A comprehensive approach to the delayed treatment of post-burn facial scars

Vitori Ivnovn Polshin, Mri Cervtiu, Igor Vldimirovih Reshetov,Alim Arsenovih Nebejev, Eldor Jonnzrov

a Department of Oncology, Radiotherapy and Plastic Surgery, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow 119435, Russia

b Department of Oncology and Plastic Surgery,Academy of Postgraduate Education of the FSBI FSCC Federal Medico-Biological Agency of Russia,Moscow 119435,Russia

c Department of Ophthalmology, I.M.Sechenov First Moscow State Medical University (Sechenov University), Moscow 119021, Russia

Keywords:Thermal burn Facial scarring Diplene film Buccal-periorbital-perioral region Adhesive membrane Deformation

A B S T R A C T

1.Introduction

According to the World Health Organization, more than 50 million people worldwide are injured annually.Compared to other victims,thermal burn victims are younger and have smaller wound areas,greater skin lesion depths, severer courses, and greater incidences of disability and mortality.1,2Even superficial injuries of the neck and face have an increased tendency for the formation of pathological scar deformities,due to the specific anatomy and functional load of the maxillofacial region.Hypertrophic and keloid scars also tend to form in the maxillofacial region, which entail not only functional limitations in the patient, disrupting chewing,breathing,and vision,but also physical deformities that deprive the patient of social activity.3(see Fig.1)

Most often, the deformation takes the form of ring- or horseshoeshaped strands, rollers, and hypertrophic and keloid arrays, involving several anatomical areas in the process.4The resulting scar deformation can lead to both aesthetic and functional disorders with characteristic anatomical changes, including deformation of the mouth and eye sphincters,nasal valve insufficiency,violation of the facial contours,and deformation of the facial skin structure.Mental disorders caused by trauma and altered physical conditions lead to social maladaptation in patients of a socially active age, which is a complex problem in the modern world.5,6

Currently, reconstructive surgeons have a wide range of different surgical techniques,including plasty with local tissues and flaps with an axial vascular pattern (on the feeding leg) taken from both regionally close and distant anatomical areas, transfer of donor flaps using microsurgical techniques, transplantation of free skin, tissue dermotension,and skin-covering prosthetics using artificial materials.The development of new biocompatible materials has expanded the scope of their use in plastic and reconstructive facial surgery owing to numerous advantages,such as abundant materials, an absence of donor areas and related complications,and the ease of modeling a material of the right size and shape that maximally satisfies the needs of doctors and patients.7

Fig.1.A 44-year-old patient with a right-side cicatricial deformity of the buccal-periorbital-perioral region.(A, B) Right-side scarring of the buccal-periorbitalperioral region.(C) Marking the operative area with 1% brilliant green.(D, E) Mobilization of the skin-fat flap of the cheek to the lower edge of the orbit and tissues in the perioral-chin region.(F,G)Preparation and implantation of a biodegradable diplene membrane.(H,I)Multiple Z-plasty.(J)Wound suturing with nodular sutures.(K) One day postoperative.(L) 6 months postoperative.

The introduction of polymer implants makes it possible to significantly expand the range of patients who can receive surgical care,reduce the number of relapses,improve the results of surgical interventions,and ultimately restore the efficiency and improve the quality of life of patients.Silicone implants are one of the most common devices used for the correction of scar deformities.They have high strength,are deformation resistant,and are easily adjusted to the desired shape.However,they can cause allergic reactions, and examining the patient’s vaccinations is sometimes necessary.

Hydrogel implants are widely used to treat scar deformities.They contain gels that can adapt to the scar’s shape and volume and have greater strength and stability than silicone implants.However, they are less flexible and more expensive.Hyaluronic acid-based fillers can fill voids and even out the skin’s surface.The use of bismuth filaments creates a support for the skin and helps restore the shape of the face.However, using fillers based on hyaluronic acid and bismuth filaments has disadvantages, including possible side effects, such as swelling,bruising,and discomfort in the area of filler insertion,and the results may be temporary,requiring repeated procedures.

Biological materials,such as skin grafts or collagen vessels,have also been used to correct scar deformities.These materials are more natural and do not cause allergic reactions; however, they may be less durable and require more time to integrate into the patient’s tissues.

The choice of treatment method depends on many factors that a specialist should consider before starting treatment,including the time of deformation of the post-burn scar and the condition of the surrounding and adjacent tissues, the lesion’s depth and coverage, whether to implement a postoperative protective regime for the patient,and the full implementation of rehabilitation measures.8

2.Patients and methods

This case is a clinical example of the surgical treatment of a patient with a post-burn deformity of the right half of the face who had repeatedly undergone nonsurgical childhood burn treatments.

