|Year : 2017 | Volume
| Issue : 1 | Page : 6-13
The management of postburn contractures of trunk, groin, and perineum: A review
Rajeev B Ahuja1, Pallab Chatterjee2
1 Sir Gangaram Hospital, Rajinder Nagar; Ex Head of the Department of Burns & Plastic Surgery, Lok Nayak Hospital and associated Maulana Azad Medical College, New Delhi, India
2 Command Hospital Air Force, Bangalore, Karnataka, India
|Date of Web Publication||13-Dec-2017|
Command Hospital Air Force, Bangalore 560 007, Karnataka
Source of Support: None, Conflict of Interest: None
While the trunk is injured in about one-fifth of burn incidents, the groin and perineal contractures are relatively infrequent. Truncal and groin/perineal involvement with disfiguring and functionally restrictive contractures are usually seen in the setting of large surface area burn injuries. In a majority of cases, the treatment of truncal contractures is aimed at mitigating the effects of hypertrophic scarring. In groin/perineal contractures, the contractures are treated to restore movements that enable the important functions of excretion, squatting, and sexual intercourse. Many innovative local and regional flaps have been described to treat such contractures that provide a durable result. Even then, split skin grafting remains a valuable method to treat these contractures, especially for the severe ones. Although tissue expansion can be frequently used to provide color and texture-matched skin resurfacing after the release of truncal contractures, it is deemed unsuitable for groin/perineal contractures owing to high complications rates.
Keywords: Burn reconstruction, groin contracture, local flaps, perineal contracture, postburn contractures, skin grafting, tissue expansion, trunk contracture
|How to cite this article:|
Ahuja RB, Chatterjee P. The management of postburn contractures of trunk, groin, and perineum: A review. Indian J Burns 2017;25:6-13
|How to cite this URL:|
Ahuja RB, Chatterjee P. The management of postburn contractures of trunk, groin, and perineum: A review. Indian J Burns [serial online] 2017 [cited 2019 Mar 26];25:6-13. Available from: http://www.ijburns.com/text.asp?2017/25/1/6/220657
| Introduction|| |
The trunk is injured in about one-fifth of burn incidents and is a frequent site for reconstructive procedures. The reconstruction of postburn contractures of the trunk poses a formidable problem in female patients because of the involvement of the breast, especially if burns are sustained in childhood or around puberty. Majority of the patients who present to the surgeon for such reconstructive needs have undergone a major spell of clinical care that required initial resuscitation and an intermediate stage of rehabilitation. The availability of potential skin donor sites depends on the extent of the burn injury sustained. Because there could be a dearth of potential solutions to postburn trunk deformities, the treating surgeon should have a master plan formulated that includes the sequence and the choice of the procedures for entire reconstructive needs.
On the other hand, both American and European Burn Associations categorize perineal/genital burns as “severe” with a recommendation for transfer to specialized burn care units for management even if the actual surface area involved is very less., The perineum including the groin region constitutes approximately 5% of the total body surface area (TBSA) and is a very important site, both anatomically and functionally, owing to the presence of the genitalia. Serious functional limitations may ensue if burns in these anatomical regions are not managed correctly.
| Scope of the problem|| |
Trunk scarring and contractures, besides the problems of breast development, are often seen associated with the axillary, neck, and groin contractures. Rarely, the contiguous involvement of the lateral surface of the trunk may occur, which may bend the spine, causing scoliosis. If the contracture remains through a period of rapid growth for a child, a structural change in the form of vertebral wedging may result.
Quite often when contiguous anatomical areas such as the groin, gluteal region, perineum, and lower neck are involved, the “extrinsic” and “intrinsic” components of the deformity need to be ascertained before embarking on a reconstructive plan. Tight scarring around the trunk could be painful, which gets accentuated during movement, exercise, or physical therapy. The scars may be itchy, unstable, and lead to cosmetic disfigurement. It is precisely for these scars that considerable experience, judgment, and the expertise of the plastic surgeon are required in patient counseling and formulating a reconstructive plan. Many patients come to the burn clinic wanting their scars removed as soon as possible, and many may have the unrealistic expectation that defects can be easily and rapidly fixed − that scars can simply be “erased.” Great patience is required at this time to educate them about the maturation of burn scars. While it is almost an axiom in the healing of surgically created incisional scars that they mature and attain 70% of their original strength at 1 year, burn scars are different. Burn scars take much longer to mature and settle down, with many authorities recommending a 2-year “moratorium” before they can be subjected to surgical treatment, with exceptions when contractures limit adequate function. Often a persistently red, itchy, painful hypertrophic scar at 1 year improves significantly if more time is given to it to settle down, aided by adjuncts such as pressure garments, silicone gel/sheeting, and intralesional injections. Operating on a red, inflamed scar to improve it esthetically is counterproductive, because the inflammatory and proliferative phases of healing will start afresh. Moreover, this strategy of intervention would arrest the gradual and subtle transition of the burn scar to a mature scar and less conspicuous scar. Therefore, “conservatism” is warranted in the treatment of such scars for improvement.
