MANAGEMENT OF POST BURN

CONTRACTURES
By: Dr Mamush A (PSR III)
Moderator:- Dr Martha ( Assistant professor,
plastic and reconstructive surgeon)
 Outline of presentation
• Objective
• Introduction
• Basic concepts and techniques of reconstruction
• Reconstruction of the burned neck
• Reconstruction of burned axilla
• Reconstruction of burned hand
• Summary
• reference
Mamush A. (MD, Plastic and reconstructive
08/09/2023 2
surgery resident)
 Objective
• To know the basic concept and technique of
burn reconstruction on specific region
• To understand option of management of neck,
axilla and hand post burn contractures and
apply it to clinical practice

Mamush A. (MD, Plastic and reconstructive

08/09/2023 3
surgery resident)
 Introduction
• Improvement in burn survival shifted focus of
burn care and research towards long term
outcomes
• Accordingly, reconstructive burn surgery has
become increasingly relevant topic in the care
of burn patient
• Burn reconstructive surgery seeks to restore
both form and function lost to burn injury and
relies on basic principles of plastic surgery
Mamush A. (MD, Plastic and reconstructive
08/09/2023 4
surgery resident)
 Cont’D
• Burn reconstruction is fundamentally about the
release of contractures and the correction of
contour abnormalities.
• It should not be focused on the excision of burn
scars
• A scar can only be traded for another scar of a
different variety.
• fundamental problem is that of inadequate skin
and soft tissue
Mamush A. (MD, Plastic and reconstructive
08/09/2023 5
surgery resident)
 Cont’D
• A burn scar that is conspicuous at 1 year
because of hypertrophy, contracture, and
erythema can become inconspicuous with
further maturation
• Excision and primary closure of burn scars
should be reserved for small scars in
conspicuous locations

Mamush A. (MD, Plastic and reconstructive

08/09/2023 6
surgery resident)
 Cont’D
• Scars under tension are angry and respond with
erythema, hypertrophy, pruritis, pain, and
tenderness.
• Relaxed scars are happy scars. They respond by
flatten, softening, becoming pale and
asymptomatic.
• Advances in laser therapy have greatly
facilitated scar rehabilitation, further decreasing
the indications for scar excision.
Mamush A. (MD, Plastic and reconstructive
08/09/2023 7
surgery resident)
 Cont’D
• Contracture releases can be accomplished with
local tissue rearrangement such as Z-plasties or
transposition flaps or by releases and skin
grafting of the resulting defects
• Release can be performed by either incising or
excising scars.
• The choice of the appropriate intervention and
timing of intervention are both determine
success or failure after burn reconstruction.
Mamush A. (MD, Plastic and reconstructive
08/09/2023 8
surgery resident)
 TIMING OF RECONSTRUCTIVE
SURGERY
• Vary; early ( in weeks) to late
• Surgery on burn scars should typically occur
once the scars has matured
• Scar maturation process will take years or
longer
• As a rule, the body should be given every
chance to try and improve on its own without
surgery
Mamush A. (MD, Plastic and reconstructive
08/09/2023 9
surgery resident)
 Cont’D
• The timing of burn reconstruction falls into
three distinct phases:
acute, intermediate, and late
• As a general rule, burn reconstruction is best
delayed until all wounds are closed,
inflammation has subsided, and scars and
grafts are mature and soft.

Mamush A. (MD, Plastic and reconstructive

08/09/2023 10
surgery resident)
 Acute phase of reconstruction
• reconstruction begins with acute care by
initiating appropriate intervention to prevent
secondary deformity
• Acute reconstructive intervention is required
during the early months following burn injury
to facilitate patient care, these include:
To close complex wounds such as open joints,
to prevent acute contractures causing irreversible
secondary damage

Mamush A. (MD, Plastic and reconstructive

08/09/2023 11
surgery resident)
Intermediate phase of burn reconstruction

• best described as scar manipulation designed to

favorably influence the healing process.
• physical and occupational therapy must continue
to correct or prevent contractures
• enhance scar maturation with the use of pressure
garments, silicone gels, and massage
• When tension is present in the scar, Judicious
surgical intervention to relieve tension positively
influence scar maturation.
Mamush A. (MD, Plastic and reconstructive
08/09/2023 12
surgery resident)
 Cont’D
• Steroids are effective in diminishing and softening
hypertrophic scars, Topical steroids are helpful.
• Steroid injections use should be limited to situations
where pressure, silicone therapy, and massage are
ineffective and surgery is not an option.
• The pulsed dye laser (PDL) is effective in decreasing
facial erythema when used in this phase, result in
more favorable long-term scar maturation.

