Written by Joseph M. Mlakar, MD on November 17, 2019
As both an acute burn surgeon and a reconstructive plastic surgeon, I am often asked by both patients and families: “When does the plastic surgery start?” I smile. What they are really asking is “When does the healing start?” What they don’t yet know is that reconstructive surgery often plays a small role in the overall post burn restoration process.
All patients, once burned, want pretty much the same things: the burns to heal, or to simply go away; freedom from pain; freedom from scars. They want to have their old life and their old self back— to be normal again.
If the burn injury is relatively minor, and scars are minimal, recovery is inevitable. The itching will come, then the nightmares. These nightmares are the brains way of trying to work through the psychological shock and turmoil. Once the patient returns to work or school, the restoration process proceeds fairly rapidly.
If the burn injury is more severe, restoration may be painfully slow. Everything may seem changed to the patient. Self. Family. Friends. Job. Whether the burn involves face, hands, or distorts the body, the immediate effect may be devastating to the newly burned person. The recovery process is longer and sometimes seemingly endless. Why? “Time is slow for those who suffer.” In patients with greater than 30% total-body surface area burns, I fully expect the recovery process to take at least two years. In our fast-paced constantly-changing society, that’s a long time.
RESTORATION IS A PROCESS
So what is this restoration process and why does it take so long? Doesn’t recovery go hand in hand with reconstructive surgery? Why can’t everything be fixed in just one surgery, scheduled tomorrow?
In my view, the post-burn restoration process is comprised of three elements:
Each process is distinct and unique. Recovery means “to heal; to return to previous form.” Typically, we recover from infectious processes, and some types of injuries. For example, a year after you heal from a broken leg, you may not even remember which leg was broken, if you have fully recovered from the injury. Recovery may also indicate a healing of the damaged psyche, as in an emotional recovery. Many burn victims require recovery from posttraumatic stress syndrome.
Reconstruction means “to repair or to make anew.” To rebuild, but not necessarily as the original or as new. Like a rebuilt engine, reconstruction has its inherent limitations. Reconstruction can return both form and function, and provides hope to the healing burn patient.
Rehabilitation is the most difficult to define. More or less, it means to learn to make due with what is left, to adapt to the loss or injury. For example, a child may lose his leg due to a bone cancer, but still learn to run and play baseball with his new prosthesis.
Rehabilitation means overcoming injuries, afflictions, or setbacks, by providing for form or function. Burn restoration is the sum of all three processes: recovery, reconstruction, and rehabilitation. With burn wounds, some tissue heals, some tissue is lost or replaced, and some tissue is irreparably damaged and endured. Restoration literally means “to make whole again.”
Burn restoration, then, means to become a whole person again, spiritually, and emotionally, and not just physically. “Get a life” has whole new meaning to the burned person.
Why is this distinction important? Because the process of restoration requires all three elements. As a surgeon, I can help direct the reconstruction. However, unless the patient plays an active role in the process of recovery (healing) and in the act of rehabilitation (adapting), no surgery that I perform will ever be truly successful.
I believe that the pivotal step in post-burn restoration is not the healing that occurs externally, but in the recovery that takes place internally. It requires a healing of the heart. Burn survivors and burn support groups often play an essential role in assisting other burn persons in overcoming the personal anguish of the burn tragedy. They lend support, guidance, and acceptance.
TIMING IS EVERYTHING
In the movie “Shawshank Redemption,” written by Stephen King, the central mantra is simple: “Get busy living, or get busy dying.” When a burned person comes to terms with oneself, as a burned person and not as a burned victim, this is the "Shawshank" moment. It is also the time when I will begin the reconstructive surgery.
Timing of reconstructive surgery, therefore, varies from patient to patient, depending on need and stage of healing. In truth, reconstructive surgery already has begun during treatment and surgery for the initial burn injury. All burn surgeons operate with a vision towards the final post-burn form. But for the sake of survival, timely wound coverage may sometimes require compromise. Aesthetic considerations can be addressed later.
Timing of post-burn reconstruction can be divided into four periods: immediate, early, late and sequential. Immediate reconstruction means to maximize reconstructive efforts during initial closure of the burn wound. A free flap (or microvascular free tissue transfer) for management of an electrical burn, is an example of this approach. Although the wound may be closed with a skin graft, perhaps a free flap is chosen to provide better long term coverage.
Early reconstruction has as many definitions as there are surgeons. To me, early reconstruction implies surgery while the scars are still very immature, which is generally believed to be within the first six months following the burn injury. For the right patient, I am a strong advocate for early reconstruction efforts. The major disadvantage in this approach is that the patients scarring process is still hyperactive, and recurrent contractures are frequent. Still, I believe early reconstruction assists the process of recovery.
Late reconstruction, then, in my definition, is surgery occurring more than six months post-burn, or when the scars are believed to be mature. Late reconstruction may lead to less surgeries and better lasting reconstructive efforts. With time, some difficulties may have already been acceptably rehabilitated, making surgical correction unnecessary.
Sequential reconstruction is a staged reconstruction process. The hallmark of sequential reconstruction is extensive pre-surgical planning between the patient and the surgeon. I believe that the majority of reconstructive needs can be addressed by this means. It makes use of any or all of the other three methods— some immediate reconstruction, some early surgery, and some late surgery. The critical elements are a workable, adaptable plan, and good communication between patient and surgeon.
