Page 294 - Read Online

Page 2 of 10 Madiedo et al. Plast Aesthet Res 2018;5:40 I http://dx.doi.org/10.20517/2347-9264.2018.40

INTRODUCTION
Burns are considered a public health problem worldwide due to their associated high mortality rates as well
[1-3]
as their great morbidity incidence and functional impairment . Severe scars and late contractures occurring
after the placement of split-thickness autografts during treatment persist as some of the most relevant and
[4,5]
frustrating sequelae in patients with deep burns . Not only do they result in deformities and functional
impairments, but they may also affect the patient’s esthetic appearance, which is distinguishable in burn
[6,7]
patients . These sequelae usually cause prolonged disability, job abandonment, and high costs to the health
[8,9]
system .
Generally, multiple reconstructive interventions are required, including Z-plasties, contracture release, skin
grafts, flaps, tissue expanders, skin substitutes, and a great variety of auxiliary treatments, in the attempt to
improve and preclude recurrence [10-13] . Furthermore, lengthened rehabilitation interventions are required in ad-
dition to multiple complementary elements, such as Lycra garments, silicone gel sheets, thermoplastic masks,
prolonged immobilization, orthosis, moisturizing lotions, lubricants, corticosteroid injections, and even radio-
therapy. Varying results obtained are poor and disheartening in some cases [14-16] .

In the literature, it is widely reported that the use of full-thickness skin grafts exhibit better texture and color,
and they significantly reduce the occurrence of contractures and scarring sequelae. However, the availability
of donor sites that will enable the use of such grafts is limited, and thus, the application of split-thickness skin
grafts becomes necessary [17,18] . Skin substitutes of human or animal origin or synthetic substitutes may be an
alternative for reconstructing the dermis, reducing the incidence of retraction from the use of split-thickness
skin grafts. These substitutes allow to compensate for the lack of donor sites of full-thickness skin grafts,
bringing satisfactory results. Nonetheless, the limited availability of these dermal matrices and their elevated
costs for most burn units in developing countries have hindered their use [19,20] .

Traction and tension forces on scars also play an important role during the formation of optimal scars. These
forces are associated with the orientation of collagen fibers in the lower dermis and are essential for correcting
hypertrophic scars, particularly when Z-plasties are performed to redirect scars into the relaxed skin tension
[21]
lines, i.e., Langer’s lines [21,22] . Nevertheless, Langer studied these relaxed skin tension lines in cadavers,
[23]
whereas Kraissl’s lines were defined in living individuals under no traumatic procedures . In this way,
Kraissl’s lines are found to be more dynamic and to correlate with wrinkle lines during muscle contraction,
making them more accurate than Langer’s lines. These lines are disposed transversely, run perpendicular to
muscle action, and they are vital in normal scarring [23,24] . In the light of the foregoing, we have suggested that
placing split-thickness skin grafts transversely, following Kraissl’s lines, on exposed areas resulting from burns
may improve the esthetic and definitive functional outcomes in burn patients. This study aimed at describing
patient evolution with split-thickness skin grafts applied by following Kraissl’s lines during a 12-month period.
To evaluate the functional and esthetic outcomes of scars in patients who underwent split-thickness skin
grafting transversely based on Kraissl’s lines to cover deep burns.

METHODS
A descriptive longitudinal case series study was conducted at the Burn Unit of Health Services (HSU) Simón
Bolívar North Subnetwork E.S.E. of the Secretariat of Health in Bogotá, Colombia, from 1 Jan 2016 to 31 Dec
2017. The study was approved by the Institutional Ethics Committee, and was based on the ethical principles
contained in the declaration of Helsinki.

The study included 138 patients with a mean age of 24.5 years (range: 7-74 years). Of this group, most subjects
were men (n = 96, 70%), with a mean age of 24.5 years (range: 7-74 years). These injuries required definitive
coverage, involved any part of the body, with the exception of the face, and were classified as superficial