The 44-year-old patient was referred to the Plastic Surgery Department of the State Clinical Hospital No.1 in Moscow in the autumn of 2022 with complaints of an aesthetic and functional deformity of the buccal-periorbital-perioral region.Based on the patient’s anamnesis,after receiving primary medical care in the postoperative period, a persistent scar deformity formed.An attempt was made to plasticize the scar deformity using local tissues(i.e.,Z-plasty with local tissues),which did not yield the expected results; the cicatricial deformities were preserved.In adulthood, repeated nonsurgical treatments were performed,including injections (>10 courses) and physiotherapeutic treatment methods (i.e., lidase electrophoresis).After the examination and anamnesis collection, the patient was diagnosed with a right-side cicatricial deformity of the buccal-periorbital-perioral region.The patient was offered plastic surgical treatment using local tissues and a biological membrane,a double-sided diplene film,in a hospital setting.

During the external examination,an asymmetry of the face at rest was noted, which increased with facial movements.An extensive scar deformation was noted in the right buccal-perioral-periorbital region,involving the superficial part of the lower edge of the circular eye muscle,surface of the cheek, nasolabial fold, mouth cleavage, nose wing, and chin.

The scar structure deformed the cheek and chin contours.During facial movements, the displacement of those structures occurred due to the contracture of the underlying muscles.On palpation,the lower third of the scar was slightly painful and had adhered to the underlying tissues,with notable growth.The upper third of the scar was heterogeneous and partially pigmented, without signs of overgrowth.The skin in the scar area did not shift relative to the underlying tissue, indirectly indicating the lesion depth.The lymph nodes in the maxillofacial region were not palpable during the examination, and no pathological neoplasms were found.

After a preoperative examination (according to the standards of the Ministry of Health of the Russian Federation), the patient was hospitalized in the Oncological Department of the State Clinical Hospital No.1 for reconstructive plastic treatment of a right-side cicatricial deformity of the buccal-periorbital-perioral region.Among the additional examinations, an MRI of the head and neck soft tissues was performed to determine the tissue of interest as well as the functional viability of the underlying tissues.This study made it possible to preoperatively choose and coordinate the surgical treatment method as well as assess the possible risks of postoperative complications.

Surgical treatment was performed in accordance with the plastic surgery protocol for local tissues.

In the operating room, under the conditions of combined endotracheal anesthesia, after three antiseptic treatments in the surgical field,the surgical intervention zone was marked with a 1% brilliant green solution,limiting the maximum area of scar tissue resection.Owing to its large size and the repeated treatments, the scar was not completely removed to avoid iatrogenic complications.The soft tissues of the scar deformation zone were infiltrated with a 1:400 aseptic saline solution containing adrenaline.Based on the previously applied markings, the skin flap for the scar deformation was resected.

The right skin-fat flap of the cheek was bluntly and acutely mobilized to the lower edge of the orbit and the tissue in the perioral-chin region.The areas of muscular contracture of the circular muscle of the mouth,the muscle that lowers the corner of the mouth,and the chin muscle were identified.Scar junctions were excised, and soft tissues were placed without tension and fixed with nodular Vicryl 4-0 sutures.

The released skin-fat flap was redistributed in the area of the resulting defect.However, when it was fixed using standard techniques followed by the conventional muscle movements of this zone, the following disadvantages were noted:displacement of the corner of the mouth,wing of the nose, and lower eyelid.Considering these preoperative issues, the formed flap was fixed in the defect zone without tension using a doublesided diplene film, which not only avoided the possibility of postoperative bleeding due to the large size of the defect zone but also fixed the skin.The flap was in the required position with the underlying tissues without displacement or the formation of a new scar contracture.

Biodegradable diplene film plates were placed in the flap area formed in the periorbital,buccal,perioral,and chin areas after treatment on both sides with a saline solution to activate the material and increase its elastic properties.

Owing to its adhesive properties, the diplene film was fixed, and a complete overlap of the formed defect occurred without displacement of the supporting structures, including the right-side corner of the mouth,wing of the nose, and lower eyelid.The amount of material used corresponded to the size and shape of the defects formed.The incision line was adapted,considering the resulting defect and in accordance with the type of multiple Z-plasty,and fixing seams were applied to assess the stability of the fixed material.Intraoperative hemostasis was achieved via electrocoagulation.The subcutaneous fat was sutured in layers with nodular Vicryl 4-0 sutures.The skin was sutured with nodular Prolene 5-0 sutures,and an aseptic pressure bandage was applied.