FINDING THE RIGHT MATCH
Both patient and physician bring individual knowledge crucial to the reconstructive process. The surgeon brings a knowledge of anatomy and wound healing, but most importantly a history of successful techniques. The patient brings the knowledge of they are, what they wish for, and what they need. The surgeon may be the architect and the builder, but the patient is the owner and the landlord. Some patients forget that they are the boss.
An old adage in plastic surgery states that “form follows function.” This means that the surgeon should choose correcting functional problems before beginning on aesthetic concerns. Surgeons sometimes use this dogma to justify releasing a scar contracture of the hand before rebuilding a scarred nose.
Well, I have some news for you. Function follows form. Things that look better tend to work better. This is especially true with people. If you want proof, wear a dress or a tie to your next office visit. People who feel good about themselves function better. Even with the contracted hand.
As a surgeon, I also know that if patients see early good results, and they trust me, subsequent surgical plans may be more elaborate and comprehensive. (And Ill eventually get to release the contracted hand).
In practice, the patient should dictate the sequence of reconstructive efforts, within reason. Remember – the patient is the owner and the driver. But communication with the surgeon as architect is key. A good surgeon will help direct the reconstructive efforts to a satisfying outcome for both parties.
What makes a good surgeon? According to burn patients, good surgeons have experience, but will consider a fresh approach. As an advisor, the surgeon is both persistent and supportive. A good surgeon provides options and explanations, and helps develop an individualized reconstructive plan. A good surgeon is a good listener.
Okay, what constitutes a good patient, the other half of the reconstructive team? In my view, a good patient is goal-oriented, optimistic but realistic, a good communicator, and acts as a full participant in decision making. But a good patient also has a good measure of three irreplaceable strengths: faith, hope, and love. Love, in the context of reconstructive surgery, means support of the burned patient by a significant other, family and friends.
In the perfect world, match of a good patient with a good surgeon should then produce a good outcome. But it doesn’t always. The reconstructive process can go astray. What happens? Physical problems can occur, such as infections, hematomas, or wound breakdown. But the real damage occurs if trust, hope, or communications breakdown.
AVOIDING THE FALLACIES
Problems, or failure to meet expectations, may alter attitudes. Four major attitude impediments to the reconstructive process include The Patient Fallacy, The Surgeon Fallacy, The Karma Fallacy, and The Fiscal Fallacy. Let’s examine briefly each one.
The Patient Fallacy is typified by a patient who wants all the scars removed, Hollywood-style. Expectations are unrealistic, given our current technologies. It’s an inflated expectation of what is possible with reconstructive surgery. If expectations are not realistic, any reconstructive effort is doomed to failure.
When I encounter this Fallacy in my practice, I reaffirm to my patients what I’ve learned by helping many burned people over the past several years. First, there is a God. Second, I’m not Him. There are limits to a surgeon’s skills.
The Surgeon’s Fallacy, conversely, is typically a capitulation of the reconstructive efforts by the surgeon, or a failure to consider other options to the original treatment plan. I am leary of a surgeon who can only offer a single option. I’ve helped many patients in my practice who were told “There is nothing else that can be done.” The Surgeon’s Fallacy occurs when a surgeon’s ego does not allow him to admit what he can or cannot do.
The third common impediment to the reconstructive process, I call the “Karma Fallacy.” The “Karma Fallacy” is the assumption that bad things will happen. Perhaps because of a complication or a setback, there is a belief that any reconstructive effort is doomed to failure. It’s important to remember that bad luck does not mean bad karma—one failure does not imply future failures. What should you expect for the next surgery?
I believe that patients can expect four things from each reconstructive burn surgery:
Form and function will improve.
Healing will take longer than expected.
Identified concerns will be addressed.
More is always possible.
In general, each reconstructive surgery will meet with some successes and some setbacks. As I instruct my patients, as long as we get more of the former than the latter, we’re moving in the right direction.
In reconstructive surgery, our efforts are not always met with successes, but at least we usually “hold our own.” And more times than not, a sequential approach leads to favorable reconstruction outcomes.
The last impediment to reconstruction, “The Fiscal Fallacy,” is also the most difficult to overcome. This is the presumption by the insurance carrier that the reconstructive process should be over, or that funds are used up, and any additional reconstructive surgeries are “cosmetic,” unnecessary, or uncovered expenses. How can I explain this problem to the parents of a child with facial burns? Nothing can halt an idea or plan in its tracks as quickly as a lack of funding. This fallacy will become our greatest challenge in this next decade of burn care.
Each of these false ideas or fallacies can undermine or cripple the reconstruction process. But each can be overcome through communication between patient and surgeon, given a light sprinkle of faith, hope, and love.
So, when does the reconstructive process end? When the patient has “recovered.” The reconstructive process affects more than the physical form. Burn injuries affect both the physical and the spiritual (psychological) portions of a person’s being. Many believe, as I do, that the spiritual damage is greater than the physical scars in most severely injured burned persons. Recovery from this “unseen injury” is the hallmark of restoration following burn injury.
Reconstructive surgery, both physically and spiritually, helps with healing of the “unseen injury” in burned people. The reconstructive process assists the recovery process, like psychotherapy with a knife. This is the true magic of reconstructive surgery of reconstructive surgery To assist in the restoration of burned people.