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CHAPTER30 Burn contracture surgery
Head and neck
Neck contractures
Linear band contractures— Z plasty
Discrete neck contraction bands can be very eectively treated with Z
plasties. Depending on the length of the band, either a large single or multiple Zs can be used. We have found these give superior aesthetic results
to Y– V plasties in the neck, probably because the transverse limb of the Z
lies in a line of election.
Technical points
• Mark the contracture band preoperatively
• Position the patient with a roll under shoulders to extend the neck
• Raise the aps with a good thickness of subcutaneous fat to avoid tip
necrosis
• Release all subcutaneous bands
• Take care to avoid the external jugular vein laterally and the especially
accessory nerve further laterally
• Use 1 in 200,000 adrenaline solution to reduce intraoperative bleeding.
It is useful to include local anaesthetic in the solution for postoperative
pain relief (Fig. 30.10)
Diuse (broadband) neck contractures
Diuse neck contractures are a common complication of upper body ame
burns. They commonly require surgery early after injury because of diculties with function and especially with protecting the airway for anaesthesia.
Typically, thick split thickness or full thickness grafts are used for resurfacing after release of broad neck contractures. Generally, it is considered
best to carry the releasing incision through platysma and to excise the platysma in the base of the release. Dermal template may also be used for
grafting if insucient autograft is available (Figs 30.11 and 30.12).
Technical points
• Excision of a little of the scar on either side of the incision helps with
achieving a wide release and prevents marginal skin necrosis at the edge
of the release.
• It is of the utmost importance to carry the release far laterally. So as to
avoid lateral persistence of contracture.
• Atrapezoid or double trapezoid ap (Fig. 30.12) is a useful method
of release of neck contractures, especially for contractures that are
wide but do not extend the full width of the neck. The Z plasties at the
margins help to prevent marginal contracture.
• Occasionally, bleeding may be severe. Adrenaline inltration is helpful,
and care should be taken to avoid excessive haemorrhage.
• Arare, but potentially devastating complication is of air embolism via
the external jugular vein. If the vein is opened inadvertently, the vein
should be compressed and the patient should be placed head down for
repair or clamping of the vein. (Also applies to internal jugular which
may rarely be encountered in a contracture.)
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HEAD AND NECK
Fig.30.10 Diagram showing possible design of Z plasties for neck contractures.
The typical angle of the oblique limb to the vertical limb of the z plasties should
be 60°, but this can be varied. Excessively acute angles (<45° may lead to skin ap
necrosis).
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Fig.30.11 Release carried laterally.
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CHAPTER30 Burn contracture surgery
Fig.30.12 Double trapezoid aps.
• Great care should be taken in releasing scars in the line between the ear
lobule and acromion, to avoid the accessory nerve.
• Aconcave defect results from release. Skin grafts should be secured
with a tie over (or similar) dressing. Negative pressure dressings are
also useful for securing grafts or dermal substitutes. There is a small risk
of postoperative external respiratory obstruction from haemorrhage/
compression under the tie- over dressing. Sta looking after the patient
should be warned to remove the tie- over immediately if stridor and
respiratory distress are present.
Flaps forneck contractures
Free aps may be very useful for neck contractures, but the surgery is relatively demanding. Consistent recipient vessels are the superior thyroid artery and the internal and external jugular veins.
It can be particularly challenging to obtain free ap tissue that does not
have excessive bulk. Options include ‘thin’ perforator aps, such as anterolateral thigh aps; a radial or ulnar forearm ap (poorer donor site); preexpanded aps (much more complex for patient). The big advantage of a
free ap is minimum requirement for aftercare and corresponding immediate benet for these uncomfortable contractures.
It is important to put transverse/ lateral tension on the ap to pull it into
the contour of the neck. However if this risks compromising vascularity by
pressure on the pedicle, this can be left for a second stage.
In thin patients, a latissimus dorsi or thoracodorsal artery perforator ap
may be used for a neck contracture.
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HEAD AND NECK
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CHAPTER30 Burn contracture surgery
The face
The eyelids
Generally burn contractures of the eyelids are released with grafts. Z
plasties are very useful after trauma or congenital problems, but uncommonly in burns.
Upper eyelid
Retraction of the upper eyelid requires urgent release with a skin graft. If
possible the graft should be inserted about 9– 10mm above the lid margin
in a curve which lies in the line of the normal upper lid crease (This may
not always be possible if the lid has retracted very high, or if there is severe
pretarsal burn). The scar is released supercial to orbicularis, creating as
large a defect for a graft as reasonably possible and extending medially and
laterally to the orbital margins.
