Post Burn Contracture Treatment in Hyderabad | Surgery & Rehabilitation

Post burn contracture treatment (PBC)

Post burn contracture (PBC) is treated with the following surgical processes, either alone or in combinations.

1. Incisional release
2. Excisional release

In a few cases, both procedures are performed, depending upon the severity of the contracture.

Incisional release: It involves incisions on the contracture bands to release the burn contracture. It includes either of the following methods.

• Z-Plasty
• Multiple Z-plasty
• W-Plasty
• V-Y closure
• Modifications of Z-plasty, etc.

Excisional release: It involves the excision of the contracture band or contracted tissue either partially (to safeguard the vital structures) or completely and then covering the wound with any of the following methods, either alone or in combinations.

• Split-Thickness Skin Grafts (STSG)
• Full-Thickness Skin Grafts (FTSG)
• Flaps
• Multiple combinations of the above may be needed in single or multistaged procedures.
  

Treatment options for post-burn contractures

1. Split-skin grafting
2. Local plastic surgical procedures: Z-plasty, W-plasty, Y-V plasty
3. Full-thickness skin grafting
4. Flap cover
5. Artificial skin substitutes
6. Tissue expansion with or without flap cover
   

1. Split-skin grafting

This is an old technique where your doctor will import healthy, unblemished, non-bulky skin without compromising nearby tissues to the defect area. The ideal locations for the graft are the buttocks or scalp. The graft will be applied to the wound once the contracture is completely released and the joint has fully extended.

There are chances of recurrence in this procedure, as the wound will contract once the split-skin graft is placed on the wound bed. This procedure might require physiotherapy in order to prevent movement difficulties, especially in children.

2. Local plastic surgical procedure

When there is a formation of bands in the contracture, your doctor might use a local procedure in order to release the burn contracture through any of the following procedures.

Z-plasty: It is a procedure that separates the scar contracture and lengthens the band. In this procedure, your doctor borrows tissue from the area next to the contracture rather than growing new tissue to stretch the band. This procedure will be applicable when the contracture is small and there is a good lot of slack skin near the contracture.

The Z-plasty is of two types:

Z-plasty-in-series (example, five-flap Z-plasty)

• The Z-plasty-in-series required a lot of the surrounding tissue.
• The design of Z should always be as large as possible. The bigger the size, the greater the lengthening obtained.

Z-plasty-in-parallel (example, multiple single Z-plasties)

• The Z-plasty-in-series requires less surrounding tissue compared to the Z-plasty-in-parallel.
• The lengthening that is really attained is significantly less.

The benefits of this method are:

• Z-plasty can increase the length of a scar via contracture release in burn contractures.
• In the case of facial scars, Z-plasty has the ability to break up face scars and shift their direction, which enhances the cosmetic outcome.
• Z-plasty can be useful in emergencies. For example, for a hand contracture, Z-plasty can increase the function and range of motion, helping to prevent contractures.

W-plasty: In this method, numerous triangles (like a series of w's) are sliced along the scar's long side and then mirrored on the opposite side. These zigzag patterns produce an irregular broken line when sutured, which reflects light poorly and obscures the original scar.

The benefits of this method are:

• The planning and execution of the W-plasty procedure is simple.
• Minimal risk, as the W-plasty flaps are not transposed, so there is no chance of flap necrosis.
• This approach is particularly useful for scars that occurred on a curved surface, such as the jaw, due to the small size of the flaps and transverse mobility.
• By breaking the scar borders into smaller triangular segments and redirecting the forces that cause contracture, changing the lines of distraction from perpendicular to oblique, and by relieving the bowstringing effect of linear scars, W-plasties may contribute in the improvement of previously hypertrophic scars.
• W-plasty achieves a camouflaging effect by dividing the scar into very small segments and mixing them with normal, unscarred skin.

This procedure is not applicable to certain areas of the body where a certain width of tissue must be given up in the revisional procedure.

