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CHAPTER30 Burn contracture surgery
Prevention ofcontractures
Many burn scar problems can be prevented by appropriate intervention and
work from the burns multidisciplinary team (which includes the patient).
Typical interventions include the following.
Nurses
• Prevention of infection
• Encourage mobilization
Surgeons
• Skin grafting to achieve early healing
Patient and family
• Compliance with exercises, massage, splints, and pressure garments
Physiotherapist/ occupational therapist
• Crucial role in encouraging and providing physical rehabilitation; instilling
determination and compliance with rehabilitation regime in the patient
and family
• Manufacture and tting of splints, moulds, silicone, and pressure
garments for scar therapy
Anaesthesia/ pain management
• Providing physical comfort so that patient can mobilize sti joints
https://t.me/med1917
CONTRACTURE DEFINITIONS
Contracture definitions
Intrinsic contracture
A contracture where scarring directly involves the site aected by
contraction.
Extrinsic contracture
A contracture of normal structures that are pulled out of position by scarring distant to the site. Atypical example of this is a normal lower eyelid
pulled into ectropion by scarring on the cheek.
Linear band contracture
A band of scar tissue surrounded by relatively normal skin. This is readily
treatable by local ap plasties with or without band excision.
Linear band contracture indiuse scarring
The skin surrounding a band contracture is scarred and Z plasties that require ap elevation carry a high risk of necrosis. Y– V plasties that do not
require ap elevation may be an option. However, in scarred skin, the Y– V
plasties may simply move the site of the troublesome band to an adjacent
area, and a larger ap or graft may be required instead.
Broadband contracture
The contracture involves the whole of an anatomical surface and requires
an incisional release or excision with inset of ap or graft to make good the
skin decit.
Joint contracture
In addition to the skin contracture, ligaments, muscles, and tendons have
shortened or ruptured to cause a secondary joint deformity that requires
treatment.
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CHAPTER30 Burn contracture surgery
Timing ofcontracture surgery: indications
Urgent
• Upper eyelid retraction causing exposure of cornea
• Severe neck contracture
• Severe oral contracture
Early
During period when scars are most active; arbitrarily in the rst 6months:
• Lower eyelid contracture causing ectropion, infection, discomfort
• Oral contracture
• Neck contracture
• Upper limb contracture interfering with important functions
• Lower limb contractures impairing ambulation
• Unstable scar with infection/ osteomyelitis
• Osteomyelitis must be treated per se before soft tissue cover is
attempted
Late
• Contractures persisting after scar therapy and resolution
• Troublesome persistent hypertrophic scars, especially unstable scars
• Any contracture treated for aesthetic reasons
• as a general rule, one should wait about 2years minimum to allow
scars to resolve as far as possible before operating for reasons of
appearance
https://t.me/med1917
TIMING OFCONTRACTURE SURGERY: INDICATIONS
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CHAPTER30 Burn contracture surgery
General principles and technical tips
• Identify and mark the contracture pre- operatively. It is important to
assess the position and posture in which the contracture is tightest
pre- operatively
• Try to diagnose underlying joint contracture preoperatively
• Remember that a contracture has arisen because of a decit of skin,
and that surgery should de designed to replace that decit. Often it is a
fascinating challenge to decide whether this can be done with local skin
or whether additional skin needs to be imported
• Ascertain whether the contracture is predominantly a linear band,
which might be amenable to a local ap procedure or whether it is
a broadband contracture, which requires additional skin in the form
of a graft or larger ap. If a linear contracture is also surrounded by
scarred skin, deciding on the best technique may be more challenging.
In such cases, err towards putting in more skin via ap or graft rather
than using local ap plasties which tend to be associated with persistent
contracture
• In children, do not be tempted to ‘cheat’ and use a local ap plasty
type procedure when additional skin is needed in a linear contracture
with diuse scar or a broadband contracture. Even if a release can be
achieved, as the patient grows, the scar tightness will soon recur
• Use full thickness grafts or aps when reasonably possible rather than
split skin grafts or dermal substitutes. Split skin grafts and dermal
substitutes shrink during healing and require more aftercare (splints,
pressure garments and physiotherapy) than do full thickness grafts
or aps. However, note that often a spilt thickness graft or dermal
substitute plus graft are the only realistic options for extensive
contractures
• When a person has survived an extensive deep burn injury, choose your
donor sites carefully:there may be a precious donor site which is crucial
for a future reconstruction that you should avoid using for an earlier
procedure (eg. if a patient may need facial resurfacing later, keep a good
donor site for large sheet grafts)
• It is very important to release all subcutaneous scar bands as well as the
cutaneous bands
• When incising to release a contracture, it is tempting to simply cut
deeper and deeper in the initial line of release. Once incision has passed
through the full thickness of the subcutaneous scar, incision in the centre
of the defect should cease, and incision recommences at the proximal
and distal margins of the initial skin incision
• After an extensive incisional release it is often best to excise some
of the scarred skin edges otherwise skin edge necrosis is likely to
compromise healing
Important rule: Keep incising at the margins of the defect. Don’t keep
going deep in the centre once you are through all the depth of the
contraction scar.
