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F. N. Williams and J. O. Lee
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Chapter 19. Exfoliative Skin Diseases: Stevens-Johnson…
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Chapter 20
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Burn Scar
andContracture
Management
JorgeLeon-Villapalos , DavidZergaran ,
andTomCalderbank
Introduction
Burn scars are direct consequences of tissue repair following
injury. Scars and contractures can be challenging when they
become symptomatic from the physical and psychological
point of view, leading to increased functional and cosmetic
disability. Any strategies that accelerate healing and preserve
tissue integrity will have a definitive impact in decreasing
pathological burn scarring. Burn depth determines ultimate
healing potential and therefore dictates initial management
and the potential for scar morbidity.
Burn wounds can be broadly classified into superficial,
characterised by rapid healing and epithelialisation with
minimal scarring and deep, characteristically requiring surgical
J. Leon-Villapalos (*) · D. Zergaran · T. Calderbank
Department of Plastic Surgery and Burns, Chelsea and
Westminster Hospital, London, UK
e-mail: Jorge.Leon-Villapalos@nhs.net; d.zargaran@ucl.ac.uk;
calderbank@nhs.net
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
J. O. Lee (ed.), Essential Burn Care for Non-Burn Specialists,
https://doi.org/10.1007/978-3-031-28898-2_20
415
416
J. Leon-Villapalos et al.
management and therefore causing the most problematic and
symptomatic of scars. Clinical assessment remains the most
frequent technique to evaluate the depth of a burn wound
although this has been shown to be accurate in up to 75% of
the cases and is subject to the clinician’s experience and
expertise [1]
It is fair to say that burn scar management starts at the
time of injury with appropriate first aid and physiology support approaches that stop the burning process, cool the burn
wound, and preserve dermal perfusion and microvasculature
[2, 3]. The provision of adequate cooling of the burn wound
with running water has also been associated with reductions
in conversion to full-thickness pattern, need for surgical
debridement and ultimately, burn scarring [4]. The Jackson
burn model [5] containing a classic description of concentric
zones of burn injury is still relevant in highlighting the need
to preserve the zone of stasis with any interventions (accurate
burn assessment, fluid resuscitation) that may speed healing
and therefore reduce scarring.
Delayed burn wound healing has therefore proved to
greatly influence the outcome of scarring. A recent study in
adult burns showed that an increase in standardised scar
assessment scores, associated with worsening scar severity, is
correlated with longer healing times after 21 days [6]. This
study replicates the findings found in the paediatric population that concludes that there is a lower risk of hypertrophic
scarring formation in scalds healed before 21days, and that
surgery is likely if healing is not achieved after that period [7].
Modern burn management comprises the attributes of
being multidisciplinary and multimodal with an emphasis on
dermal preservation and functional and cosmetic restoration.
This approach ensures best outcomes in any circumstances of
burn severity or aetiology. As burn treatment starts in the
pre-hospital period with appropriate first aid, it can be stated
that the first deterrent towards abnormal burn scarring is
Chapter 20. Burn Scar andContracture Management
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appropriate assessment and management by pre-hospital
teams and emergency health professionals.
It has been reported that multidisciplinary burn team
approach in the admission to specialised burn services is
independently associated with significant survival benefit
[8]. This is independent of the aetiology of the burn [9].
There are also definitive advantages in treating scars due
to burns within a multiple team approach. The patient with
a burn scar should be managed holistically focusing on
functional and cosmetic improvement and rehabilitation.
The non-burn specialist will need to strike the right balance and decide when referral for further management by
the scar management team is necessary. This will warrant
early intervention, objective scar assessment to address
physical and psychological issues and will offer the patient
the best choice of treatment that may include combination
therapy and the use of the best technology available.
Multimodality pertains to the use of different burn
wound management techniques adapted to the different
initial presentation pattern (superficial vs deep) to warrant
early healing and minimal scarring. This is coupled with
the concept of dermal preservation. A study comparing
different excisional techniques found, unsurprisingly, that
“dermal preservation during acute burn excision is key to
obtaining superior healing/scar outcomes, however, determining the most appropriate excision tool is an ongoing
challenge” [10]. The message stated appears obvious: the
better you manage the burn wound in the acute period in
a multidisciplinary fashion, the better scar quality will be
obtained. A superficial burn with plenty of self-regeneration potential will heal in an unproblematic fashion with
minimal or no visible scarring or cosmetic mismatch. A
deep burn requiring surgical excision that is performed in
a too aggressive fashion will involve a much larger symptomatic scar that will impact on normal function, cosmesis,
psychology, and self-image of the patient. We will assess
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J. Leon-Villapalos et al.
later in the chapter the different multimodalities available
in scar management.
