⚠️ Teaching Case Note: This case has been de-identified and reconstructed for educational purposes. Clinical details reflect real surgical decision-making and outcomes. Patient identity is fully protected.
From Hiding Behind a Camera to Facing the World Again
She was 8 years old when hot liquid changed the course of her life. The scalding left large-area burns across her face, neck, and upper chest. Multiple skin grafting procedures followed over the years — but by her early twenties, the mature hypertrophic scars had begun to contract. Her neck could barely extend. Her lower lip had turned outward. The natural contour between her chin and neck had disappeared entirely.
For a 24-year-old graphic designer whose work depends on presence, confidence, and client-facing communication, the physical and psychological toll was severe. PHQ-9 scored 14 — moderate depression. Body dysmorphic disorder screening came back positive. She described her daily life as “constantly tilting my head to avoid cameras.”
She came to Shanghai Ninth People’s Hospital seeking more than surgery. She was seeking a way back.
The Assessment: Function, Form, and Mind
The clinical picture was detailed and demanding. Neck extension range of motion measured just 35° — well below the normal threshold of 60°. The chin-to-lip distance was shortened by 1.2 cm. Vancouver Scar Scale scored 11 out of 13. High-frequency ultrasound revealed scar thickness of 4.8 mm with disorganized dermal collagen and thinned subcutaneous fat. Doppler imaging showed rich perforator vessels at the scar margins but sparse central blood flow — critical information for flap planning.
Swallowing and speech remained compensated, but years of abnormal posture had produced cervical myofascial pain. The psychology team diagnosed post-traumatic body image disorder and recommended concurrent psychological intervention throughout the surgical process.
The multidisciplinary team — reconstructive surgery, burn rehabilitation, dermatology, clinical psychology, and anesthesia — reached consensus: conservative treatment had been exhausted. Surgery was indicated. The plan: staged tissue expansion (already completed pre-operatively) followed by precise scar excision, flap advancement, tension management, and comprehensive anti-scar intervention. The goal was a three-in-one outcome: functional restoration, aesthetic reconstruction, and psychological recovery.
The Surgery: Staged, Precise, and Tension-Free
Six months before the main procedure, rectangular tissue expanders had been placed in the healthy skin of the lateral neck and upper chest. By the time of surgery, the expanders had been inflated to 110% of rated capacity — enlarging the available flap area by approximately 2.5 times. This pre-expansion is what made tension-free closure possible.
Dr. Zhu Shijie’s team designed composite Z-plasty and W-plasty incisions along the original scar margins. Sharp dissection proceeded to the normal subcutaneous fat plane. The contracted fibrous bands were fully divided, releasing the platysma and superficial fascia tension and restoring the natural cervical lordosis and cervicomental angle.
The pre-expanded flap was then advanced into the defect using a four-layer tension-reduction closure: deep fascia, subcutaneous tissue, dermis, and epidermis. Key tension zones were closed with absorbable barbed sutures in continuous intradermal fashion; the epidermis was approximated with interrupted 6-0 monofilament nylon. Intraoperative tension measurement confirmed wound closure pressure below 15 mmHg.
At the wound margins, a combination of triamcinolone acetonide (20 mg/mL) and 5-fluorouracil (50 mg/mL) was injected subcutaneously to suppress fibroblast proliferation. The wound was covered with silicone-containing biological dressing, and negative pressure drainage was maintained for 24 hours.
Total operative time: 2.8 hours. Blood loss: approximately 110 mL. ICG fluorescence imaging confirmed uniform flap perfusion. No neurovascular injury. Immediately post-operatively, the cervicomental angle had been restored to 95° and the lower lip closed naturally.
Recovery: Structured, Sustained, Transformative
At 72 hours post-op, drains were removed and progressive active-passive neck mobilization began. Multimodal analgesia combined NSAIDs with local cold therapy.
At two weeks, sutures were removed. VSS had already dropped to 7. A custom medical compression garment (25–30 mmHg) was prescribed for ≥23 hours daily, combined with twice-daily silicone gel application.
At three months, sequential pulsed dye laser (PDL) and fractional CO₂ laser treatments began — targeting vascular proliferation and promoting collagen remodeling. Neck ROM had recovered to 65°. PHQ-9 had fallen from 14 to 6.
At six months: VSS 4/13, POSAS 16/50. Cervical myofascial pain had resolved. Lower lip eversion was fully corrected. She had returned to full-time work and client-facing meetings.
At twelve months: scar texture and pigmentation were approaching the surrounding normal skin. No recurrent contracture. Her own words: “From tilting my head to avoid cameras, to holding my head up and facing the world — what was released wasn’t just scar tissue. It was my life.”
About Dr. Zhu Shijie
Dr. Zhu Shijie is a senior attending physician at Shanghai Ninth People’s Hospital, specializing in burn reconstruction, scar revision, and skin grafting. He is known for combining functional restoration with aesthetic outcomes in complex trauma cases, with particular expertise in staged tissue expansion and multi-modality scar management protocols.
How CMCS Supported This Patient
China Medical Concierge – Shanghai (CMCS) coordinated the full care pathway: case review and specialist matching at Shanghai Ninth People’s Hospital, MDT scheduling, pre-operative tissue expander placement logistics, on-site interpretation for all consultations and consent discussions, accommodation support near the hospital, and post-operative follow-up coordination including laser treatment scheduling and psychological referral.
For international patients managing complex reconstructive or burn-related cases in China, CMCS provides end-to-end support — from first inquiry to final follow-up.
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