Y-V plasty: This procedure is useful for linear sheet contractures. The Y enters the regular skin, and the V runs the entire length of the band. To create a V, the flaps are simply pulled forward. The skin laxity should be enough for the formation of V.

The benefits of this method are:

• There is a low risk of flap tip necrosis since there is no need for undermining, which lessens the possibility of the flaps' blood supply being compromised.
• Scar tissue is reoriented as a result of this technique.
• The length of the contracture band is not important. This technique is helpful with really long contracture bands.
• The Y-V plasty is an easy procedure. It is possible to refine the flap advancement degree while the procedure is being done.

It is actually impossible to remove a thick scar band, and the cosmetic results are very poor.

3. Full-thickness skin grafting

Full-thickness grafting has a better texture match than split-skin grafting after the contracture has been released, and it also has a lower rate of recurrence. Because there is more dermis in a full-thickness graft, there will be less wound contraction.

Full-thickness grafts are impractical after severe burns because there may not be enough skin to spare. A healthy donor site is required for full-thickness grafts in order for them to enter and exit. This process frequently causes hyperpigmentation, which has poor cosmetic effects.

4. Flap cover

There are two types of flaps covers:

• Pedicled flaps
• Free flaps.

Both are local and free fasciocutaneous flaps (a tissue flap, which consists of skin and underlying tissues, including a collagen-rich lining tissue, fascia), which are successfully used to relieve the burn contracture.

There is a wide variety of flap choices, which allows the surgeon to make judgments according to each individual case. Local pedicled laps are occasionally ineffective in extensive burn areas due to a lack of local skin plasticity or simply a paucity of available or suitable donor locations. In such cases, your doctor will opt for a free flap.

The size of the free flap should be similar to that of the defect area. Free flap might provide you with an unacceptable cosmetic result as they import tissue which is different in colour, thickness, and texture. There is no chance of recurrence in flap covers, which is the key factor.

5. Artificial skin substitutes

These are bilayer artificial dermis products that consist of a porous bovine collagen spongy matrix combined with an overlying temporary epidermal substitute comprised of a silicone sheet (Example: Integra). It reduces contraction by reducing the inflammatory responses.

• The quality of an artificial skin substitute resembles that of a full-thickness skin with improved flexibility and suppleness.
• No presence of scar hypertrophy.

This procedure has a high cost and more intensive dressing requirements.

6. Expansion of tissue with or without flap cover

It is a simple procedure where the colour, texture, and thickness of the expanded skin are the same as the adjacent skin. In a burn contracture, these tissue expanders are used in combination with pre-expanded or a fasciocutaneous flap. The neck, chest, and scalp are the ideal sites for tissue expansion procedures.

It will be challenging for your doctor to treat burned extremities in the lower limb with tissue expanders. The risks associated with these expansions include infection, leaking, skin ischemia, and even failure. In order to minimise the rate of complications, you should go to routine follow-up appointments

General principles of burn contracture release

• Prior to distal contractures, proximal joint contractures should be released by your doctor. For instance, if the shoulder and elbow have a restricted range of motion, then there will be little value in having a mobile wrist.
• Each joint should be taken into account independently. If there are several joints that need to be released, each contract should be completely released. Your doctor might opt to use the Y-Vplasty method to release contractures in multiple joints.
• Your doctor will always prioritise function over cosmesis; it is preferable to have a functional joint with a disappointing cosmesis than to have a joint that cannot move but is cosmetically perfect.
• When split-thickness grafts are placed over a wound, they have the potential to form recurrent contractures.Therefore, your doctor might arrange physiotherapy sessions that help to mobilise the joint in order to avoid this. An alternative to split-skin grafts is a flap that has its own blood supply, which could result in an improved cosmetic look.
• The critical underlying structures may occasionally become visible and call for release. For instance, if the ankle joint is released dorsally, it exposes the extensor tendons.