Scar andContracture Assessment
Continuous developments in acute burn care have reduced
mortality and morbidity [11] due to improved treatment
protocols, and specifically, in the assessment and management of inhalational injury, the intensive care of the critically ill burn patient, and the recognition for the need of
judicious early excision and wound coverage. This has led
to increased survivability and decreased hospital length of
stay [12]. Despite these advances, burn scars and contractures remain a challenge. Abnormal burn scarring has been
described as one of the major unmet needs in burn care
[13]. Whilst ideally a burn scar should be soft, pliable, and
with minimal discoloration or depigmentation, the reality
is that severe deep burns may leave pathological, unsightly,
symptomatic scars. These cause both functional and psychological impairment that may manifest as unsightly contractures that decrease range of motion, cause pain and
itch, and exhibit cosmetically undesirable changes in pigmentation, vascularity, thickness, colour, pliability, and
surface area. All these determinants affect quality of life
and impact severely in the well-being of the patient [14, 15]
and need to be taken into consideration when we assess
the patient with a burn scar.
Burn scars can affect all ages from both the physical and
psychological points of view. In children, specifically, a
degree of sensitivity needs to be considered during the
consultation as there can be associated long-term psychosocial and psychological difficulties and “reported lowered
quality of life, particularly related to scarring and appearance” [16]. Psychological support is an important part of
the management of the patients with burn scars. A recent
survey highlighted that “patients with burn scars have
Chapter 20. Burn Scar andContracture Management
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higher levels of pre-existing psychological difficulties,
carry a greater number of scars and experience more
symptoms”, specifically due to “appearance-related concerns, social anxiety, acceptance and coping” [17].
Scar History
A thorough history (Table20.1) to assess and manage burn
scarring should introduce first, a description that includes the
mechanism of burn injury. This is an important factor in the
potential outcome of burn scars. We found in the burn literature an observational study that sought to investigate the
similarities and differences of wound healing and resultant
scarring and stated that the mechanism of injury greatly influences wound dermal recovery [18]. The provision of first aid
T . Key points in the history taking for scar assessment
Original injury
• Mechanism of injury
• Provision of first aid at time of injury
• Depth and total body surface area of original injury
• Time to full healing / dressing free activity
• Need for acute surgery for original injury
• Comorbidities and current medications
• Skin type
• Subjective scar description or use of scar scale:
– Functional concerns: pain, itch, decreased function, and
impact on activities of daily living
– Cosmetic concerns description: thickness, colour, relief
pigmentation, pliability, vascularity, surface area
• Type of scar
• Need for referral
420
J. Leon-Villapalos et al.
is also an important determinant in the development of
pathological, symptomatic scarring. The description of the
original assessment of the depth and extent of the burn is
mandatory. It must also include the time to full healing of the
burn wound. Other important determinants of burn scarring
are the need for surgery to achieve healing, and any comorbidities or medications that may affect the restoration of the
tissues and the ultimate quality of the scar. A number of
important factors not to be missed in the scar assessment history are the skin type, colour, and ethnicity of the patient with
a burn scar. Both the incidence of symptomatic pathological
burn scar (atrophic vs hypertrophic vs keloid) and the
response to the different modalities of scar treatment are
heavily shaped by the type of skin [19].
It is widely accepted that the assessment of the scars can
be broadly divided, following a thorough history as detailed
above, into objective and subjective. Undoubtedly, the use
of modern instrumentation for objective scar assessment
provides a “more reliable evaluation of the scar, by a better reproducibility and lower inter-assessor variation” [20].
Nevertheless, the use of these objective tools may be limited for the non-burn specialist due to the need to purchase potentially expensive devices that require appropriate
training, increase data collection time, and may not be used
frequently enough in the management of these patients.
For descriptive purposes, objective tools assess the colour
and biomechanical characteristics of the scars with techniques such as laser, ultrasound, and tension measurement
devices [21–23]. We will be concentrating in the subjective
approach to the scar, which is the one more tailored to the
non-burn specialist.
Scar Subjective Assessment andScar Scales
We will expand on the subjective assessment. Even though
a simple descriptive approach of the scar is possible by taking simple terms and applying them verbatim in the history
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taken from the patient (my scar is “ugly”, “thick”, “stiff”
“dark”, “red”), the potential need for referral to an expert
scar centre warrants a more structured description of the
pathological features of the scar. The function and cosmetic
appearance can be compromised because the scar is abnormal in its colour, thickness, pliability, surface area, and
causes pain and pruritus. The severity of these changes can
be described using scar scales.
Even though there is no definitive consensus on the
ideal scar scale, the most commonly used scar scales are
the Vancouver Scar Scale (VSS) [24] and Patient and
Observer Scar Assessment Scale (POSAS) [25], although
there are other less frequently applied scales [26, 27]. The
VSS scores pigmentation, vascularity, pliability, and scar
height and thickness, but it does not take into consideration functional and psychological sequelae of scars despite
several modifications [28].
The POSAS relies on two different assessment scales
corresponding to the observer and to the patient. The six
measures considered for the patient contain parameters
similar to those measured by VSS but include functional
concerns such as pain and itching in addition to colour,
stiffness, thickness, and surface irregularity. The observer
scale parameters include vascularisation, pigmentation,
thickness, relief, pliability, and surface area. The addition of
scores provides a comparison of the scar of the patient to
normal, uninjured skin that defines the severity of the
pathological scar.
Pathological Scar Types
The physical examination of the scar of the patient can be of
immense diagnostic and therapeutic value, both to start
uncomplicated lines of treatment or to provide an accurate
description when making a referral to the expert scar centre.
Even though a consensus scar classification has been agreed
[29], this can be simplified for the scar on their way to full
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