Microsurgical Reconstruction for Severe Scar Deformity

Reconstructive Strategies

Severe scar deformities often occur after deep burns, scalds, severe trauma, infections, postoperative tissue defects, or repeated scar proliferation.

The problems they cause go beyond unsightly skin surfaces and may include skin contracture, soft tissue defects, organ traction, restricted joint movement, changes in the shape of the mouth, eyes, and nose, decreased fine motor skills in the hands, and even affect eating, closing the eyes, lifting the head, making a fist, walking, and daily life.

Common scar treatments primarily involve laser therapy, injections, silicone, pressure therapy, and tension-reducing care; however, severe scar deformities involve structural changes, shifting the treatment goal towards 'reconstruction.'

Plastic surgeons need to release contractures, excise inelastic scar tissue, restore local skin length and soft tissue thickness, and cover the wound with appropriate tissue. The value of microsurgery is particularly evident in these complex scenarios.

Why is microsurgical reconstruction suitable for complex scars?

Microsurgery involves delicate operations under a microscope or magnification equipment, allowing for the anastomosis of small blood vessels and nerves, and the transfer of flaps or composite tissues with blood supply. For patients whose local skin has been damaged by burns or scars and who lack sufficient healthy tissue nearby, microsurgery can transfer tissue from other parts of the body to reconstruct the damaged area.

For example, after severe neck burns, adhesions between the chin and chest wall may occur, leading to the disappearance of the neck contour, eversion of the lower lip, and downward pulling of the corners of the mouth and nasal alae. Burns during childhood, if treatment is delayed, may also result in mandibular hypoplasia, significantly affecting the function and appearance of the jaw and neck. Such deformities are difficult to resolve with simple excision and approximation sutures and often require thorough release followed by reconstruction with a free flap.

What do doctors evaluate before microsurgical reconstruction?

Plastic surgeons first assess the extent, depth, hardness, blood supply, ulceration, infection, and functional impact of the scar. For example, in the neck, they check the ability to lift and turn the head; in the hand, they assess the ability to extend fingers, make a fist, and oppose the thumb; for the eyelids, they check for incomplete closure, entropion, and corneal irritation; on the face, they evaluate whether the nasal alae, corners of the mouth, vermilion border, and eyelid position are being pulled.

For hand burns and scars, simply estimating the area is far from sufficient. It is also necessary to evaluate the wound, scar, deformity, and range of motion based on the functional anatomy and aesthetic characteristics of the hand to improve the specificity of treatment.

Additionally, for pediatric scars, growth and development must be considered. Since children are in a rapid growth phase, scar assessment and treatment need to take into account skin sensitivity, compliance, cooperation of guardians, risk of contracture, and limited ability to assess function.

Chin-chest adhesion deformity: Reconstruction of neck contour and mobility

Cervicomental adhesion is a typical type of scar contracture following severe burns, where the patient's chin is pulled towards the chest by the scar, making neck extension difficult and causing the cervicomental angle to disappear. In severe cases, the lower lip, corners of the mouth, nasal alae, and lower eyelids may also be deformed due to traction. The treatment goal is to release or excise the contracture scar, correct secondary deformities, and restore the cervicomental contour and physiological structure of the neck.

Treatment of cervicomental scars requires thorough release of the contracture scar, with separation performed between the scar and normal tissue layers, and full exposure of the normal depth of the cervicomental angle achieved by tilting the head back. When repairing the wound surface, it is advisable to choose a large, soft, thin flap. This demonstrates that microsurgical reconstruction is not only about covering the wound but also about restoring contour, skin elasticity, and range of motion.

Facial Scar Deformity: Emphasis on Fine Layering in Microsurgical Aesthetic Repair

Facial scars significantly impact appearance and function. Scars on the eyelids, nasal alae, corners of the mouth, lips, eyebrow area, cheeks, and mandibular margin can lead to asymmetry of facial features, restricted expressions, difficulty closing the eyes, limited mouth opening, or misalignment of the vermilion border.

Microsurgical aesthetic repair of facial scars emphasizes handling tissue layers under magnification to minimize secondary damage, aiming to place scars in natural skin folds or concealed areas as much as possible.

