|Year : 2013 | Volume
| Issue : 1 | Page : 50-54
Classification of post-burn contracture neck
Mohamed Makboul, Mahmoud El-Oteify
Department of Plastic Surgery, Assiut University Hospital, Assiut 71526, Egypt
|Date of Web Publication||22-Nov-2013|
Department of Plastic Surgery, Assiut University Hospital, Assiut 71526
Source of Support: None, Conflict of Interest: None
Post-burn neck contracture (PBC) is one of the most common burn sequela. These contractures affect the patient significantly causing both functional limitations and esthetic disfigurements. Hence, the reconstruction of this area is a challenge to surgeons who must choose a technique, which restores the function and also improves the esthetic appearance. Aims: The aims of this study are to provide a simple classification of PBC and offer surgical solutions for each section of our classification. Materials and Methods: This retrospective study was carried out on 140 patients with PBC neck who were classified according to the functional defect and the anatomical type of scar. Results: We offer a simple classification system for PBC neck depending on the degree of contracture into mild, moderate and severe and also according to the type of the scar into linear, band or broad type.
Keywords: Classification of neck contracture, post-burn contracture, reconstruction of post-burn contracture
|How to cite this article:|
Makboul M, El-Oteify M. Classification of post-burn contracture neck. Indian J Burns 2013;21:50-4
| Introduction|| |
Neck contracture and deformities as consequences of burns pose one of the greatest challenges to plastic surgeons in reconstructive surgery. 
This area is, like the face, a zone exposed to diverse injuries, such as scalds, electrical flashes, splashes, etc. Mentosternal or even cervicothoracic contractures cause serious problems, functional and esthetic. The traction forces caused by burn scar contracture may pull and cause insufficient neck extension, incomplete oral occlusion, cicatricial ectropion and alter tracheal position, which results in difficult intubation that can be life-threatening and can result in multiple serious complications and sequels, which require early surgical correction. 
Exposed regions like the face and neck are commonly involved in severe burns especially in patients who did not use appropriate protective equipment in occupational accidents. Anterior cervical contractures are characterized by the limitations in the range of neck motion, most noticeably extension. The scar may extend to or involve the face and the chest, thus, causing a synechia effect. 
Physical and esthetic deformities resulting from this type of disfigurement in exposed areas, such as the face and neck can cause significant depression,  which affects the patient's quality-of-life. Esthetic reasons alone would place cervicofacial contractures as a priority for reconstruction. ,,,,,
This article will classify post-burn neck contracture (PBC) according to the degree of deformity and the type of the scar into 9 groups. By organizing our classification, an attempt can then be made to provide guidelines, or more specifically, a plan for reconstruction of PBC according to the available healthy tissues.
| Materials and Methods|| |
A retrospective study was done on 140 patients with PBC neck who were treated in our institute between January 2008 and December 2011. We clinically examined the degree of neck contracture and accordingly a classification system for PBC neck according to the severity of contracture and functional impairment includes three degrees:
Scar appears only during neck extension with the loss of the cervicomental angle and the neck extension from 95 to 110°.
Scar appears in the resting position, which hinders any more neck extension and the neck extension from 85 to 95°.
Neck is already in the flexed position and the scar is limiting any neck movement and the neck extension is >85°.
Each degree of neck contracture was classified according to the shape of the scar into three types:
In which the scar tissue is a fibrous tissue line.
In which the scar width forms less than 50% of the anterior surface of the neck.
In which the scar width forms more than 50% of the anterior surface of the neck.
We classified our patients into 9 groups as shown in [Table 1].
|Table 1: Patients classifi cation according to the contracture severity and the type of the scar|
Click here to view
Complete release or excision of the scar tissue was done depending on the thickness and the condition of the scar tissue.
Different modalities of reconstruction were used for management of neck contracture such as skin graft, local fasciocutaneous flaps and distant flaps. Anticipating that we would encounter a wide range of the patients and intervention types, we planned to categorize the patients and procedures rather than to make comparisons based on individual patient characteristics.
Post-operative splinting using neck collar was used for at least 6 months to guard against recurrence of contracture.
Post-operative follow-up was done for 1 month, 3 months and 6 months post-operatively by the surgeon to assess the post-operative results and the complications and the recurrence of contracture.
| Results|| |
By organizing the degree of contracture with the scar type, we established a simple classification system for PBC
Linear scar can cause mild, moderate or severe contractures [Figure 1].
Band scar can cause mild, moderate or severe contractures [Figure 2].
Broad scar can cause mild, moderate or severe contractures [Figure 3].
In linear scar type, local flaps were done for the mild and moderate degrees of contracture using Z-plasty, multiple Z-plasty, or double-opposing Z-plasty [Table 2], releasing the scar tissue until healthy underlying tissues [Figure 4] and [Figure 5].
|Figure 5: Mild linear contracture neck repaired by 5-flap (doubleopposing Z-plasty)|
Click here to view
In severe linear scar type, X-release of the scar tissue was done usually supraplatysmal. Platysmal release was done in one case in which the muscle is included in the scar tissue. Resurfacing of the resulting defect after release of the contracture was done using skin graft [Table 2] and [Figure 6].
|Figure 6: Moderate Linear contracture neck repaired by X-release and skin graft|
Click here to view
In mild degree of band contracture and in seven cases of moderate band contractures, local flaps were done in the form of double-opposing 5-flap [Table 2] and [Figure 7].