Groin and perineal contractures
The incidence of perineal burns is uncommon. Alghanem et al. reported the incidence of perineal burns to be about 12/1000 admissions way back in the early 90s. In recent times, Haung mentioned a fairly consistent incidence of 1–1.5% perineal burn injuries admitted in Shriners Burns Hospital at Galveston, Texas. Thakur et al. reported treating six patients with perineal contractures from a total of 237 patients in a tertiary care center in India over a 5-year duration. The perineum often escapes burn injury due to its deep location between the thighs. Generally, it is an extrinsic contracture of the surrounding area, that is, the lower part of the abdomen, the inguinal area, and the adjacent thighs that secondarily distort the perineum. It is reported that in the pediatric age group, 56% of patients suffering perineal burns develop contractures needing some form of surgical release, with either local flaps or skin grafts.
Burn injuries to the genitalia and perineum are usually the result of a child spilling hot liquid on themselves. These burns are usually partial-thickness injuries. Deep perineal burns are usually associated with either large TBSA flame burns or immersion injury. In a review of a decade of experience in a major burn center in United States, Angel et al. found that genital and perineal burns occurred in the context of major burns and were rarely isolated. A total of 64.1% of the burns were caused by hot liquids (scalds), 29.5% were flame burns, 3.8% contact burns, and 2.6% electrical burns.
The mode of injury in developing countries may be different. Sawhney reported six children with perineal burns that had been sustained by the spilling of kerosene on the clothes from a burning stove or due to the explosion of such stoves. Balakrishnan et al. reported perineal burns due to hot water, chemicals, and grease in males secondary to spouse abuse. Thakur et al. described the management of perineal burn injuries that were caused by the burning firewood, while cooking in a “chullah” (an earthen floor-level cookstove). Wani and Raashid have described perineal burns caused by “kaangri,” or, an indigenous earthen pot containing glowing charcoal, which is used in Kashmir during the winter months for warmth, for which it is kept between the legs under a large flowing robe. Abdel-Razek reported accidental chemical (sulfuric acid) burns to the genitalia in 12 patients.
Contractures in the groin and perineum lead to problems in squatting, walking, sitting, urination, defecation, and sexual function. Squatting, a common posture adopted in India and Southeast Asia for urination and defecation, becomes extremely difficult and frequently is the chief presenting complaint. Around 25% of all adult patients with burns experience a loss of libido or orgasmic dysfunction. Direct injury to the genitalia increases the number of patients who have sexual dysfunction to a significant higher level.
| Management of truncal contractures|| |
In majority of the cases, the treatment of truncal contractures is aimed at mitigating the effects of hypertrophic scarring. The scarring over the trunk may not always be severely restricting, but they require attention because of cosmetic disfigurement or associated morbidity.
Management of nonhealing ulcers, scars, and pigment changes
Epithelialisation over the wounds, which healed by secondary intention, may not be stable and may undergo frequent breakdowns due to movement or friction from wearing pressure garments. Nonhealing ulcers or unstable scars are treated most expeditiously by excision and split skin graft (SSG). Depending on the availability of donor skin, it may be decided to resurface surrounding hypopigmented skin, at least the areas that remain exposed even with clothing.
A chronic nonhealing ulcer from any disease, burns, or trauma may lead to Marjolin’s ulcer. Most commonly, this malignant transformation is to a squamous cell carcinoma. It is estimated that approximately 2% of burn scars undergo malignant transformation over time. The average time to develop a Marjolin’s ulcer is very variable but could be as long as 32.5 years. The latency period is inversely proportional to the age of the patient at the time of injury, which implies that the younger the patient is at the time of injury, the longer he will remain tumor-free before the scarred site shows the signs of cancerous change. A high level of suspicion must be maintained for all scars that breakdown and ulcerate. High (>30%) metastatic rates and highly aggressive recurrences are reported in Marjolin’s ulcer, with overall 5-year survival rates of <10%. It is not clear if this is due to late detection or intrinsic aggressive tumor behavior., Treatment continues to remain a complete surgical excision of the tumor on precise oncologic principles.