Mamush A. (MD, Plastic and reconstructive

08/09/2023 13
surgery resident)
 Late-phase reconstructive surgery

• These include all post burn deformities that are

stable and consist of mature scars and grafts.
• The experience, judgment,. and expertise of
the plastic surgeon are extremely important
during this period

Mamush A. (MD, Plastic and reconstructive

08/09/2023 14
surgery resident)
 Reconstructive Plan
• A prospective plan for reconstructive surgery
is developed with the patient and the patient's
family during the intermediate phase or at the
time of established post burn deformities
• The aim of reconstructive procedure is to
improve both function and the appearance of
the operated area
• Planning reconstructive sequence is helpful

Mamush A. (MD, Plastic and reconstructive

08/09/2023 15
surgery resident)
 Basic concepts and techniques
• Contractures: Burns cause tissue loss, wounds
heal with contraction, and contractures result.
It can be either intrinsic or extrinsic.

• Tension: Tension deforms normal body

contours, and the resulting abnormal shape
draws attention to the injured area.
Tension must be eliminated.
by either release and grafting or Z-plasties

Mamush A. (MD, Plastic and reconstructive

08/09/2023 16
surgery resident)
 Cont’D
• Donor Sites: Donor site availability is often
problematic in burn reconstruction
• Split-thickness grafts from the buttocks, thighs
are best used for contracture releases of the
trunk and extremities
• Full-thickness skin grafts from the retro
auricular area, cervicopectoral area, and the
upper inner arms are best reserved for head and
neck reconstruction.
Mamush A. (MD, Plastic and reconstructive
08/09/2023 17
surgery resident)
 Cont’D
• Release and Grafting: Burn contractures are
usually limited to the superficial scars or grafts.
Releasing incisions or excisions should be limited
whenever possible to the superficial scarred tissues
alone
Overcorrection of the contracture is always attempted
and grafts are sutured with a bolster dressing.
Placing fishtail dart at the ends of the releasing
incisions

Mamush A. (MD, Plastic and reconstructive

08/09/2023 18
surgery resident)
 Cont’D
• Z-plasty: The Z-plasty operation is an essential
and powerful tool for burn reconstruction.
• When a Z-plasty is performed properly, recruiting
lateral tissue, two goals are accomplished
– The central limb is lengthened, decreasing
longitudinal tension on the scar
– the width of the scarred area is decreased by the
medial transposition of lateral flap

Mamush A. (MD, Plastic and reconstructive

08/09/2023 19
surgery resident)
 Cont’D
• Wherever burn scar
crosses a concave
surface, there is a
tendency for the scar to
contract, hypertrophy,
and "bowstringing."
• Z-plasty helps alleviate
this common problem.

Mamush A. (MD, Plastic and reconstructive

08/09/2023 20
surgery resident)
 Cont’D
• Laser Therapy: Its a successful treatment
modality during the period of scar proliferation
and is an effective alternative to scar excision,
particularly in patients with hypertrophic facial
burn scars.
– its beneficial effect on scar erythema and
hypertrophy
– decreases pruritis & pain

Mamush A. (MD, Plastic and reconstructive

08/09/2023 21
surgery resident)
 Cont’D
• Grafts: Skin grafts are pivotal in bum
reconstruction
 Split thickness skin graft
 Full thickness skin graft

• Flaps: Flaps, with or without tissue expansion,

are useful for burn reconstruction.
 its important for complex defect such as open
joint, exposed neurovascular structure, to provide
coverage that allows for later complex
reconstruction
Mamush A. (MD, Plastic and reconstructive
08/09/2023 22
surgery resident)
 Cont’D
• Tissue Expansion: transform the treatment of
post burn alopecia.
– Bald areas of 50% of the scalp can be successfully
reconstructed
– The scalp is an ideal site for tissue expansion
– The use of tissue expansion in other areas of burn
reconstruction is more problematic.

