Luci’s locks: Regrowing a burn victim’s hair
BACKGROUND: When the skin comes in contact with something hot, cells in the skin die. The depth of the injury depends on the intensity of the heat and length of time that it is applied. If severe enough, the full thickness of the skin can be destroyed, along with tissues under it. Burns can also result from contact with certain chemicals. Burns are classified by the depth of each the injury so that the appropriate treatment is used.
· First Degree: superficial-redness of skin without blisters
· Second Degree: partial thickness skin damage-blisters
· Third Degree: full thickness skin damage-skin is white and leathery
· Fourth Degree: 3rd degree with damage to deeper structures, like tendons, joints, and bone (Source: http://www.assh.org)
TYPES: There are many different types of burns. Heat burns (thermal) are caused by fire, hot objects, heat, steam, or hot liquids. Cold temperature burns are caused by skin exposure to windy, wet, or cold conditions. Chemical burns are caused by contact with household or industrial chemicals in a liquid, solid, or gas form. Natural foods, like chili peppers, contain a substance that irritates the skin and cause a burning sensation. Electrical burns are caused by contact with electrical sources or by lightning. Radiation burns are caused by the sun, sunlamps, tanning beds, X-rays, or radiation therapy for cancer treatment. Friction burns are caused by contact with any hard surface like roads, carpets, or gym floor surfaces. Breathing in hot air or gases can injure your lungs. Breathing in toxic gases, like carbon monoxide, can cause poisoning in the lungs. (Source: www.webmd.com)
NEW TECHNOLOGY: For severe cases, tissue expansion is an option. Tissue expansion is a procedure that allows the body to grow extra skin. It is done by inserting a silicone balloon expander underneath the skin that needs to be repaired. Then the balloon gradually fills with salt water over time causing the skin to grow and stretch, keeping the skin under tension causes new cells to form. Tissue expansion is used in conditions like breast reconstructive surgery, repairing burns, scars, large birth marks, and hairy areas like the scalp. After the skin stretches, the scaring is removed surgically and the expanded skin is extended to meet healthy un-scarred skin. The expanded skin has a smaller risk of dying because the skin is still attached to the donor’s area blood and nerve supply. The main advantage of the procedure is that it provides a good match of texture, color, and hair bearing quality. The main disadvantage of the procedure is related to the length of time needed to stretch and grow the skin, which can be three to four months. Repeated visits to the surgeon are required for salt water injection to expand the balloon. Risks related to the anesthesia and the surgery can include bleeding and infection. (Source: http://www.burn-injury-resource-center.com/2013/01/)
Dr. Joseph Williams, Chief of Plastic Surgery at Children’s Healthcare of Atlanta, talks about an innovative procedure that helped one young burn victim get her hair back.
When you saw Luci for the first time, how old was she?
Dr. Williams: She was probably around two years old.
What did you see? What was the first thing that you were going to try to tackle?
Dr. Williams: Well, the first thing I saw was a girl that was completely engaging. It was very easy to overlook the physical issues that brought her to me. The most obvious physical problems she had was that she had no hair and that she had obviously suffered a significant burn to her scalp which had destroyed a large part of the hair band area. That was her mother’s main concern as well.
How were you going to handle that? That is such a big part about being a girl; to look like everybody else.
Dr. Williams: It’s a very difficult problem. The only real hair substitution is through a transplant of hair follicles, and that requires both a healthy area to take the hair from and a reasonably healthy area for the hair to be transplanted.
So she didn’t have that, right?
Dr. Williams: She didn’t have either one. She had I would say, 80 to 85% of her scalp was involved and the hair was missing, so she had of a small strip in the back.
All of that was covered with scar tissue, which made a hair transplant impossible, correct?
Dr. Williams: What remained on the scalp was scar tissue and graft, and so that was also a very difficult recipient site for the hair follicles. We understood that that option was not going to work well. Even if that was a possibility, that required her to be much older because that’s in an office procedure completed by people who do hair transplants. So that wasn’t a good option. The second option is to try to recruit scalp from what is there, and that was a possibility. The third option would be a synthetic coverage like a wig.
You only had, how much? Could you put that into a perspective for people to work with?
Dr. Williams: Between two and three inches of hair in the back.
What were you going to have to do?
