supple dorsal tissue which is advanced into web space. These flaps can later on be combined with forms of z-plasties [29]. The second most common contractures behind neck contractures are the axillary scar contractures and they are difficult to improve. With z-plasties, small linear bands can be removed. Larger contractures can be treated with release and thick split thickness skin graft or full-thickness skin graft. Ogawa et al. describe treatment of severe contractures with pedicled flaps or with regional and free tissue transfer [30]. Usually palmar burn scars involve a large surface and result in tight contractures. Mild forms can be treated with a sequence of z-plasties. If it is a severe contracture, release of the scar may be required leaving a large defect. Full-thickness skin graft can be used to fill this defect. Full-thickness skin grafts are preferred over split-thickness graft because they have a decreased effect of secondary contraction to minimize scarring. If the contracture release leads to exposed tendon or bone, local flaps may be used [31].

#### **2.1. General principles of contracture release**

limb, scalp or back. In cases with multiple and massive contractures, the donor sites should be checked and plan charted out for "which donor site for which contracture." For neck, axilla and facial resurfacing, large sheets are important to be required while comparatively smaller

The grafts become stable usually in 3 weeks time. Daily physical therapeutic exercises are required to keep the joints in range of motion. These exercises are continued till the grafts mature and range of motion is achieved. Care of the grafted areas is done till the graft loses its tendency to contract and can be pinched and moved over the recipient area [7]. According to Burn Association Repositories' data, it has been found that 500,000 burn victims seek medical treatment every year, and 39% of these injuries involve upper extremity and hand [2, 21, 22]. There are several risk factors for the formation of hypertrophic scars like young age, infection,

In the acute phase of the thermal injury and during initial scar maturation, scar management can ameliorate hypertrophic scar formation and prevent scar banding. Timing of the operative procedure should allow enough time for complete scar maturation, as premature intervention can result in increased inflammation and additional scarring. Reconstructive procedures usually start 6 months after injury. For the correction of mild and moderate hypertrophic scar contractures, local skin flaps are commonly used to avoid more complex procedures [24]. Simple linear scar bands which can be seen across joints can be treated best with a scar-lengthening Z-plasty. The classic Z-plasty is designed with its central limb along the hypertrophic scar band and with a 60° angle of the lateral limbs. By making the corner 90° before extending the Z-plasty to 60°, perfusion to the tip of the Z-plasty is improved [25]. The flaps can be raised in scar tissue if maintained thick and involving underlying adipose tissue to achieve active lengthening of 75%. Creating the angle to 90° results in lengthening of 125%, however, involves larger limbs. To modify this approach, a series of smaller z-plasties along a scar can be performed. This helps to achieve similar lengthening but avoiding donor site morbidity with larger flaps. While larger flaps are used for axillary contractures, smaller flaps are used for palms and digits [26]. In web space contractures, modifications of plasties and a variety of local flaps are commonly devised [27, 28]. Because of its geometric design, the 5-flap Z-plasty is frequently used to create concavity and lengthening within the web space. Another option is the V-Y advancement flaps that use the supple dorsal tissue which is advanced into web space. These flaps can later on be combined with forms of z-plasties [29]. The second most common contractures behind neck contractures are the axillary scar contractures and they are difficult to improve. With z-plasties, small linear bands can be removed. Larger contractures can be treated with release and thick split thickness skin graft or full-thickness skin graft. Ogawa et al. describe treatment of severe contractures with pedicled flaps or with regional and free tissue transfer [30]. Usually palmar burn scars involve a large surface and result in tight contractures. Mild forms can be treated with a

pieces of graft are adequate for eyelid or finger contractures [7].

skin stretch and anatomic location (axilla, neck) [23].

**2. Operative burn scar management**

**1.4. Postoperative care**

108 Hot Topics in Burn Injuries


#### **2.2. Time for surgical contracture release**

Burn contracture release is undertaken once it is deemed "mature." Interfering with an active scar leads further contracture formation. Contracture and hypertrophic scar formation increases in the first 6 months, and full scar maturation will occur after 2 years. When the scar is active, it is pliable and amenable to stretching by physiotherapy [32].