X-release and skin graft was used for the management of severe band contractures, 12 cases of moderate band contractures and in all the degrees of broad contractures [Table 2], [Figure 8] and [Figure 9].
|Figure 8: Moderate broad contracture neck repaired by X-release and skin graft|
Click here to view
|Figure 9: Severe broad contracture neck repaired by X-release and skin graft|
Click here to view
Partial flap dehiscence was noted in only 4.5% of patients (five cases), which healed by daily dressing and did not need any further surgical interventions.
Partial skin graft loss was a complication found in four cases (13.33%), two cases needed secondary skin graft, while the other two cases healed with only dressing.
Recurrence of contracture was found in nine cases (6.43%), six cases had a skin graft for resurfacing, while only three cases had local flaps for the management of PBC. We found that the recurrence was of milder degree than the previous contracture.
| Discussion|| |
The head and neck area is the most important esthetic and functional region in burn patients. The natural neck position makes the head in the most optimal alignment for daily interactions. Unlike other joints, which are normally in maximal extension (e.g., the knee), the neck is in a neutral contracted position during standing. Due to the wrong position of the head on the neck during burn management and the pillow under the head not the shoulder, the chronic flexion contracture is often seen in deep extensive burns of the neck and this may be attributed to the flexion position taken by the patient to minimize the tension on the neck and hence decreasing the pain sensation. 
Many classification systems were found in the literature, most of them were based on the severity of the contracture as Achauer in 1991, who classified anterior neck contractures into mild, moderate, extensive and severe depending on what fraction of the anterior part of the neck is involved in the contracting band. 
Onah introduced a classification system for PBC included major numeric categories of 1-4, which encompassed position, severity and likely problems. Subgroups within each numeric category were used to designate the width of the contracture, which had implications for the options available for reconstruction.  Although there is some similarity of this classification with our work, it was somewhat complicated type of classification in comparison to the simplicity of ours.
Tsai et al.,  classified PBC by defining the zones of scar contractures in burn patients with anterior cervical contractures. This classification did not deal with the shape of the scar causing the contracture and the aim of this classification was to use it in microsurgical reconstruction.
According to our classification system, guidelines were framed for the management of PBC depending on the availability of healthy un-scared tissues.
In linear contracture, usually there is available healthy tissue, especially in mild and moderate degrees, so local flaps such as Z-plasty,  or double-opposing Z-plasty (5-flap)  can be used to break and lengthen the linear scar.
In severe and sometimes in moderate linear contracture, in spite of the available surrounding healthy tissues, tissues in X-axis more than what is available in Y-axis, hence skin graft or flap may be needed for resurfacing after release of the contracture.
In band contracture, skin graft is usually needed for resurfacing after release of the contracture especially in moderate and severe degrees, while in mild degrees local flaps as Z-plasty, double-opposing Z-plasty (5-flap), or double-opposing 5-flap could be used.
In broad contracture, skin graft is usually needed for resurfacing after release of the contracture with any degree.
The presented classification system for PBC is simple and useful to describe the severity of the contracture and the type of the scar causing the contracture and also helps in choosing the reconstructive options.
| References|| |
|1.||Pallua N, Machens HG, Rennekampff O, Becker M, Berger A. The fasciocutaneous supraclavicular artery island flap for releasing postburn mentosternal contractures. Plast Reconstr Surg 1997;99: 1878-84. |
|2.||Laredo Ortiz C, Valverde Carrasco A, Novo Torres A, Navarro Sempere L, Márquez Mendoza M. Supraclavicular bilobed fasciocutaneous flap for postburn cervical contractures. Burns 2007;33:770-5. |
|3.||Tsai FC, Mardini S, Chen DJ, Yang JY, Hsieh MS. The classification and treatment algorithm for post-burn cervical contractures reconstructed with free flaps. Burns 2006;32:626-33. |
|4.||Pallua N, Künsebeck HW, Noah EM. Psychosocial adjustments 5 years after burn injury. Burns 2003;29:143-52. |
|5.||Edlich RF, Nichter LS, Morgan RF, Persing JA, Van Meter CH Jr, Kenney JG. Burns of the head and neck. Otolaryngol Clin North Am 1984;17:361-88. |
|6.||Kobus K, Stepniewsky J. Surgery of post-burn neck contractures. Eur J Plast Surg 1988;11:126-8. |
|7.||Voinchet V, Bardot J, Echinard C, Aubert JP, Magalon G. Advantages of early burn excision and grafting in the treatment of burn injuries of the anterior cervical region. Burns 1995;21:143-6. |
|8.||Iwuagwu FC, Wilson D, Bailie F. The use of skin grafts in postburn contracture release: A 10-year review. Plast Reconstr Surg 1999;103:1198-204. |
|9.||Feldman JJ. Reconstruction of the burned face in children. In: Serafin D, Georgiade NG, editors. Pediatric Plastic Surgery. Vol. 1. St. Louis: Mosby; 1984. |
|10.||Fernández-Palacios J, Baeta Bayón P, Cubas Sánchez O, García Duque O. Multilevel release of an extended postburn contracture. Burns 2002;28:490-3. |
|11.||Achauer BM. Neck reconstruction. In: Achauer BM, editor. Burn Reconstruction. New York: Thieme Medical Publishers; 1991. p. 79-86. |
|12.||Onah II. A classification system for postburn mentosternal contractures. Arch Surg 2005;140:671-5. |
|13.||Furnas DW, Fischer GW. The Z-plasty: Biomechanics and mathematics. Br J Plast Surg 1971;24:144-60. |
|14.||Hirshowitz B, Karev A, Levy Y. A 5-flap procedure for axillary webs leaving the apex intact. Br J Plast Surg 1977;30:48-51. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
[Table 1], [Table 2]