Microsurgery “without borders”: new limits for reconstruction of post-burn sequelae in the humanitarian setting

Summary

Post-burn contractures account for up to 50% of the workload of a plastic surgery team volunteering in developing nations. Best possible outcome most likely requires extensive surgery. However, extensive approaches such as microsurgery are generally discouraged in these settings. We report two successful cases of severe hand contractures reconstructed with free flaps on a surgical mission in Kenya. Microsurgery can be safely performed in the humanitarian setting by an integration of: personal skills; technical means; education of local personnel; follow-up services; and an effective network for communication.

Introduction

Post-burn contractures constitute a formidable foe for reconstructive surgeons in developing countries, accounting for 50% of the workload of a general plastic surgery mission. Complete contracture release is desirable to achieve the best possible outcome, but operators might be discouraged from performing microsurgery and flap reconstruction in these settings. We believe, however, that reconstructive microsurgery can be safely performed and should be offered as a surgical option. We report two cases of severe hand contractures treated with release and reconstruction with free flaps during a surgical mission in rural Kenya. At the time of treatment, there were no reports on the use of free flaps in the humanitarian setting.

Case description

Setting

The Missionary Hospital of North Kinangop is located in central Kenya at an altitude of 2,500 meters and approximately 130 km northwest of the capital Nairobi. The hospital provides 4th level health care services to a catchment population of around 180,000 people. The operating theatre is equipped with a surgical binocular head microscope (Carl Zeiss). Three-week plastic surgery missions have been carried out on a regular basis since April 2014, coordinated by the non-profit association Help for Life Foundation Onlus (Padova, Italy) together with the Clinic of Plastic and Reconstructive Surgery of the University of Padova, Italy.

Case 1

The visiting reconstructive surgeons were introduced by the in-house surgical team to the case of a 17-year-old boy who had sustained a severe accidental scald burn on his left palm at the age of 2. The burn had been neglected, with consequent development of post-burn contracture causing severe impairment of hand function (Fig. 1). Six months prior to consultation, an attempt had been made to correct it (combination of local flap and split-thickness skin graft). This was unsuccessful therefore reconstruction with an anterolateral thigh (ALT) perforator flap was planned. The flap was to be taken from the middle segment of the lateral thigh. A pre-operative Doppler was used to assist in locating suitable perforating vessels.

Fig. 1. Seventeen-year-old male patient suffering from post-burn contracture of left hand’s volar surface causing a global impairment to hand function.

The flap was dissected until a musculocutaneous perforator was identified and then circumscribed (Fig. 2a). The donor site wound was closed directly. Complete debridement of scar tissue and scar removal on the palm was extended distally to the metacarpal-phalangeal joints and flexor tenolysis was performed. The flap was inserted into the fresh wound on the palm (Fig. 2b). Arterial anastomoses was performed end-to-end with the ulnar artery; a single venous anastomoses was performed, with adequate intraoperative drainage. Postoperative monitoring with Doppler ultrasound probe was unremarkable until hour 18, when an increased swelling of the flap was noted. By hour 25, the swelling was marked with soft tissue hardening, and pain was strong at minimum pressure over the free flap. The free flap was monitored to assess skin colour, refill and temperature, but as the patient was dark-skinned the assessment was more difficult, and he was taken to the operating theatre for flap revision (Fig. 3a). A hematoma was found behind the flap with thrombosis of one of the comitant veins and partial thrombosis of the anastomotic vein. The flap underwent a second microvascular venous anastomoses and revision of the first vein with clot removal and perfect venous drainage of the perfused flap. Postoperative management was uneventful and the swelling regressed within the following 30 hours (Fig. 3b). A plaster slab was applied and wounds were monitored with regular dressing changes. A rehabilitation program was discussed with the inhouse physiotherapist, to be conducted at the hospital’s outpatient clinic. Due to the few wound care resources available outside the hospital setting, the patient was kept in until the wounds had nearly healed, and was discharged on day 19. Four months after surgery, the operating team evaluated the patient’s clinical picture and estimated recovery of physiologic hand posture at rest to be 70% (Fig. 4). Estimated recovery of range of motion (degrees) in the fingers is shown in Table I.

Fig. 2. Intraoperative view: (a) a free anterolateral thigh flap is harvested from the right thigh and used to cover the tissue defect left after releasing, (b) reaching a satisfactory new functional position.

Fig. 3. (a) At 25 hours post op, extreme swelling of the flap required a revision procedure, where a second venous anastomosis was performed to support venous drainage; (b) at 30 hours post revision the swelling has reduced.

Fig. 4. Follow up at 4 months. A satisfactory degree of extension has already been reached with active and passive physical therapy.

Table I. Clinical assessments of pre-operative and post-operative range of motion for case 1.

