BURN CARE AND PREVENTION JOURNAL

Deep extremity burns often result in tendon or bone exposure, creating substantial reconstructive challenges. Flap surgery is standard but may be contraindicated in patients with comorbidities or compromised vascular status. Perifascial areolar tissue, a highly vascularized autologous connective tissue, offers an alternative for such defects. We retrospectively reviewed 11 patients with upper or lower extremity burns with tendon or bone exposure, treated with abdominally harvested perifascial areolar tissue grafts and simultaneous skin grafting between January 2019 and December 2020. The mean patient age was 50.7 years, with a mean defect size of 3.3 × 3 cm². Burn etiologies included high-voltage electrical burns (36%), scalds (27%), and flame burns (27%). Patient survival in those with perifascial areolar tissue grafts was 93.8%, and skin graft survival was 68.6%. One perifascial areolar tissue graft failure occurred in the ankle, and partial skin graft necrosis developed in 4 patients; most patients healed with conservative care. No tendon adhesions were observed. Perifascial areolar tissue grafting is a reliable, cost-effective technique for small- to medium-sized extremity burn defects, especially in patients unsuitable for flap surgery, allowing simultaneous skin grafting when healthy granulation tissue is present.

KEY WORDS: Bone exposure, Burn reconstruction, Complex burn cases, Perifascial areolar tissue, Tendon exposure

Deep burns of the extremities frequently result in tendon or bone exposure due to thin overlying skin and minimal subcutaneous tissue.¹ Reconstruction is challenging, particularly in patients with comorbidities or compromised vascular status, where local or free flap surgery may be infeasible.^2,3 Alternative strategies, such as dermal substitutes or delayed skin grafting, are associated with high costs, prolonged healing, and infection risk.^4,5
Perifascial areolar tissue (PAT), located between the muscle fascia and deep subcutaneous fat, is highly vascularized and can survive in ischemic conditions via a bridging phenomenon.^6,7 The thin, pliable nature of PAT allows placement in concave defects or narrow fistulous tracts. Although PAT grafts have been successfully applied in ischemic ulcers, fistulas, and orthopedic exposures,^8,9 their use in extremity burn reconstruction remains limited.

MATERIALS AND METHODS

We performed a retrospective review of patients treated at our burn unit between January 2019 and December 2020. Inclusion criteria were second- or third-degree burns of the upper or lower extremities with tendon or bone exposure that were treated with abdominal PAT grafting and simultaneous skin grafting. We excluded burns outside the extremities.
The PAT grafts were procured from the abdomen through a 5-cm incision above the inguinal crease. Dissection proceeded to the vascularized layer over the rectus fascia without injuring the underlying muscle fascia. Grafts were elevated en bloc using Metzenbaum scissors or low-energy cautery, and perforator vessels were cauterized. Suction drains were placed, and the donor site was closed in layers. The PAT graft was applied to the defect over granulation tissue, ensuring full contact, and immediately covered with a split- or full-thickness skin graft. We recorded the demographic data, burn etiology, defect size and location, postoperative complications, and follow-up duration.

Eleven patients (7 male, 4 female) with a mean age of 50.7 years (range, 32-67 y) were included, with a mean follow-up of 11.8 months. Defect sizes ranged from 1 × 1 to 5 × 5 cm (mean 3.3 × 3 cm²). Burn etiologies were high-voltage electrical (36%), scald (27%), and flame (27%). Among the PAT grafts, 11 were applied to upper extremity and 5 to lower extremity defects.
Overall survival rate of patients with PAT grafts was 93.8%, and skin graft survival was 68.6%. One PAT graft failed in the medial ankle and was successfully regrafted after 2 weeks. Partial skin graft necrosis occurred in 4 patients; 3 patients healed with conservative management and 1 patient required regrafting. Donor site seroma was observed in 1 patient, which resolved within 1 month with compression. No tendon adhesions were reported during follow-up.
Case examples included a 58-year-old woman with finger tendon and bone exposure after a scald injury, a 55-year-old man with hand burn and multiple comorbidities, and a 35-year-old man with high-voltage burns exposing the tibialis anterior tendon after previous flap coverage.

Coverage of exposed tendons, bones, and neurovascular structures in burn injuries remains challenging. Local flaps may fail due to compromised vascularity, and free flaps require microsurgical expertise and adequate patient health.^2,3 Dermal substitutes provide an alternative for small- to medium-sized defects, but cost and delayed closure remain limitations.^4,5
Use of PAT grafting can offer several advantages: accessible donor sites, a short learning curve, no need for microvascular anastomosis, and applicability in patients with poor vascular status.^11,12 In our series, PAT graft survival was high, with complications primarily related to the overlying skin graft rather than the graft itself. Failures were associated with fat inclusion, infection, or mechanical shear. Medial ankle defects posed the greatest challenge, and alternative flap coverage may be preferable in such cases.¹³
This study represents 1 of the first reports of PAT grafting for extremity burn reconstruction, suggesting the use of PAT grafting as a practical, cost-effective alternative to dermal substitutes or conventional flap surgery.

Perifascial areolar tissue grafting is a reliable method for reconstruction of small- to medium-sized extremity burn defects with exposed tendons or bones. Perifascial areolar tissue grafting is particularly useful in patients unsuitable for flap surgery and allows simultaneous skin grafting when healthy granulation tissue is present. Perifascial areolar tissue grafting may provide a low-cost, effective, single-stage solution in complex burn cases.

Volume: 5 Issue: 3 September 2025

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