https://t.me/med1917
GENERAL PRINCIPLES AND TECHNICAL TIPS
• When skin grafting, excise as much of the subcutaneous scar as possible
to achieve a well- vascularized bed for your graft. Scar is a very poor bed
for a skin graft. If your graft fails, the contracture will almost certainly
recur. This is especially important for dermal substitutes that require a
scar free bed for consistent take
• When creating a release prior to skin grafting, create the largest defect
reasonably possible so that as much extra tissue is inserted as possible.
When a ap of normal skin is used to repair the defect, a slightly less
extensive release may be eective, as the ap can stretch with time
• If you are incising to release a contracture and it is not releasing as
well as you hope, excise some of the scar. Often this will enhance the
release
• Commonly after a scar release, the defect for skin grafting will be deeply
concave. Use a good- sized graft that contours well into the defect, and
a tie- over dressing to control the graft. If the bed is very irregularly
contoured, mesh the graft to improve take (eg. axilla)
Topical negative pressure dressings are a good alternative to tie- over dressings and have been shown to be particularly useful with dermal substitutes.
• In the upper limb, release contractures proximal to distal (eg. shoulder–
elbow– hand or wrist– palm– ngers). This may have to be done in staged
operations, or can be done in a single procedure
• Operating on the hand:document sensation preoperatively and don’t
cut the digital nerves
• If a patient has multiple contractures, it is often advantageous to operate
on several contractures in the same procedure
• Try to avoid excessive distress (especially postoperative pain) for the
patient. He/ she may need many operations
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CHAPTER30 Burn contracture surgery
Approach tocontracture surgery
Plan carefully: involve the patient and therapist in the decision- making
process as much as possible. Often the choice of technique for treating a
contracture will be inuenced by the patient’s own views and preferences
for donor tissue. Try to have a holistic approach that takes account of the
patient’s current and future needs from a physical, social, and psychological
point of view. It may be useful to involve the team psychologist in the
planning process.
Make sure the patient understands that a graft or ap is likely to look like
a ‘patch’ and may look especially bad early or after the surgery. Warn about
scar hypertrophy and aftercare.
Get to know the patient and counsel him/ her carefully before doing anything major from a surgical point of view. Sometimes it is useful to start o
with quite a minor surgical procedure if possible so that the patient understands that surgery is not necessarily an aversive experience (primary burn
treatment is likely to bring unpleasant memories).
Have a number of ‘workhorse’ procedures, which you use for dierent
types of contracture, and get to know these techniques.
For example:
• We tend to use Y– V plasties for long linear bands, except in the neck
where we use Zs because a Z puts some of the scar in a transverse
crease. We use Zs or ve- ap plasties for short bands
• We use a lot of full thickness grafts for broadband contractures.
Commonly these grafts are harvested by abdominoplasty or
mini- abdominoplasty
• Around the axilla, we use a lot of local aps because there is often
skin laxity with many perforators and the circumex scapular and
thoracodorsal vessels
• We use a two- stage dermal substitute for resurfacing and for extensive
contractures
• We use free aps for dicult contractures
The aforementioned are not necessarily the ‘best’ techniques for every indication, but there is a great advantage to surgeon and patient in using a
technique that is familiar and has the highest chance of working. Dierent
surgeons will have their own techniques that are most reliable in their hands.
An ambitious and elegant technique that fails can be a disaster for the
patient.
https://t.me/med1917
FULL THICKNESS GRAFTS
Split skin grafts
For the most extensive and severe contractures, split skin graft is often the
only technique that will supply sucient extra skin to make good the massive decit. If a large thick split skin graft is required (eg. for severe neck
or hand contracture), consider overgrafting the donor site for this skin
graft with a much thinner adjacent graft, so as to avoid problem of severe
delay in donor site healing. (However, it is important to warn the patient
that the overgrafted donor site leaves a scar which may be aesthetically
unsatisfactory.)