Dr. Williams: What we ended up doing was to place balloons underneath the skin. Those balloons were placed in one operation and then we allowed that area to heal for about three to four weeks. Then we gradually expanded that area significantly; the balloons were about 700 ccs.
How big is that for people?
Dr. Williams: I’m not even sure what the conversion on that would be. I would say it’s about 10 by 14 cm, that’s probably about 7” by 4” or something like that. The standard size is quite big. The size of your hand is probably a good way to look at it. There were two expanders placed and both of them were about the size of the hand, maybe just a little bigger. It incorporated the area of the scalp that was in the hair band and obviously a little bit more than that. What we hope to do is to place the balloons in then use that technique to recruit the scalp and the hair band area and then allow that to be used to cover as much of the scar tissue as possible.
How long did it take to expand it to that big?
Dr. Williams: The one problem with the scalp, and especially scalps in young children, is that it’s very tight. You don’t have a lot of laxity or space, and so the expansion process can vary quite a bit. I believe her extension took about three and a half to four months, and it had to go very slowly at times because she obviously would get to the point where it was uncomfortable. We would expand it once a week, maybe twice a week, and then wait a little bit. If she was uncomfortable, we let the skin stretch and then go back and expand it.
When you would expand it, how much would you expand it?
Dr. Williams: Probably about 30 cc’s. Again, that’s maybe about half a cup; something like that.
Could she feel that when you expanded it?
Dr. Williams: She could. You can definitely feel it getting bigger.
Was it painful for her?
Dr. Williams: Well, she’s a very brave girl. Part of the expansion process is to place needles in a port underneath the skin, and you have to be able to access the port and then place the fluid through that. It’s difficult for a child to have anything related to needles and it’s even more difficult when you know it’s going to happen. It has to happen once or twice a week for a period of two to three months so it is difficult for them, especially at this age. She felt very uncomfortable with that, even though it didn’t last very long. She was obviously scared, but took it well. Then to actually expand, we would expand until she felt that it was getting tight or becoming a little painful. So, that’s what it involved.
If I understood correctly, there’s another round of expansion for her? You’re going further?
Dr. Williams: There is. I said 80% of the scalp was involved and I would say we were able to cover about 50% of it, maybe 60% of it. Our goal would be to go back, take that same tissue that we expanded, and again increase it to a point where we could advance it and hopefully create a natural hairline for her in the forehead.
When would you do that again?
Dr. Williams: I would probably say about a year, maybe a year and a half from the last one to really let the tissues heal and allow the expansion to completely work.
What’s next for Luci after that?
Dr. Williams: She doesn’t have a lot in terms of eyebrows and she also has issues with her nose and the skin between her eyes, so at some point we would need to address that. The eyebrows are probably addressed best with hair transplant. You can actually transplant hair in there and it would be a lot more natural than what we could provide; that may be a few years down the road. The nose will need to be addressed sooner because as she gets older the skin in that area is tight, so it doesn’t grow like the other bones in her face and her nose will remain small and continue to get smaller. At some point we need to address that and probably reconstruct her nose with a bone graft.
We were impressed with her mother, who was also burned, and you can’t even tell she was burned. Will we ever get to that point with Luci?
Dr. Williams: I would hope so. Maybe from speaking distance you would not be able to notice, but obviously her burns are in a much more visible area. As you said, that’s a very important area, and even more so with women, so it’s going to be a lot more difficult to hide that. Between the surgeries, makeup, and other things, I think we can make that almost normal appearing.
Are you just so impressed with that little kid?
Dr. Williams: With both of them. With the daughter, who obviously has an incredible amount of strength, and with the mom, who was willing to take this on and loves her beyond words and also understands what it’s going to take in this process to get to that point. That’s a lot to volunteer for. It’s hard enough when you’re the parent, it’s much more difficult when you’ve volunteered for that and have adopted somebody knowing exactly what’s going to be involved. So, I admire them both. I really do.
Is there an age when you think she’ll be done?
Dr. Williams: That’s a good question. I would certainly hope that we could get most of this done by the time she gets into her teenage years. That’s such an important period of time for these kids and shapes a lot in terms of their confidence and so forth. So, I think that would be a very good goal; to try to get that done before they’re teenagers.
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