Half of all burn victims seen in emergency rooms every year have burns to their head and neck. Advances in medicine have dramatically increased the survival rate of those who suffer severe burns.
Joel Feldman, M.D., plastic surgeon at Mount Auburn Hospital in Cambridge, a teaching hospital of Harvard Medical School, sees patients from all over the world and says while many people survive the physically devastating effects of a severe burn, living with the emotional damage can be more devastating. “The quality of life after the injury is directly proportional to the quality of reconstruction that burn patients have to their face. You can cover up scars on your arms or legs. But your face is the first thing the world sees,” says Dr. Feldman.
Mount Auburn Hospital is a world-class facility with a world-class team of physicians and medical staff. For 30 years, Dr. Feldman has been among the top plastic surgeons in the world, developing new techniques and teaching them to others. “It takes quite an experienced team to work in facial reconstruction,” says Dr. Feldman. “Mount Auburn Hospital provides me with wonderful anesthesiologists, caring for the patient during long, complex operations. The nursing care is top-notch as well. Many of the nurses have been here as long as I have and get to know the patients quite well.”
Dr. Feldman says there are two elements to facial reconstruction. One element is surface reconstruction, which replaces scarred tissue with unscarred skin. There are two basic methods for replacing scarred skin: flap surgery and skin grafting.
Flap surgery performed on a patient with head burns, for example, is done by rotating unscarred skin up from the neck or upper torso with it still attached at one end to the body to maintain a blood supply. Using skin flaps from a local or adjacent area to the scarred skin helps maintain its normal texture, color and quality.
“I prefer to use the flap surgery technique in most cases, if I can,” says Dr. Feldman. “Using local tissues is best for color matching and will blend the best. Skin from an area farther away usually has a different color and texture.”
Another flap surgery technique is called free flap. This technique takes skin from a different area of the body, and with that also takes a layer of fatty tissue containing blood vessels. It differs from pedicled flap surgery in that this block of tissue is completely detached from the body. It’s inserted into an area that needs the new skin, and the blood vessels in the block of tissue being moved are sewn to the blood vessels at the recipient site under the microscope.
Skin grafting is different than flap surgery. With flap surgery, a blood supply comes with the new tissue, but with skin grafting, no fat is carried along with the skin, which is completely detached from the body and sewn into a recipient site where the scarred skin has been removed. The new skin graft then has to pick up a blood supply by in-growth of new blood vessels from the recipient bed. Dr. Feldman says skin grafts usually have a different color or texture than normal facial skin.
Another option surgeons use if there isn’t enough local skin for a flap surgery is called skin expander. A balloon is placed under the skin and inflated with sterile salt water to stretch the skin over a period of several months, essentially creating more local skin. “Little by little, as you’re blowing this balloon up, you’re stretching the skin; almost like a woman’s abdomen stretches during pregnancy,” explains Dr. Feldman. “Once you’ve reached enough skin stretching, then you can take out the balloon and swing the stretched skin flap over to resurface the scarred area.”
The other element to facial reconstruction is the three dimensional elements of the face: the nose, chin, eyelids and ears. “They have a three-dimensional quality to them and rebuilding those contours is at least, if not more important than restoring normal surface texture and color,” says Dr. Feldman.
To rebuild an ear, for example, Dr. Feldman says he performs a cartilage graft, taking cartilage from the ribs. He carves the framework of an ear out of the rib cartilage and then places it in a pocket under the skin. Later, the new ear is elevated from the side of the head by placing a skin graft behind it. He takes rib cartilage to rebuild noses as well. “Wherever I can, I try to blend the practice of cosmetic plastic surgery with reconstructive plastic surgery to make the most beautiful nose I possibly can,” says Dr. Feldman. “Most people, when they think about caring for burn victims, they just think about skin grafting. But skin grafting or resurfacing is sometimes the easiest part of the reconstruction. It’s rebuilding the three-dimensional elements that’s sometimes the more challenging part.”
Dr. Feldman says very often his patients need a series of procedures. “It’s not unusual for me to do five, six or 10 operations to complete a facial reconstruction. Burn patients have to be courageous and brave.”
“Frequently, I’ll get an invitation to a wedding of a patient whose face I rebuilt or they got married and are having kids. These patients can sometimes be difficult to look at prior to surgery, but now they can go back out into the world and live a happy life. To me that’s the real payoff,” says Dr. Feldman.
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