3.Results

In the early postoperative period,minimal edema was noted despite the extensive surgical area,with no hemorrhagic secretions and primary healing.Postoperative management was performed according to the standard protocols for the treatment of patients undergoing plastic surgery with local tissues.The stitches were removed on the 8th day,and the patient was discharged in good condition.Currently,the patient is being monitored remotely.The facial muscle functions were fully preserved,and the skin flap was fixed in the required position with the underlying tissues using an adhesive diplene film without displacement and the formation of a new scar contracture,as well as without displacement of the supporting structures,i.e.,the right-side corner of the mouth,wing of the nose,and lower eyelid.

4.Discussion

We used a biodegradable polymer film made of diplene, which was synthesized by Professors Gevorgyan and Chukhajyan at Yerevan State University.It is a colorless, elastic, and soft material consisting of a combination of hydrophilic and hydrophobic layers.The main components of the membrane are natural and synthetic water-soluble polymers and copolymer derivatives, particularly polysaccharides and their derivatives.High adhesion to the surgical wound’s surface was observed,owing to the presence of a plasticizer in the hydrophilic layer.The hydrophobic layer isolates the tissues from external mechanical influences and the penetration of microorganisms.The film is a “single layer,”despite the two-layer nature,with no signs of the separation of one layer from another.Films have various medical uses—to cover wound surfaces;in the preparation of surgical fields; to prevent skin irritation by secretions from intestinal and other fistulas; in the thoracic and abdominal cavities, to strengthen the sutures of anastomoses applied at various levels of the gastrointestinal tract; to cover deserialized surfaces of the thoracic and abdominal cavities to prevent the formation of adhesions;and during operations on parenchymal organs,to stop capillary bleeding.Chervatyuk et al.9described the use of a diplene film for eyelid reconstruction after tumor treatments.

Based on this clinical case, performing reconstructive interventions using a biodegradable diplene adhesive film has numerous advantages,including the following:a reduction or absence of the risk of bleeding due to the material’s hemostatic function;the fixation of surrounding tissues due to the material’s adhesive properties, which prevents the displacement of the corner of the mouth, nose wing.and lower eyelid during facial muscle movements;the possibility of individual modeling and the ability to replicate the curvature and dimensions of the wound’s surface without creating a deformation of the surrounding soft-tissue structures,which avoids developing peripheral contouring; the material biocompatibility, wherein the polymer material is completely biocompatible,has no cellular toxicity, and does not cause allergic, inflammatory or rejection reactions;and the unrestricted contraction and relaxation of the facial muscles.

Six weeks after the subcutaneous implantation of the diplene membrane,the membrane was completely resorbed without any toxic effects on the body.The fibrous tissue at the membrane implantation site was thickened,and small groups of macrophages,single multinucleated cells(foreign body cells), lymphohistiocytic perivascular infiltrates, and an increased number of vascular elements were detected.

Only an individual approach to the treatment of patients with different scar lesions enables optimal aesthetic results that satisfy both the patient and doctor,since none of the developed therapeutic methods universally achieve optimal scar corrections.The goal of the attending surgeon should be to determine the priority and sequence of the surgical treatment for scar deformities to achieve maximum results with a minimum number of operations.10,11

5.Conclusion

Monitoring patients with scar deformities is crucial because they may develop disabling complications, including functional limitations and impaired chewing and respiratory and visual functions, thereby depriving the patient of social activity, in addition to providing poor aesthetic results.Using a biodegradable diplene film with pronounced adhesive properties to reconstruct the buccal-periorbital-perioral region is an effective method for treating such patients.Further large-scale,long-term studies are needed to refine the indications and improve the methodology.

Ethics approval and consent to participate

This study has received the ethical approval from the Ethics Committee of the I.M.Sechenov First Moscow State University.The patient provided written informed consent prior to study enrolment.

Consent for publication

The patient included in this study gave written informed consent to the publication of the data contained in this study.

Authors’ contributions

Polshina VI:Writing-Original draft,Conceptualization,Methodology.Cervatiuc M: Writing-Original draft, Conceptualization, Methodology.Reshetov IV: Writing-Review and editing, Methodology.Nebejev AA:Writing-Review and editing, Conceptualization, Methodology.Jonnazarov E:Conceptualization,Methodology.

Declaration of competing interests

The authors declare that they have no competing interests.