Mamush A. (MD, Plastic and reconstructive

08/09/2023 23
surgery resident)
 Evaluation and Treatment
• Successful burn reconstruction requires perspective, patience,
a thorough understanding of the problem, and judicious
application of the fundamentals of burn reconstruction.
• When contractures have a predominantly linear component ,
the Z- plasty can be used for reconstruction
• Z-plasties can also be used on the narrower, linear,
components of diffuse areas of hypertrophic scarring
• When contracted scars or grafts are diffuse and Z-plasty or
other local flap rearrangement is not possible, then release
and split-thickness skin grafting is usually the best option to
correct contractures.
Mamush A. (MD, Plastic and reconstructive
08/09/2023 24
surgery resident)
 several critical prerequisites
• patient must want the procedure performed
and be psychologically prepared for the procedure
• patients have realistic expectations
regarding what can be achieved with
reconstructive surgery(scars can simply be
“erased”)
• explain to patients that several procedures are
often needed
• Procedures should be grouped
Mamush A. (MD, Plastic and reconstructive
08/09/2023 25
surgery resident)
Reconstruction of the burned neck
• neck is one of the most common locations for a
functional burn contracture to form
• Early debridement and grafting and aggressive
splinting are crucial to prevent neck contractures
• The neck is also the first region of the face that
should be addressed when beginning
reconstruction because tension in this region can
cause disfigurement and discoloration of the
entire face
Mamush A. (MD, Plastic and reconstructive
08/09/2023 26
surgery resident)
 Mamush A. (MD, Plastic and reconstructive
08/09/2023 27
surgery resident)
 Cont’D
Post burn neck contracture
– Mild
• Scar band involving less than 1/3 of anterior surface of the
neck
• Treated by local flaps or z plasties
• If >20% tissue expanders should be considered
– Moderate
• Greater than 1/3 but less than 2/3 of anterior surface of neck
• Local flaps inadequate
• Tissue expander first choice followed by distant flaps/skin
graft
Mamush A. (MD, Plastic and reconstructive
08/09/2023 28
surgery resident)
 Cont’D
• Severe
– Greater than 2/3 of anterior surface of the neck
– Skin graft or distant flap
• Extensive
– Mentosternal adhesion
– In neglected burns
– Skin graft is necessary

Mamush A. (MD, Plastic and reconstructive

08/09/2023 29
surgery resident)
 Cont’D
• Parameter to keep in
mind when
reconstructing patient
with post burn neck
contracture

Mamush A. (MD, Plastic and reconstructive

08/09/2023 30
surgery resident)
 Cont’D
• Surgical correction
– Local flaps
• Z-plasties for linear bands
– Convert vertical bands to transverse orientation
• Local transposition flaps
• Combination
– Local flaps + orient the scars as transversely as possible + skin
graft

Mamush A. (MD, Plastic and reconstructive

08/09/2023 31
surgery resident)
 Cont’D

Mamush A. (MD, Plastic and reconstructive

08/09/2023 32
surgery resident)
 Cont’D
• Tissue expansion
– Loses some of its effectiveness in neck region
• No hard tissue immediately beneath the expander
• Flaps in the neck tend to contract after transposition
– Neck angle doesn’t counteract flap shrinkage as opposed to
scalp
– A role in selected cases
• Lateral skin can be stretched and transposed medially
– Avoids skin graft

Mamush A. (MD, Plastic and reconstructive

08/09/2023 33
surgery resident)
 Cont’D
• Distant flaps
– Flaps vs grafts debate
• Cervicomental angle, lower neck contour like laryngeal
cartilages, the SCM muscle and sternal notch are
obscured with flaps
– Large thick split thickness grafts preferred over multistage
pedicled flaps
• Large relatively thin free flap are possible

Mamush A. (MD, Plastic and reconstructive

08/09/2023 34
surgery resident)
 Cont’D
• Skin grafts
– Most commonly used resurfacing materials in extensive
neck contractures
• Intubation may be impossible and surgeon should prepared for
emergency release or tracheostomy
• Fibreoptic bronchoscopy are very useful
• Release before intubation with LA and ketamine may be
necessary
– Complete release
• Incising all contracture bands as deep as strap muscles and as
wide as possible
– Release at surgery is the maximum possible improvement

Mamush A. (MD, Plastic and reconstructive

08/09/2023 35
surgery resident)
 Cont’D
– Medium to thick STSG applied after thorough
release and hemostasis secured
– Pressure dressing applied and neck immobilized
for several days
– 89% recurrence without splintage and 17%
recurrence if a splint used
– FTSG gives better result for noncompliant patients
in wearing splint

Mamush A. (MD, Plastic and reconstructive

08/09/2023 36
surgery resident)
 Cont’D

Mamush A. (MD, Plastic and reconstructive

08/09/2023 37
surgery resident)
 Reconstruction of Axillary Contracture
• Axillary burn scar contracture are common after deep
thermal burn involving upper trunk or extremities
• The contracture produce both anatomical and
functional deformities
• Surgical correction for axillary contracture still
challenge
• Satisfactory reconstruction need detail preoperative
evaluation of the anatomy of axilla involved by scar
contracture and prioritizing available donor site