To reconstruct the contracture, surgical treatment should be combined with release and splitskin grafting. This recently is called conventional waiting approach. For example, in the acute lower lid treatment, some studies showed that full-thickness grafts reduce the incidence of subsequent ectropion release [33]. It is important that, when flap cover of the defect is planned, this timing restriction is not applicable. Some authors support waiting for 2 or 3 weeks acutely, prior to undertaking release and free flap cover, and have reported success rates of 94% [34].

#### **2.3. How to treat the burn scar contractures**


When there is a mild contracture which means that there is 50% of joint movement possibility, to lengthen the scar, Z-plasty can be performed. In more severe cases, different surgical procedures are needed.

the band, but borrows tissue adjacent to the contracture. Unless there is a short contracture band with a good deal of lax adjacent skin, Z-plasty is possible. These can be thought of as Z-plasty-in-parallel or Z-plasty-in-series [36]. The Z-plasty-in-series (e.g., five-flap Z-plasty) recruits a large amount of adjacent tissue. The Z should always be designed as large as possible. The bigger the Z-plasty is in size, the greater the lengthening obtained. When compared the Z-plasty-in-parallel (e.g., multiple single Z-plasties) recruits much less adjacent tissue than Z-plasty-in-series. The actual lengthening obtained is relatively

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**Figure 2.** Z-plasty in series (5-flap Z-plasty); Z-plasty in parallel (multiple Z-plasties).

If the surrounding tissue is less pliable, this technique can be used. There is a risk of ischemic necrosis when the undermining and subsequent transposition of skin flaps are in an area of scarring and fibrosis (especially the tips). The reorientation of the scar can also result in distor-

Y-V plasty is especially useful in linear sheet contractures. The V extends the whole length of the band, and the Y passes into normal skin. The scar is not excised. The flaps simply are pulled forward to form a V [37]. To achieve this, skin laxity should be enough [38], and the

**1.** There is little risk of flap tip necrosis because the blood supply of the flaps is less compro-

**3.** The contracture band length is not important. This technique is especially useful in very long contracture bands. The running Y-V plasty is especially useful in these cases.

**4.** 100% lengthening of the long axis of the contracture which is the theoretical lengthening

This is only true when the flap can be advanced half the length of the sides of the V forming the flap. For two reasons, the actual lengthening obtained is much less than it is supposed to be. The first reason is as the burnt tissue has lost its elasticity, it is often difficult to advance the burnt skin. The second reason is interdigitation of each adjacent advancement flap. While

less (**Figure 2**).

*2.3.2.2. Y-V plasty*

tion of the surrounding tissues.

"pinch" test is useful to evaluate this [39].

mised as there is no need for undermining.

**2.** This technique effects reorientation of scar tissue.

The advantages of this technique:

of the contracture [38].

To remove the contracture, even a band or a sheet of scar tissue must be fully released. Unless local adjacent skin flaps are used, the release and the reconstruction can be considered as two different procedures, e.g., Z-plasty. The contracture release incision must be placed at the meridian of the joint and must be "fish-mouthed" at either end, and should extend into normal tissue medially and laterally. Using a swab on the index finger will "sweep" tissue away from the center contracture and divide "softer" bands. By using this manoeuvre, the extent of the defect to be covered will be increased. It is also designed to be sure that the wound is formed from normal tissue, not scar.

#### *2.3.1. Split-skin grafting*

This traditional method of split-skin grafting helps the defect import non-scarred, healthy, non-bulky skin without the need to compromise local tissues. The graft is ideally harvested from buttocks or scalp, which are cosmetically acceptable sites [35]. Once the contracture is fully released and full joint extension is achieved, then the graft is only applied to the wound bed. The ability to release multiple joints at the same sitting is an advantage, but leading to hypertrophic scar formation is a disadvantage. Also, when a split-skin graft is placed on a wound bed, the wound will again contract and recurrence might occur and re-release can be required again.