Thin split skin grafts tend to shrink postoperatively and have a high incidence of recurrence of contracture. Their use is not recommendation for
burn reconstruction.
Full thickness grafts
Full thickness grafts are extremely useful for moderate- sized defects after
incisional release of contracture or scar excision. The abdomen is the typical donor site via various transverse lower abdominal incisions including
abdominoplasty. Postauricular and supraclavicular can provide the colour
match desired for facial skin (the latter can be pre- expanded to resurface
larger facial defects). Any other site of skin laxity permitting direct closure
may be used included various innovative options (eg. skin harvest from the
undersurface of breast via a reduction or mastopexy).
Grafts tend to be ‘large’ in comparison to the average full thickness graft
for other indications, so the graft should be thinned carefully to remove fat
from the deep surface, and great care taken to remove all scar from the
recipient bed so as to encourage good take.
Careful compressive dressings such as tie- over or tie through dressings
are generally used, and splints used on the limbs.
Full thickness grafts generally require less aftercare than most grafts, although if there is patchy take, scar hypertrophy and pigmentation problems
may occur, so the patient should be warned of these potential occurrences
and possible treatments.
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CHAPTER30 Burn contracture surgery
Dermal substitutes
Dermal substitutes (also known as dermal regeneration template or matrix)
are very useful for burn contractures, especially in patients with a paucity of
good donor sites. Thin skin autografts are used with the dermal substitute
to produce an outcome that varies in quality from that achieved with a thin/
medium/ thick split skin graft, depending how well the dermal component
has taken. In most cases, the result does not achieve the quality of a full
thickness graft (or normal skin), and aftercare with pressure garments and
splints is typically required for dermal substitutes.
They are indicated for broadband contractures and for resurfacing of ex-
tensive areas after scar excision.
Use of dermal substitutes is more demanding technically than split autografts, with higher risk of infection. It is critically important to excise all of
the scar from the bed to achieve good take, and in the neck it is considered
best to excise platysma from the bed for good take of dermal substitute.
Two- stage dermal substitute is a collagneous matrix that has a silicone
external layer:the external layer remains in situ for 2– 3 weeks before secondary thin autograft is applied.
One- stage dermal collagen matrices may have the autograft applied at
time of application.
Key technical points
• Completely release the contracture so there is no residual tension or
distortion
• Use tie- over dressings or topical negative pressure dressings plus splints
where indicated:shearing is a disaster for these grafts
• Be very careful about infection; prophylactic antibiotics are commonly
indicated
• Avoid excessive frequency of dressing changes
• Single stage may look very ‘tatty’ in early weeks, but still
re- epithelialize well
• Have a good aftercare programme
Local flaps
Where suitable tissue exists, a local ap procedure, either by some type of
‘plasty’ or by a ap transfer such as an islanded ad hoc perforator ap, is
close to the ideal method of contracture release, providing reliability, good
tissue colour match, and little need for aftercare. However, the temptation always exists for the surgeon to ‘force’ a technique to treat a contracture when there is insucient tissue available, with a variety of adverse
consequences.
Even where tissue is available poor outcomes may result from undue bulk
of many specic locoregional aps (eg. unthinned scapular aps for the axilla) so careful assessment and good judgement are pre- requisites for application of local ap techniques.
https://t.me/med1917
TISSUE EXPANSION
Free flaps
Free aps may be very useful for dicult contractures and complex defects
especially in the head and neck, and the upper and lower limbs. Commonly
recipient vessels are undamaged by the burn injury (except in electrical injuries where more caution is necessary).
The greatest challenge is often to match the contour and colour (some
aps tend to be too bulky and normal skin may look aesthetically incongruous in the centre of an area of scar).
A multiplicity of dierent options is available, and discussion of these is
beyond the scope of this chapter. However, our experience is that burn
patients tend to do well with free tissue transfer when well counselled and
prepared. It is commonly possible to use the relatively long anaesthetic to
address several other contractures at the same time.
Tissue expansion
Tissue expansion tends to be of particular value for treatment of severe
scars causing aesthetic embarrassment. Examples include post- burn alopecia and partial facial or neck defects in which there is normal skin available
to expand in order to resurface a scarred area with local tissue of appropriate colour, texture, and hair growth.
Patient counselling is of great importance. Incisions should be placed radial to the expander where possible to reduce the likelihood of dehiscence
and exposure.
Flaps should be ‘over- expanded’ as almost always there is more retraction of expanded skin than one expects. Where possible, incisions for aps
in hairless skin should follow aesthetic unit principles.
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