Both, hypo- and hyperpigmented scars are a cause for dissatisfaction and a reduced quality of life. The loss of melanocytes in deep burns and their regeneration on recovery, whether spontaneous or postsplit skin grafting, is unpredictable. Superficial dermabrasion performed to the level of the dermal papilla can be used for dyspigmentation in the patient with burns. The coverage is performed with a source of healthy epithelial cells including suction blisters, thin autografts, and cultured epithelium.,, A recent advance has been to use carbon dioxide laser as a dermabrading tool, because it is claimed to be more accurate, less bloody, and quicker than mechanical dermabrasion. The Q-switched neodymium:yttrium aluminum garnet (Nd:YAG) laser may be helpful in patients with hyperpigmentation, although there are no quality studies to confirm this.
The extensive hypertrophic scarring with running bands over the trunk may be cosmetically unappealing and may also restrict function. The prevention of hypertrophic scarring can be rewarding if customized pressure garments are worn, which ensure a requisite pressure of 20–25 mmHg. The garments may be used with silicone sheeting/gel if the area of involvement is localized., These are time-tested methods with a long history of clinical benefit. The judicious use of the intralesional injections of triamcinolone, verapamil, or 5FU helps in softening the scars and controlling further fibroblast proliferation in hypertrophic or keloidal tendency. Lasers especially pulse-dyed lasers and fractionated CO2 laser have been quite helpful in lowering erythema in scars or in modulating atrophic scars, respectively.
Surgical options for scar management
Burn scars may be excised and resurfaced with a suitable technique if nonsurgical modalities such as pressure garments, lasers, or intralesional injections are inadequate, inappropriate, or not available. Surgical options in this region include tissue expansion besides Z-plasty (or other local flap arrangements) and SSG.
Z-plasties are useful when contractures have a predominantly linear component, and there is a relative excess of vascular, elastic tissue, even if not normal skin, lateral to the contracture. Z-plasty also minimizes the need for most postoperative therapy, including pressure garments.
When contracted scars are large and diffuse, the best options are SSG or tissue expansion. An overambitious approach to resurfacing should be restrained. The paucity of local skin precludes tissue expansion, and in extensive burns, there may be a paucity of skin graft donor sites. SSG is easy, expeditious, and often effective in relieving the tension across the scars, while also treating pigmented patches.
The use of tissue expanders can be a very valuable adjunct in many cases. They are easily placed under the skin, be it the chest, abdomen, or back. Quite often, it is necessary to place two or more expanders to generate sufficient local skin for resurfacing over the trunk.
Tissue expansion provides a source of local skin that may be used as advancement or rotation/transposition flaps, and it permits a direct closure of the donor site. After deciding on the desired flap movement, a suitably sized and shaped expander is chosen by measuring the dimensions of the recipient area. Although literature is replete with several mathematical models in deciding the most appropriate size and shape of the expander, the selection can be easily made clinically by recipient site requirements and the donor flap available for expansion. As a rule of thumb, the available donor skin before expansion should never be less than the recipient area. The minimum expander base should be a little more than the recipient area, although the largest expander possible should be selected. Expander volume is not much of a clinical guide, because overexpansion is always possible.
The expander is placed under the deep fascia through a short incision parallel to the defect and about a centimeter into healthy skin. The port of the expander is located at a short distance. Magnasite expanders are convenient because they have an inbuilt port but are more expensive. Keeping the port external is also an option if proper hygienic conditions can be maintained during the period of expansion. Approximately 10 days after insertion, the expansion can be initiated. Full expansion is achieved over 3–4 months at weekly/biweekly intervals. The width of the expanded skin over the dome should at least equal two times the recipient area plus 30% (to allow skin retraction). Hallock described the utility and safety of the overexpansion of the expanders very early in its evolving concepts, and nowadays, overexpansion beyond the manufacturer’s volume recommendations are routine. After complete expansion, the expander is removed through an incision that traces the proposed flap. The optimal mobilization of the flaps is accomplished by releasing the periphery of the capsule under the expanded tissue. Capsular scoring incisions perpendicular to the direction of movement help in flap mobilization.