Because there is a risk such as immobilization difficulty, bleeding and infection, the split-skin grafts are at risk of suboptimal "take." Then the patient needs physiotherapy for motion of joint especially in children. Donor site morbidity is also a problem.

#### *2.3.2. Local surgical procedures*

#### *2.3.2.1. Z-plasty*

If there is a contracture which is due to a band, then a "local" procedure which both divides the contracting band and lengthens it is amenable avoiding the need for a donor site. The Z-plasty is a technique that divides the scar contracture and lengthens the band by importing local lateral adjacent tissue. Z-plasty does not create new tissue to lengthen

**Figure 2.** Z-plasty in series (5-flap Z-plasty); Z-plasty in parallel (multiple Z-plasties).

the band, but borrows tissue adjacent to the contracture. Unless there is a short contracture band with a good deal of lax adjacent skin, Z-plasty is possible. These can be thought of as Z-plasty-in-parallel or Z-plasty-in-series [36]. The Z-plasty-in-series (e.g., five-flap Z-plasty) recruits a large amount of adjacent tissue. The Z should always be designed as large as possible. The bigger the Z-plasty is in size, the greater the lengthening obtained. When compared the Z-plasty-in-parallel (e.g., multiple single Z-plasties) recruits much less adjacent tissue than Z-plasty-in-series. The actual lengthening obtained is relatively less (**Figure 2**).

If the surrounding tissue is less pliable, this technique can be used. There is a risk of ischemic necrosis when the undermining and subsequent transposition of skin flaps are in an area of scarring and fibrosis (especially the tips). The reorientation of the scar can also result in distortion of the surrounding tissues.

#### *2.3.2.2. Y-V plasty*

**a.** Z-plasty **b.** Y-V plasty

110 Hot Topics in Burn Injuries

**4.** Flap cover

**3.** Full-thickness skin grafting

**5.** Artificial skin substitutes

procedures are needed.

*2.3.1. Split-skin grafting*

required again.

*2.3.2.1. Z-plasty*

*2.3.2. Local surgical procedures*

formed from normal tissue, not scar.

**6.** Tissue expansion with or without flap cover

When there is a mild contracture which means that there is 50% of joint movement possibility, to lengthen the scar, Z-plasty can be performed. In more severe cases, different surgical

To remove the contracture, even a band or a sheet of scar tissue must be fully released. Unless local adjacent skin flaps are used, the release and the reconstruction can be considered as two different procedures, e.g., Z-plasty. The contracture release incision must be placed at the meridian of the joint and must be "fish-mouthed" at either end, and should extend into normal tissue medially and laterally. Using a swab on the index finger will "sweep" tissue away from the center contracture and divide "softer" bands. By using this manoeuvre, the extent of the defect to be covered will be increased. It is also designed to be sure that the wound is

This traditional method of split-skin grafting helps the defect import non-scarred, healthy, non-bulky skin without the need to compromise local tissues. The graft is ideally harvested from buttocks or scalp, which are cosmetically acceptable sites [35]. Once the contracture is fully released and full joint extension is achieved, then the graft is only applied to the wound bed. The ability to release multiple joints at the same sitting is an advantage, but leading to hypertrophic scar formation is a disadvantage. Also, when a split-skin graft is placed on a wound bed, the wound will again contract and recurrence might occur and re-release can be

Because there is a risk such as immobilization difficulty, bleeding and infection, the split-skin grafts are at risk of suboptimal "take." Then the patient needs physiotherapy for motion of

If there is a contracture which is due to a band, then a "local" procedure which both divides the contracting band and lengthens it is amenable avoiding the need for a donor site. The Z-plasty is a technique that divides the scar contracture and lengthens the band by importing local lateral adjacent tissue. Z-plasty does not create new tissue to lengthen

joint especially in children. Donor site morbidity is also a problem.

Y-V plasty is especially useful in linear sheet contractures. The V extends the whole length of the band, and the Y passes into normal skin. The scar is not excised. The flaps simply are pulled forward to form a V [37]. To achieve this, skin laxity should be enough [38], and the "pinch" test is useful to evaluate this [39].