Before facial scar repair, it should be confirmed that the patient does not have a pronounced scar-prone constitution. The injury or previous surgery should have undergone a relatively stable period, and factors such as the direction of the original scar relative to skin folds, soft tissue displacement, and subcutaneous depressions should be included in the design. Microsurgical aesthetic repair also requires consideration of skin layer alignment, fine needle and thread suturing, tension reduction, and postoperative scar prevention.

During microsurgical reconstruction, plastic surgeons consider incision direction, skin texture, soft tissue thickness, local depressions, expression-induced tension, and postoperative scar reformation. The more precise the facial reconstruction, the lower the likelihood of noticeable scars and secondary repairs in the future.

Pediatric Hand Scar Contracture: Balancing Growth and Function in Microsurgery

Pediatric hand scar contractures are common after burns, scalds, and trauma. Due to the intricate structure of the hand, where skin, tendons, nerves, blood vessels, and joints are concentrated in a small area, scar contracture can lead to difficulties in finger extension, making a fist, narrowing of the thumb web space, webbed fingers, and reduced thumb function.

Microsurgical treatment of pediatric hand scar contracture deformities requires selecting appropriate methods such as full-thickness skin grafts, local flap transfers, rectangular web space flaps, dorsal island flaps of the proximal phalanx of the index finger, and wrist artery snuffbox perforator flaps based on the specific situation. Preoperative assessment should include checking finger mobility, tendon adhesion, and web space adhesion, and the repair method should be chosen according to the size of the defect and exposure of deep tissues after scar release.

Reconstruction of a child's hand should not focus solely on the current appearance, as the child will continue to grow, and the fingers will continue to develop. Scar tissue has poor elasticity, which may again restrict growth and movement in the future. Therefore, after microsurgery, splints, rehabilitation training, scar care, and long-term follow-up are necessary.

Scar-related Entropion: Protecting Ocular Surface Function Under the Microscope

Eyelid scar deformity involves precise functional reconstruction. Scar-related entropion is caused by scar contraction of the tarsal plate and conjunctiva, resulting in the inner layer of the eyelid being shorter than the outer layer. This causes the eyelid margin to roll inward, with eyelashes rubbing against the cornea, potentially leading to severe damage to the eye structure and visual function.

For microsurgical treatment of scar-related upper eyelid entropion, doctors perform wedge resection of the tarsal plate and precise suturing under a microscope. Depending on the situation, this may be combined with excision of redundant upper eyelid skin, gray line incision, tarsal strip embedding, or local electrolysis of trichiasis.

Microscopic operations allow for clearer anatomical layers and easier control of the width and depth of tarsal strip excision. Therefore, microsurgery is not only used for 'large flaps' in scar deformity treatment but also for precise correction of millimeter-level structures such as eyelids, fingers, and facial areas.

Long-term management is required after microsurgical reconstruction.

After microsurgical reconstruction, new incisions and flap edges will still form scars. Postoperative care should include pressure application, tension reduction, silicone therapy, infection prevention, sun protection, splinting, and rehabilitation exercises.

Particularly after neck and hand reconstruction, it is essential to maintain stretching and functional exercises; otherwise, new scars may contract again. After eyelid reconstruction, it is important to monitor the position of the eyelid margin, trichiasis, corneal irritation, and closure status.

Patients with severe scar deformities also need to establish reasonable expectations, as microsurgery can significantly improve appearance and function, but it usually cannot restore the skin completely to its pre-injury state.

For scars with a long course, large area, deep structural damage, or those occurring during a child's growth period, staged treatment may be necessary. This includes initial release and coverage, followed by local refinement, laser treatment, injections, fat grafting, or secondary reconstruction.

In which situations is it advisable to consult a microsurgical reconstruction specialist early?

If scars have caused difficulty in neck extension, adhesion between the chin and chest wall, inability to fully extend fingers, inability to open the thumb web space, eyelid entropion or ectropion, incomplete eye closure, mouth corner traction, nasal wing deformation, large burn contractures, or recurrent ulceration, it is recommended to seek evaluation by a plastic surgeon as soon as possible.

Children's scars require early assessment because they may be accompanied by pain, itching, sensory abnormalities, functional impairment, and psychological issues. Growth and development will continue to affect scar changes. Delaying treatment until bones, joints, tendons, and facial development are affected will increase the difficulty of treatment.