Tissue expansion is painful and socially incapacitating for the patient during the expansion phase. In addition, it has a substantial complication rate, such as infection, exposure, or extrusion, ranging from 13 to 20%, which may require the premature removal of the expander and abandonment of the procedure.
It may also be possible to expand the skin of the trunk to resurface adjacent areas in the neck or groin following scar excision or the release of contracture. Unexpanded fasciocutaneous flaps from the trunk are available to cover deeper defects, either resulting from acute burns [Figure 1] or after the release of severe contracting tissue on the chest (or the breast).
|Figure 1: The use of fasciocutaneous flaps in burn scars. (a) A young adult sustained electrical injury, which exposed his polytetrafluoroethylene bypass graft from the left subclavian to the axillary artery. A 1:3 ratio fasciocutaneous flap was marked on the lateral trunk to cover the defect. (b) Sixth day postoperative result showing the vascular graft is well covered and the donor defect has been closed primarily. A slight violet discoloration of an edge of the flap is seen due to design constraint from another electrical burn in the region of the proposed flap. There was no flap loss and the wounds healed well|
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Other novel surgical techniques have been added to the armamentarium in recent years. Zheng et al. described the repeated harvest of the scarred skin from the back in the face of a limited availability of donor sites in patients suffering extensive burns.
In a patient with burns with relatively high Body Mass Index (BMI) and accumulated subcutaneous fat in the burned areas of the trunk or extremities, a technique of liposuction scar reconstruction has been described. The liposuction of the adipose tissue is done beneath the scarred area by usual tumescent technique, followed by the excision of the scar and direct skin closure aided by “liposculpted sliding flaps.” Such sliding flaps are invested of their neurovascular supply that provides robust, innervated closure without tension after the direct ablation of the scars.
Lateral truncal contractures
Grieshkevich has focused on the importance of recognizing the morbidity of lateral truncal contractures. The lateral truncal contractures cause the restriction of body movements and have the potential of causing scoliosis in growing children. While they can be treated with repeated release and grafting; local tissue arrangements such as Z-plasty, V-Y/Y-V plasty, and subcutaneous pedicle flaps are also helpful. Greishkevich described trapeze flap-plasty, which elongates the contracted zone by 100–150% and provides durable results.
Splinting for truncal contractures
Truncal contractures have the potential to cause various degrees of kyphosis/scoliosis or both, especially in growing children. The restrictive effect of lateral truncal contractures during the period of rapid growth of children is known to cause vertebral wedging. The splinting of the trunk early enough after the injury may mitigate against such complications. Splinting is also crucial after the surgical release of the contractures to allow unimpeded healing. Thermoplastic splints are light in weight and can be easily customized to the patient. They are more acceptable to children compared to the heavy splints fashioned out of plaster of Paris.
| Management of the groin and perineal contractures|| |
Classification and clinical presentation
Grishkevich proposes two basic perineal contracture types:
- Scar fold of the perineum (of variable severity): This type is seen more frequently. The inelastic scar band, better observed with the thighs in abduction, causes tightness and the restriction of movement. The scar fold may be seen anteriorly in the suprapubic area or between the ischial tuberosities.
- Perineum obliteration: This is a result of much deeper and widespread burns, in which the inner thigh surfaces fuse together resulting in perineal area obliteration. Contiguous areas are also injured including the pubis, inguinal, anal zone, and genitalia.
Thakur et al. also proposed a classification based on the “extrinsic” or “intrinsic” nature of the contracture and labeled these as “primary” or “secondary” contractures, respectively.
Among the various procedures available, the modality chosen is aimed at providing the best functional outcome.