Occasionally, in a very deep burn, the graft may have to be placed on
orbital septum.
Conventionally, medium to thick split skin grafts have been used for the
upper eyelid, both so as to preserve the best donor sites for full thickness
grafts for later reconstruction around the face, and because full thickness
grafts tend to be sti when used in the upper eyelid.
Lower eyelid
Typically lower eyelid contractures (causing ectropion) are released with
full thickness skin grafts from the post- auricular area or supraclavicular fossa
that give the best colour match for facial skin.
The release can be carried out in a ‘melon- slice’ shape, or be extended
more laterally towards the temple, reaching the orbital margin. Both
methods tend to give a good correction, although the latter tends to give a
superior aesthetic result. Generally, the bigger the graft, the better the aesthetic result because of avoidance of scars on the lid itself.
Upper and lower eyelid contractures— technical points
• Inltrate with 1 in 200000 Adrenaline solution with a ne hypodermic
needle to reduce bleeding. Use bipolar diathermy as precisely as
possible to avoid necrotic patches under the grafts
• Try to create as large a defect as reasonably possible to make an
optimum release
• After upper eyelid release, insert a temporary tarsorraphy suture
between the centre of the lids to splint the upper eyelid in position
• After lower eyelid release, a suture can be placed in the centre of the
lower eyelid and taped up to the forehead to splint the lid in position
(Frost suture)
• Use tie- over dressings. It helps if the ‘bolus’ for the tie- over is sti
and matches the contour of the lid to avoid the tie over pulling the
conjunctiva and tarsus away from the eye. Options include using K wire
around the edge of bolus dressings or making a bolus of thermoplastic
mouldable plastic splint to fashion a semi rigid bolus for tie over dressing
• Use antibiotic eye ointment to prevent infection and desiccation
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Occasionally, lower eyelid contractures are caused by severe scarring of the
cheek rather than by intrinsic contracture of the lid itself (extrinsic contracture). In this event, release should ideally include some form of release or
resurfacing of the cheek scar too, to avoid an incomplete release.
The mouth
Early on after facial burn injury, microstomia may result from severe scar
contracture. To a degree this can be prevented by frequent use of oral
splints, but there are often problems with patient compliance.
Commonly it is necessary to release the oral commissures early after
burn injury if increasing tightness occurs. Our preferred method is to do a
Y– V plasty where a V- shaped ap of oral mucosa is planned on the inside of
the mouth with the apex of the V at the commissure. The V is made into a
Y with an external transverse incision from the commissure running laterally
for about 1cm. The V ap is incised and the stem of the Y is incised to
divide the contracted commissure. Often some orbicularis muscle has to be
divided. It is a dicult judgement to know how much of this to divide as it
is an important muscle for oral continence, so it is best to err on the side of
caution if in doubt. The V ap is then advanced into the transverse external
defect. Often small ‘Burow’ triangles of vermillion or oral mucosa have to
be trimmed above and below the inset ap to allow it to inset neatly.
This minor procedure often has to be repeated after a few months on a
couple of occasions, but this seems preferable in the long term to very unsightly rectangular patches of skin graft inset at each commissure, which is
the typical alternative to release commissure scars.
Severe scarring often restricts movement of upper and lower lips and
causes retraction of upper lip and ectropion of the lower lip with various
functional problems. However, unless this is very severe, it is best to give
these scars time to mature before undertaking revision (1– 2years)
Where possible, the lips should be released and the upper lip skin and
chin resurfaced with good sized ‘aesthetic unit’ grafts rather than attempting
piecemeal releases with Zs or small grafts.
Using large grafts on the aesthetic unit principle generally gives much
better functional and aesthetic results, than attempting minimum sized
grafts.
If resurfacing the face for aesthetic reasons, wait till scar resolution
is well advanced, and stick to aesthetic unit principles for resurfacing
facial scars.
An occasional exception to this is when isolated raised hypertrophic scars
can be shaved down, grafted and treated with pressure to improve overt
lumpiness. This requires careful aftercare.
Anaesthesia
For face and neck contracture surgery it is essential to involve the anaesthetist in the decision- making process as there are many ways in which the
airway can be compromised at induction of anaesthesia, during and after
surgery.
THE FACE
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CHAPTER30 Burn contracture surgery
Groin/ perineum and lower limb
Groin and perineum
Flexion contractures of the hip result from tight scars across the anterior
aspect of the inguinal are and thigh.