The advantages of this technique:


This is only true when the flap can be advanced half the length of the sides of the V forming the flap. For two reasons, the actual lengthening obtained is much less than it is supposed to be. The first reason is as the burnt tissue has lost its elasticity, it is often difficult to advance the burnt skin. The second reason is interdigitation of each adjacent advancement flap. While using the "straight-line" advancement flaps, the problem is that the stretching of the skin limits the actual obtained lengthening. That is the reason only Y-V technique can be applied in mild contractures.

and temporalis fascial flaps are generally used [34]. There is a wide variety of flap choice which allows the surgeon to make judgments according to each individual case. There is no risk for recurrence, and this is the key advantage of flap. Free flaps may lead to an unacceptable cosmetic result because they import tissue different in color, thickness and texture. The flaps size must be as the same size as the defects size. Free flaps lead to a large donor defect and often require themselves a covering split-skin graft. Usually the adjacent tissue is burnt and the thick hypertrophic nature of the scar may make dissection of the recipient vessel difficult. Microvascular circulation should be kept up at higher level. Post-operative complications including complete or partial failure are disastrous. The free flap is an expensive and demanding procedure. It is a good option to apply when only one joint has a severe contrac-

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Following Yannas and Burke's original design, artificial skin templates have been developed [45]. Integra is a bilayer artificial dermis product consisting of porous bovine collagen spongy matrix combined with an overlying temporary epidermal substitute comprised of a silicone sheet. Combination of bilayer artificial dermis with split-skin grafting has been used by Soejima to reconstruct burn contractures [35]. The skin quality resembles full-thickness skin and also there is improved flexibility and suppleness, and scar hypertrophy does not exist [46]. There is reduced inflammatory response accompanying artificial skin substitutes, thus leading to reduced contraction. Donor site morbidity from split skin graft harvesting lower take rates than conventional autografts, more intensive dressing requirements and higher cost implications are the disadvantages [47]. This procedure has two steps. Sometimes it is noticed that areas of keloid scarring (and joint extremities in children) do not give good response to artificial dermis and tend to lead to recontracture or hypertrophic scar formation [35]. Hunt et al. treated a small series of neck contractures with Integra and they all developed recontracture [48]. The results of Integra over joints are disappointing despite adequate splintage [46]. In the management of complex wounds, Integra has been successful, but contamination and subsequent infection can lead to adverse results. A multicenter post-approval study in the United States including 216 burn injury patients found that the total incidence of infection in Integra-treated sites was 16.3% [49]. Another multicenter study managed with Integra following release of scar contractures noted a 20% infection rate. The second most common complication underneath Integra was fluid collection with 14% [50]. Matriderm is a thin (1 mm) single layer dermal matrix composed of collagen types I, III, and V and it has been marketed

Expansion of tissue is a simple procedure. The color, texture and thickness of the expanded skin is the same as adjacent skin. Tissue expanders together with a pre-expanded free [52] or fasciocutaneous flap [53] can be used in contractures caused by burns. Expansion of tissues

ture from broad sheet of scar in the extremities.

as a single-stage dermal template for reconstruction [51].

helps the maximum utilization of the non-involved areas.

*2.3.6. Expansion of tissue with or without flap cover*

*2.3.5. Artificial skin substitutes*

**5.** Y-V plasty is a simple procedure. While the operation is performed, the flap advancement degree can be refined. There is a disadvantage of this technique. Excision of a thick scar band is not actually possible, and there are poor cosmetic results (**Figure 3**).

The W-plasty, double-reverse V-Y plasty [40] and X-plasty [41] are the variations of the methods described above. To remove web-shaped burns, the seven-flap plasty has been described [42].

#### *2.3.3. Full-thickness skin grafting*

After the contracture release is complete, reconstruction with full-thickness grafting has a better texture match than with split-skin grafting, and is associated with less recurrence [13]. A full-thickness graft provides less wound contraction, because it has more dermis in the graft. After large burns, there may be limited available skin; thus in such cases, full-thickness grafts are impractical. Taking graft is much more tenuous than with split-skin grafts, when a contour to the underlying bed is required, like whole cheek, which is not a flat surface. Fullthickness grafts need a healthy bed on which to take and leave a donor site. They usually exhibit hyperpigmentation which causes poor cosmetic results.