Case 2

Doctors without Borders/Médecins sans Frontières (MSF) Nairobi contacted North Kinangop Hospital regarding the case of a 14-year-old boy who had sustained severe bilateral flame burns on the hands from parental abuse seven months before. He had been hospitalized and acutely treated with split thickness skin grafts harvested from both thighs. The patient was evaluated by an anesthesiologist on the humanitarian mission, and clinical pictures were used for a preliminary surgical consultation. His current problem was bilateral hand contractures with swan neck deformity and severely limited finger flexion and extension (Fig. 5). A surgical plan was discussed and dominant hand (right) reconstruction was planned with ALT perforator flap. Both thighs had hypertrophic scars from previous skin harvesting. The flap was planned over the middle segment of the lateral thigh (Fig. 6a).

Fig. 5 a, b, c. Fourteen-year-old male patient suffering from post-burn contracture of right volar surface causing en boutonnière multiple deformities.

Fig. 6 a, b, c. The operative plan consisted of hand dorsum release and subsequent coverage of the dorsal defect with a free anterolateral thigh flap harvested from the right thigh.

A pre-operative Doppler was used to assist in locating suitable perforating vessels.

The surgical approach consisted in a two-stage procedure: a) complete debridement of scar tissue and correction of finger deformities with K-wires; b) soft tissue reconstruction of hand dorsum. The rationale for this was to perform surgery in the safest way possible, as the team consisted of only two operators. The two procedures were performed with a 24-hour break for anesthesiology reasons. The flap was harvested with a septal perforator and the exposed muscle covered with split thickness skin grafts (Fig. 6b). The flap was inset into the fresh wound in the dorsum (Fig. 6c). Arterial anastomoses was performed end-to-side with the radial artery; a single venous anastomoses was performed, with adequate intraoperative drainage (Fig. 7). Monitoring was performed with Doppler ultrasound probe for 48 hours. Postoperative progress was uneventful and a customized plaster slab was applied. Due to the few wound care resources available in the patient’s area of origin, he was kept in until the wounds had nearly healed. He was discharged on day 21 with instructions for K-wire removal, and an intensive rehabilitation program of active and passive movements to be conducted at MSF’s clinic. Two months after surgery, using clinical pictures, the operating team estimated recovery of physiologic hand posture at rest to be 80% (Fig. 8). Estimated recovery of range of motion (degrees) in the fingers is shown in Table II. Topical vasodilators, such as lidocaine or papaverine, were not used in this series. All patients received fluid resuscitation, as appropriate, to keep their blood pressure in the normotensive range (90/60 to 140/90 mmHg) and heart rate between 60 and 100 beats per minute.

Fig. 7. Immediate postoperative view: all the long digits were stabilized in the new functional position with k-wires. The flap survived without the need for revision and with minor areas healed by secondary intention.

Fig. 8 a,b. Follow up at 2 months. The flap is stable and the new position is satisfactory.

Table II. Clinical assessments of pre-operative and post-operative range of motion for case 2.

Discussion

Sequelae to burns are responsible for significant mortality and morbidity worldwide, especially in developing countries.^1,2 The routine use of fire for domestic needs is the leading cause of burns in central African rural areas, where emergency services are limited and public resources devoted to fire fighting are few. Kenya, like most other countries in central Africa, still lacks a sufficient number of burn units for adequate treatment of the population.²Most patients decide to treat themselves with home remedies, and the wounds are left to secondary healing with severe complications as a result. Patients with severe postburn contractures and impaired function are usually left without medical or social support other than that offered by humanitarian organizations. Hence, medical missions providing surgical corrections of burn contractures can greatly impact the quality of life of the local population.³ Ongoing projects of international plastic surgery volunteerism are growing in number, some of them already well-established and others emerging. All of these organizations seek to deliver not only surgical and medical care but also knowledge and information to the population.

In the field of upper extremity reconstruction, the ideal flap should meet specific requirements. This is especially important with the hand, where the flap needs to be thin and pliable in order to mold the contour of the hand while still providing sufficient coverage of the underlying structures. ^4,6 Often, free perforator skin flaps are the best choice of treatment when thin pliable tissue is required, particularly where more simple techniques do not provide a satisfactory solution.⁷ Reports have shown how suitable donor areas might be found where the skin has suffered previous injuries.⁸ We feel that reconstructive microsurgery might be an option to consider in surgical missions, considering the number of massively-burned patients who need large anatomical regions resurfaced. However, a number of requirements must be met in order to provide patients with comprehensive care and successful outcome (Table III). Communication plays a vital role in all phases of management, ranging from remote pre-operative assessment to follow-up. New technologies and telemedicine allow us to communicate more effectively.

Table III. Performing reconstructive microsurgery on surgical missions: aspects to be considered for a successful outcome.

Conclusion

The management of severe burn scars remains complex, and cases encountered on a humanitarian mission present further specific challenges. If a proper network of short-term and long-term postoperative support can be guaranteed through the combined efforts of multiple parties, microsurgical reconstruction should be considered as a feasible alternative, even in a resource-limited context.