For Linear band contractures, Z plasty, Y– V plasty, or local transposition/ propeller aps may be used depending on the dimensions of the band
(Figs30.13 and 30.14).
Rarely a contracture in this area may need a ap (eg. after electrical injury) In such cases, options include a tensor fascia latae, anterolateral thigh,
or rectus femoris muscle ap. Various permutations of rectus abdominis
muscle aps are very useful for coverage of large defects around the groin,
proximal thigh, external genitalia, and perineum.
Perineum
Perineal contractures are relatively rare, but can be very unpleasant and
dicult to treat if severe.
Simple linear bands bridging across between the proximal thighs, vulva,
penis or anus, can be released with Z plasties or Y– V plasties, as local aps
in this area tend to be relatively well vascularized.
For more severe contractures, a defunctioning colostomy should be considered as part of the management. Extensive grafting (split skin) is often required, and tie- over dressings are usually necessary because of the dicult
contour. It is often helpful to mesh the grafts to optimize take.
Gracilis muscle is simple to elevate and very useful for coverage of defects around the genitalia and perianal area.
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GROIN/PERINEUM AND LOWER LIMB
Fig.30.13 For broadband contractures, local aps from the groin, hypogastic area
or thigh may be useful, if the area scarred is not very extensive. However, most
often for broadband contractures in the groin, scarring is extensive and an extensive
release and split skin graft is required (as the defect is commonly large, full thickness
grafts are not often indicated in this site). Split skin grafts commonly do fairl y well.
Dermal substitutes may be useful in this area.
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Fig.30.14 Diuse broadband exion contracture at hip suitable for release and skin
graft or dermal regeneration template.
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CHAPTER30 Burn contracture surgery
Popliteal fossa and knee
The popliteal fossa is a common site for contracture after burns of the
lower limb.
For linear band contractures a wide variety of options are available.
Multiple Y– V plasties or Z plasties are the simplest options for relatively
mild bands with some skin laxity. For thicker bands a local ap of propeller
ap style may be used, but the donor site often cannot be sutured directly,
so a skin graft is commonly required for the donor site.
For broadband contractures, skin grafts or aps are required; it is often
useful to use either a trapezoid ap release or two incisional releases proximal and distal to the joint to prevent making a deep incisional release into
the popliteal fossa.
If a deep incisional release into the popliteal fossa is required, the popliteal vessels may be exposed. In this event a fasciocutaneous or perforator
based propeller ap may be turned to cover the fossa, as long as reasonably
scar- free skin is present either in the proximal calf (the medial or lateral
distal thigh may also be used for a distally based ap). These aps are also
very useful for more moderate contractures as they put a ‘re- break’ of
normal skin in to break up the contracture and place the skin graft on the
donor site on the side of the limb where contraction of the graft is not such
an issue (Fig. 30.15).
In the rare event of the popliteal vessels being exposed and no skin ap
being available, it is straightforward to turn up one of the gastrocnemius
muscles to cover the popliteal fossa and create a safe graftable defect. If this
has to be done as a turnover with the tendon facing supercially, the tendon
should be excised to produce an optimum bed for a graft.
In the most severe contractures, requiring aps, large skin grafts may be
required to close all the defects. The bed for these grafts is often of irregular
contour and a mesh graft is the best option to ensure good graft take.
Full correction of knee exion contractures is important as subtotal corrections, leaving the knee exed, usually result in recurrent contracture. Try
hard to get full extension at the time of surgery, but if complete knee extension is not possible postoperatively then as soon as the graft or ap has
healed it is important to consider further serial casting to gain full extension
or gradual correction using the Ilizarov principle using an external xator.
As with most joints contracture, postoperative splinting and physiotherapy are essential parts of the treatment.
The anterior knee is not often a site of a functional contracture per se,
but may commonly be a site of an unstable scar with underlying supercial
infection of patella. Debridement and ap repair is sometimes necessary if
this fail to heal. The typical option for repair of this is a medial gastrocnemius muscle ap covered by a split skin graft. In addition, many useful skin
aps also exist for coverage of the anterior knee.
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POPLITEAL FOSSA AND KNEE
Fig.30.15 Polpiteal fossa contracture may be released with proximally or distal
based aps raised predominantly sub fascially. Avoid raising the proximally based
ap from over the common peroneal nerve on the lateral aspect of knee. If a large
perforator is in the base the ap can be islanded.
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