#### *2.3.4. Flap cover*

Flap cover can be either a pedicled flap or free flap. To release the burn contracture, both local [43] and free [44] fasciocutaneous flaps are successfully used. In most of the superficial burns, perforators to the deep fascia are usually protected. In this case, a burn scar may itself be used as part of this flap [43]. In large burn areas, local pedicled flaps are sometimes inappropriate, however, due to the lack of local skin plasticity or simply a paucity of available or acceptable donor sites. In this situation, using a free flap should be considered. The latissimus dorsi, serratus anterior, lateral arm, scapular, gracilis, anterolateral thigh, arterialised venous

**Figure 3.** Y-V plasty. V is marked along the contracture band and Y extension passes into normal tissue on each side.

and temporalis fascial flaps are generally used [34]. There is a wide variety of flap choice which allows the surgeon to make judgments according to each individual case. There is no risk for recurrence, and this is the key advantage of flap. Free flaps may lead to an unacceptable cosmetic result because they import tissue different in color, thickness and texture. The flaps size must be as the same size as the defects size. Free flaps lead to a large donor defect and often require themselves a covering split-skin graft. Usually the adjacent tissue is burnt and the thick hypertrophic nature of the scar may make dissection of the recipient vessel difficult. Microvascular circulation should be kept up at higher level. Post-operative complications including complete or partial failure are disastrous. The free flap is an expensive and demanding procedure. It is a good option to apply when only one joint has a severe contracture from broad sheet of scar in the extremities.

#### *2.3.5. Artificial skin substitutes*

using the "straight-line" advancement flaps, the problem is that the stretching of the skin limits the actual obtained lengthening. That is the reason only Y-V technique can be applied

**5.** Y-V plasty is a simple procedure. While the operation is performed, the flap advancement degree can be refined. There is a disadvantage of this technique. Excision of a thick scar

The W-plasty, double-reverse V-Y plasty [40] and X-plasty [41] are the variations of the methods described above. To remove web-shaped burns, the seven-flap plasty has been

After the contracture release is complete, reconstruction with full-thickness grafting has a better texture match than with split-skin grafting, and is associated with less recurrence [13]. A full-thickness graft provides less wound contraction, because it has more dermis in the graft. After large burns, there may be limited available skin; thus in such cases, full-thickness grafts are impractical. Taking graft is much more tenuous than with split-skin grafts, when a contour to the underlying bed is required, like whole cheek, which is not a flat surface. Fullthickness grafts need a healthy bed on which to take and leave a donor site. They usually

Flap cover can be either a pedicled flap or free flap. To release the burn contracture, both local [43] and free [44] fasciocutaneous flaps are successfully used. In most of the superficial burns, perforators to the deep fascia are usually protected. In this case, a burn scar may itself be used as part of this flap [43]. In large burn areas, local pedicled flaps are sometimes inappropriate, however, due to the lack of local skin plasticity or simply a paucity of available or acceptable donor sites. In this situation, using a free flap should be considered. The latissimus dorsi, serratus anterior, lateral arm, scapular, gracilis, anterolateral thigh, arterialised venous

**Figure 3.** Y-V plasty. V is marked along the contracture band and Y extension passes into normal tissue on each side.

band is not actually possible, and there are poor cosmetic results (**Figure 3**).

exhibit hyperpigmentation which causes poor cosmetic results.

in mild contractures.

112 Hot Topics in Burn Injuries

described [42].