Substantial raw area may develop after an adequate release of the groin contractures. A large deficiency of tissue is effectively resurfaced by providing skin grafts, even though many local flaps can occasionally be designed. Sawhney recommended a wide undermining of the abdominal skin flap to facilitate its advancement downwards to cover the raw area in front of the pubis, and the raw area on either side was covered with sheets of thick SSGs. The grafts are often meshed to allow better conformability and are secured by bolster dressings. If adequate donor sites are available, thick split SSGs are preferable. Sheet or meshed skin grafts provide reasonable esthetic results [Figure 2]. If donor sites are limited, it is possible to reharvest from previous sites, especially the scalp or back, or to harvest from the scrotum following tumescence. If the lower abdominal skin is available, tissue expansion could be another alternative for resurfacing. The principles of expansion remain the same as explained above in the management of truncal contractures. However, specifically for the groin, Gottileb et al. warned about an inordinate amount of complications from infection and erosion. In addition, it is difficult for a patient to tolerate the “bulge” of an expander in the groin, which interferes with normal daily activities. There are anecdotal reports regarding the use of flaps in severe or the recurrent cases of inguinal contractures. Nangole et al. described the use of pedicled anterolateral thigh (ALT) flap to treat a case of severe, recurrent groin contracture in a young girl with three failed attempts. Uygur et al. presented a series of five inguinal contractures resurfaced by pedicled ALT flap with good long-term results. Interestingly, Ergun presented the case of a female patient who underwent modified abdominoplasty for releasing lower abdominal and groin burn scar contractures, providing the dual benefit of improved body contour and burn scar release!
|Figure 2: Bilateral groin contractures managed with skin grafts. (a) A 15-year-old female child with extensive bilateral groin contracture and postburn scarring of the lower abdomen and both thighs. (b) The bilateral release of the groin contracture resulted in large raw areas. (c) The groin and upper thigh raw areas were resurfaced with sheets of SSG placed parallel to the natural crease lines. Long silk threads are in place to apply a “bolster dressing” for adequate pressure. (d) Postoperative result at 4 weeks showing a well-settled graft. Further management requires wearing tight customized undergarments with sponge sheets. Silicone gel/sheets may be used as appropriate, under the garment|
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Because perineal contractures are infrequent, and they present in a wide spectrum of severity, some controversy still exists on the most appropriate modality of resurfacing, following release.
Many of the milder forms of contractures with scar bands running across the perineum can be adequately released and resurfaced by utilizing local tissue arrangement, such as Z-plasty, double-opposing/multiple Z-plasties, or V-Y advancement.,,,,, Grishkevich described the use of his trapeze flap-plasty for the treatment of such contractures.
Extensive perineal contractures can only be resurfaced by SSG. Many investigators have reported the successful use of skin grafts to resurface large raw areas after the release of perineal contractures [Figure 3].,, With >89% of their patients achieving full functional recovery, Wani and Raashid concluded that SSG was safe, less time consuming, and technically easy. Wani and Raashid, as well as Pisarski et al., recommended SSG for the perineal contractures of any severity., Skin grafts are prone to contract leading to some recurrence of contractures, with 20% recurrence rate in one study. After successful graft “take,” tight-fitting undergarments with sponge padding is worn for a minimum of 6–12 months. These custom-designed pressure garments incorporate a wide elastic band, which is sited over the inguinal furrow between the thighs and perineum, to maintain abduction.
|Figure 3: Perineal contracture managed with skin grafting. (a) A 6-year-old boy with a tight and broad contracting band in the perineum. (b) Contracture was released, and bilateral raw areas were split skin grafted. Long silk threads are in place for “bolster dressing.” (c) Showing postoperative result several months after surgery. A small contracting band is seen in the perineum. The compliance of abduction splints in this region is low and this results in a higher incidence of recurrence. This contracting band can now be released by a Z-plasty|
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Sun et al. reported the use of groin flap in the postburn contracture of the perineum and Grishkevich further refined its use in a series of four cases. The pedicled groin flap, based on the superficial circumflex iliac artery, can yield a large amount of skin (up to 20 cm × 10 cm), and the flap can be used bilaterally. However, Gottileb and Grevious believed that the geometric flaps of adjacent inelastic, scarred skin are rarely adequate, and additional skin grafting is necessary following the release of the scar.
The use of tissue expanders has not found acceptance in the treatment of perineal contractures owing to high complication rates.
| Conclusions|| |
The truncal and groin/perineal involvement with disfiguring and functionally restrictive contractures are usually seen in the setting of large surface area burn injuries. The treatment of truncal contractures is largely aimed at mitigating the effects of hypertrophic scarring. In the groin/perineal contractures, the contractures are treated to restore movements that enable the important functions of excretion, squatting, and sexual intercourse. Along with split skin grafting, many innovative local and regional flaps have been described to treat such contractures that provide a durable result. Although tissue expansion can be frequently used to provide color and texture-matched skin resurfacing after the release of truncal contractures, it is deemed unsuitable for groin/perineal contractures owing to high complication rates.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]