Mamush A. (MD, Plastic and reconstructive

08/09/2023 38
surgery resident)
Classification of axillary burn contracture

• Achauer classified them in to 4 type

Type 1. anterior or posterior axillary fold only, usually
associated with mild restriction of motion
managed by local flap (z-plasty, y to v advancement)
best for correction
Type 2. both anterior or posterior axillary fold with the
apex spared, moderate to severe restriction of motion
present
more complex repair (large flap or skin graft
required)
Mamush A. (MD, Plastic and reconstructive
08/09/2023 39
surgery resident)
 Cont’D
Type 3. the entire axilla , usually associated with
marked limitation of motion
 usually large split thickness skin graft required
for correction
Type 4. scars of the adjacent area
nearby scar can also cause reduction in shoulder
movement
treatment has to be individualized (recognize the
real cause of shoulder movement restriction)

Mamush A. (MD, Plastic and reconstructive

08/09/2023 40
surgery resident)
 Surgical correction
• Scar band of either anterior or posterior
axillary fold
Avoid skin graft
Use unburned skin to break up the scar band
Consider multiple Z- plasty , double opposing Z-Plasty
For minor contracture, consider Y to V plasty

Mamush A. (MD, Plastic and reconstructive

08/09/2023 41
surgery resident)
 Cont’D

Mamush A. (MD, Plastic and reconstructive

08/09/2023 42
surgery resident)
 Cont’D
• local transposition flap
of unburned tissue along
the inner arm and lateral
chest can be used for
smaller release.

Mamush A. (MD, Plastic and reconstructive

08/09/2023 43
surgery resident)
 Contractures involving both anterior &
posterior axillary fold
• Managed by regional
flap
 latissimus dorsi
Fasciocutaneous flap
 Scapular and
parascapular flap

Mamush A. (MD, Plastic and reconstructive

08/09/2023 44
surgery resident)
 Contracture involving Entire Axilla
• This require extensive release and skin graft
• The release must be through, which usually involve release of
180° of arc of rotation of the joint .
• Fish tail type bifurcation made at the end of the release to prevent
contracture band from developing at the end of the release.
• The apex of the axilla can be a problem
Can be bypass by double release
Transpose the head pectoralis muscle
• Postoperatively: after the graft the shoulder immobilize for 05
days
Nigh splint, physical therapy to prevent recurrence

Mamush A. (MD, Plastic and reconstructive

08/09/2023 45
surgery resident)
 Reconstruction of the burned Hand

• A classic hand burn injury involves the dorsum

– More exposed and has very thin skin
– A typical reaction is to shield the face or body with
our hands
• Complications
– Joint stiffness
– Scar contracture

Mamush A. (MD, Plastic and reconstructive

08/09/2023 46
surgery resident)
 Cont’D

Mamush A. (MD, Plastic and reconstructive

08/09/2023 47
surgery resident)
 Classification
A. Claw deformity
B. Palmar contracture
C. Web space deformity
1. Web space contracture
2. Adduction contracture
3. Syndactylism
D. Hypertrophic scar and contracture bands
E. Amputation deformity
F. Nail bed deformity
Mamush A. (MD, Plastic and reconstructive
08/09/2023 48
surgery resident)
 Claw deformity

• Result from unopposed

contracture of dorsal hand
burn
• Burned hand claw
deformity
– MP joint extended

– Thumb adducted

– PIP joint flexed

Mamush A. (MD, Plastic and reconstructive
08/09/2023 49
surgery resident)
 Cont’D
• Following stabilization of
patient from cardiovascular
and respiratory point of view
 The first priority should be
look for eschar on extremities
and do escharatomy
 The second priority is splinting
in anticlaw postion ,to minimize
permanent contracture
 Institute active and passive
range of motion immediately
 Elevate the hand
 Early coverage of the wound

Mamush A. (MD, Plastic and reconstructive

08/09/2023 50
surgery resident)
 Cont’D
• Reconstruction of an • General approach
established claw  resurface dorsal surface
deformities can be may require distant flap to
difficult allow subsequent joint
• Two major priorities of and tendon reconstruction
reconstruction are:  joint release: include
release of joint capsule,
1. To improve MP motion collateral ligament
2. To obtain a satisfactory  Institute immediate range
PIP position. of motion

Mamush A. (MD, Plastic and reconstructive

08/09/2023 51
surgery resident)
 Cont’D
• Severely burned stiff
PIP joint is usually not
amenable for
tendon/joint
reconstruction
• A good option is
arthrodesis of the PIP
joint in appropriate
degree of flexion