*2.3.4. Flap cover*

*2.3.3. Full-thickness skin grafting*

Following Yannas and Burke's original design, artificial skin templates have been developed [45]. Integra is a bilayer artificial dermis product consisting of porous bovine collagen spongy matrix combined with an overlying temporary epidermal substitute comprised of a silicone sheet. Combination of bilayer artificial dermis with split-skin grafting has been used by Soejima to reconstruct burn contractures [35]. The skin quality resembles full-thickness skin and also there is improved flexibility and suppleness, and scar hypertrophy does not exist [46]. There is reduced inflammatory response accompanying artificial skin substitutes, thus leading to reduced contraction. Donor site morbidity from split skin graft harvesting lower take rates than conventional autografts, more intensive dressing requirements and higher cost implications are the disadvantages [47]. This procedure has two steps. Sometimes it is noticed that areas of keloid scarring (and joint extremities in children) do not give good response to artificial dermis and tend to lead to recontracture or hypertrophic scar formation [35]. Hunt et al. treated a small series of neck contractures with Integra and they all developed recontracture [48]. The results of Integra over joints are disappointing despite adequate splintage [46]. In the management of complex wounds, Integra has been successful, but contamination and subsequent infection can lead to adverse results. A multicenter post-approval study in the United States including 216 burn injury patients found that the total incidence of infection in Integra-treated sites was 16.3% [49]. Another multicenter study managed with Integra following release of scar contractures noted a 20% infection rate. The second most common complication underneath Integra was fluid collection with 14% [50]. Matriderm is a thin (1 mm) single layer dermal matrix composed of collagen types I, III, and V and it has been marketed as a single-stage dermal template for reconstruction [51].

#### *2.3.6. Expansion of tissue with or without flap cover*

Expansion of tissue is a simple procedure. The color, texture and thickness of the expanded skin is the same as adjacent skin. Tissue expanders together with a pre-expanded free [52] or fasciocutaneous flap [53] can be used in contractures caused by burns. Expansion of tissues helps the maximum utilization of the non-involved areas.

The number of new scars and donor site morbidity is reduced. Neck, chest and scalp are the most suitable areas where tissue expansion is commonly performed. In the lower limb, expansion is especially difficult in the burned extremity [54]. While planning the expansion, it is often difficult to predict the size of the defect. Expansion has the risks of infection, leakage and skin ischemia, and even failure. The patients should attend regular follow-up to improve outcomes and reduce complication rates.

### **3. Clinical assessment**

1. Is the reason for the contracture an intrinsic force or an extrinsic force?

For example, if there is a burn scar on the cheek, then lower lid ectropion can occur without any intrinsic lower eyelid deformity.


**4. Conclusion**

of motion).

**Author details**

**References**

2009;**25**(4):511-528

The algorithms above are an attempt to simplify the approach to burn contracture release. Naturally, there are situations where the algorithm might not be applicable, and the surgeon,

**Figure 5.** Algorithm for the cover of burn contractures of the extremities after release: broad sheet of scar (ROM = range

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in all such cases, must plan an approach according to knowledge and experience.

Near East University Hospital, Faculty of Medicine, North Nicosia, Northern Cyprus

ment of burn scar contractures: A review. Burns & Trauma. 2017;**5**:5

[1] Stekelenburg CM, Mark RE, Verhaegen PDHM, et al. Perforator-based flaps for the treat-

[2] McKee DM. Acute management of burn injuries to the hand and upper extremity.

[3] Monstrey S, Hoeksema H, Verbelen J, et al. Assesment of burn depth and burn wound

[4] Kwan P, Hori K, Ding J, et al. Scar and contracture: biological principles. Hand Clinics.

[5] Tredget EE, Levi B, Donelan MB. Biology and principles of scar management and burn

reconstruction. The Surgical Clinics of North America. 2014;**94**(4):793-815

Pertevniyal Bodamyalızade, Emel Erdal Çalıkoğlu and Serap Maden

Address all correspondence to: pniyal@gmail.com

Journal of Hand Surgery. 2010;**35**(9):1542-1544

healing potential. Burns. 2008;**34**(6):761-769

**5.** Check if the band includes only one joint or if it involves other joints.

Below, there is an algorithm to help surgeons to choose the best reconstruction process for burn contractures after release (**Figures 4** and **5**) [32].

**Figure 4.** Algorithm for the cover of burn contractures of the extremities after release: band contracture (ROM = range of motion).

**Figure 5.** Algorithm for the cover of burn contractures of the extremities after release: broad sheet of scar (ROM = range of motion).