Mamush A. (MD, Plastic and reconstructive

08/09/2023 52
surgery resident)
 palmar contracture
• Are uncommon
• Associated with
grasping hot objects like
– Charcoal
– Heater
– Stove
– Iron

Treatment : complete
release and skin graft

Mamush A. (MD, Plastic and reconstructive

08/09/2023 53
surgery resident)
 Web space deformity

• Three types
1. Web space contracture-skin only
2. Adduction contracture-muscle
fibers
3. Syndactylism -
• Four grades
Grade 1 one fourth of the distance
from MP to PIP
Grade 2 up to one half
Grade 3 up to three fourths
Grade four greater than three fourths

Mamush A. (MD, Plastic and reconstructive

08/09/2023 54
surgery resident)
 Web space contracture
• The most common Option for surgical
webspace deformity treatment:
• It result from scar band  V to M plasty
which obliterate the dorsal  Rectangular flap
aspect of webspace
• Management:
prevention: early physical
therapy and placing skin
graft with the digit in
abducted position

Mamush A. (MD, Plastic and reconstructive

08/09/2023 55
surgery resident)
 Cont’D

Mamush A. (MD, Plastic and reconstructive

08/09/2023 56
surgery resident)
 First webspace contracture (Adduction
contracture of the thumb)
• Adduction contracture of the • Option :
first webspace has significant  Z plasty (60°,give
impact on over all hand
optimal result)
function.
• Managed with surgical  Four flap or five flap Z
intervention and physical Plasty:
therapy  For webbing is over long
distance
• Goal of surgery:
 to break up and to add length
to straight line contracture
 To reform web space by
employing local flap
Mamush A. (MD, Plastic and reconstructive
08/09/2023 57
surgery resident)
 Postoperatively:
 apply bulky dressing
 Splint the thumb in
abducted and extension
position
 Day time compressive
wrap & Glove with
interdigital webspace
inserts & conformer
 early physiotherapy

Mamush A. (MD, Plastic and reconstructive

08/09/2023 58
surgery resident)
 Amputation deformity
• It can result from 4th degree burn or from
severe electrical burn injury.
• Reconstructive option to restore function after
amputation include:
 phalangization
Pollicization

Mamush A. (MD, Plastic and reconstructive

08/09/2023 59
surgery resident)
 Nail bed deformity
• Eponychial retraction & • extensive release of the
proximal nail exposure dorsal soft tissues and
can be caused by dorsal resurfacing of the
digital burn scar resulting defect with an
contracture FTSG
• distally based • Restoration of normal
bipedicled flap, which is anatomy can thus be
designed to release the achieved and results in
proximal nail fold normalized nail growth
and improved DIP flexion
contracture.
Mamush A. (MD, Plastic and reconstructive
08/09/2023 60
surgery resident)
 Cont’D

Mamush A. (MD, Plastic and reconstructive

08/09/2023 61
surgery resident)
 Postoperative management: splints,
pressure garments and rehabilitation
• Effective post operative plan is crucial
• following contracture release, immobilization occurs for the
first 5–7 days postoperatively to allow for adequate healing
to occur
• patients are immobilized in a position that optimizes
function
• Once graft/flap take has been achieved mobilization occurs.
• utilize splints for weeks to months following contracture
release to minimize contracture recurrence

Mamush A. (MD, Plastic and reconstructive

08/09/2023 62
surgery resident)
 Summary
• Burn reconstruction is basically about the release of
contractures and the correction of contour abnormalities
• For successful burn reconstruction, one must learn to
appreciate scars and understand their behavior.
• Advances in laser therapy have greatly facilitated scar
rehabilitation
• Contracture releases can be accomplished with local
tissue rearrangement such as Z-plasties or transposition
flaps or by releases and skin grafting of the resulting
defects
Mamush A. (MD, Plastic and reconstructive
08/09/2023 63
surgery resident)
 Reference

1.Steven E.Hedrik handbook of plastic surgery. 2nd edition, 2006

2.Grabb &smith’s plastic surgery, 8th edition, 2014.

3. Jeffrey E. Janis:- Essentials of plastic surgery. 2nd edition, 2014

4. Adrian M. Richards:- Keynotes on plastic surgery, 2nd edition, 2002

5. David N. Herndon:- Total burn care, 4th edition, 2012

6. Neligan (2013) volume 4. reconstructive burn surgery

Mamush A. (MD, Plastic and reconstructive

08/09/2023 64
surgery resident)
 THANK YOU

Mamush A. (MD, Plastic and reconstructive

08/09/2023 65
surgery resident)