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ORIGINAL ARTICLE
Year : 2013  |  Volume : 21  |  Issue : 1  |  Page : 58-63

Functional and esthetic considerations in reconstruction of post-burn contracture of the neck


Department of Plastic Surgery, Guwahati Medical College, Guwahati, Assam, India

Date of Web Publication22-Nov-2013

Correspondence Address:
Seema Rekha Devi
Professor and H.O.D, Department of Plastic Surgery, Gauhati Medical College, Guwahati, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.121885

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  Abstract 

Background: Post-burn contracture (PBC) of the neck is a challenging problem for reconstructive surgeons in view of not only functional and esthetic considerations but prolong physiotherapy and splintage as well. The aim of this study is restoration of form and function with special attention to functional and esthetic considerations in reconstructing such defects. Materials and Methods: Total 40 numbers of patients with PBC of anterior neck were studied from 2009 to 2011 in the Department of Plastic Surgery. All the patients were assessed for degree of the extension (cervicomental) angles, the nature of scar tissue, and the available normal skin surrounding the contracting band. The PBC of neck was divided into three categories according to the degree of extension to type-1(mild) when extension angles were >90°, type-2 (moderate) when extension angles were ≤90°, and type-3(severe) with mentosternal synechiae. Contractures with narrow band were treated with Z-plasty in type -1 and Z-plasty along with skin grafting in type-2. Contractures with broad band were treated with flap surgeries with or without skin grafting in type-1 and 2. Contractures in type-3 were treated with only skin grafting. The flaps were local advancement flaps, expanded flaps, and supraclavicular flaps. Results: All type-1a patients were treated with only Z-plasty. One patient in type-1b was treated with expanded flap; the other patient was treated with unilateral supraclavicular flap along with full thickness skin grafting. Seven patients in type-2a contracture were treated with Z-plasty. Here one patient was treated with only Z-plasty, and six patients were treated with Z-plasty along with full thickness skin grafts. Seven patients in type-2b contracture were treated with flap surgery. In type-3, all contractures were released with excision of the scars; and the defects were resurfaced with split thickness skin grafts. The esthetic quality of the neck was judged by the patient, operating team, and patient's relative. The result of postoperative scar neck was also found esthetically fair to good. The cervicomental angle of 100-125° was attained in our cases.

Keywords: Neck extension angles (cervicomental angles), post-burn contracture (PBC), skin grafting, supraclavicular flaps, Z-plasty


How to cite this article:
Devi SR, Kalita H, Baishya J, Boruah P. Functional and esthetic considerations in reconstruction of post-burn contracture of the neck. Indian J Burns 2013;21:58-63

How to cite this URL:
Devi SR, Kalita H, Baishya J, Boruah P. Functional and esthetic considerations in reconstruction of post-burn contracture of the neck. Indian J Burns [serial online] 2013 [cited 2021 Oct 24];21:58-63. Available from: https://www.ijburns.com/text.asp?2013/21/1/58/121885


  Introduction Top


Post-burn contracture (PBC) of the neck is a serious and common complication of neck burns. There is an increase in incidence due to decline in mortality of extensive burns. The PBC neck causes limitation of neck functions, abnormal posture, restrict eating, and swallowing. It may be associated with ectropion of the lower lip, and in severe case the mentosternal angle is obliterated with pulling down the chin to the chest, which are devastating functional and cosmetic deformities for the patients, and cause significant depression, therefore affecting the patient's quality of life. The treatment of this deformity is a challenging problem for reconstructive surgeons. The aim of this study is restoration of form and function with special attention to esthetic considerations in reconstructing such defects.


  Materials and Methods Top


A total of 40 patients of PBC of anterior neck were studied from 2009 to 2011 retrospectively attending the Department of Plastic Surgery. Age of the patients ranged from 5 to 50 years (average age 25.9 years). There were 12 males (30%) and 28 females (70%) [Table 1].
Table 1: Patient distribution in different types on post-burn anterior neck contracture

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All the patients were assessed for degree of the extension (cervicomental) angles, the nature of scar tissue and the available normal skin surrounding the contracting band.

We have used the following classification for anterior neck contracture in this study. [1]

Type 1: Mild anterior contracture. The patient was able to flex the neck and bring the neck and jaws to the anatomical position while erect. In addition, limited extension away from the anatomical position (>90°) was possible with inability to view an object located on the ceiling (180° to the erect patient) in the center of the visual field. In our series there were seven such patients.

Type 2: Moderate anterior contracture. Patients with this type of contracture were able to flex the neck and bring the neck and jaws to the anatomical position while erect. Attempts at extension away from the anatomical position resulted in a significant pull at the (uninvolved) lower lip. The extension (cervicomental) angles in this type were <90°. We had twenty-three patients in type-2 contractures.

Type 3: Severe anterior mentosternal contracture. The patient's neck was contracted in the flexed position, and the chin (and less frequently the lower lip) was occasionally restrained down to the anterior trunk. The patient was unable to reach anatomical position of the neck and jaws. In the attempt, the superior limbus of the unaffected eye was covered and the inferior limbus of the unaffected eye was clearly seen. The attempt also usually pulled on the (uninvolved) lower lip.

We have also sub-classified each type into:

  1. narrow band,
  2. broad band, and
  3. broad band with insufficient adjacent supple neck skin.


In our study we measured the cervicomental angle in the patient's photographs. The patients were asked to be in erect or sitting position looking straight & then they were asked to extend the neck. Extension was stopped when there was appearance of pull of lower lip downwards. Patients were photographed in this particular position. In the photograph, a line (A) was dropped in the central axis of the patient`s body. The second line (B) was drawn along the center of visual axis. Then third line (C) was drawn parallel to the line (B) passing across the mentum. The extension (cervicomental) angle was measured accordingly.

We classified PBC of anterior neck into type-1 [Figure 1] when extension angles were >90°, type-2 when extension angles were ≤90° [Figure 2], and type-3 with mentosternal synechiae.
Figure 1: Extension in type 1 contracture

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Figure 2: Extension (cervicomental) angle in type II contracture

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Before correcting the contracture, due consideration was given to the attire the patient usually wears. The exposed part of the neck in male and female was noted and discussed with the patient. Two supraclavicular flaps from either side was used simultaneously when required.

All patients were operated under general anesthesia. In case of difficult intubation neck contractures were partially released under local anesthesia to facilitate intubation. Contractures with narrow band were treated with Z-plasty in type-1 and Z-plasty along with skin grafting in type-2. Contractures with broad band were treated with flap surgeries with or without skin grafting in type-1 and -2. Contractures with broad band in type-3 were treated with only skin grafting [Table 2] and [Table 3]. The flaps were local advancement, expanded, and supraclavicular flaps. The supraclavicular flaps were unilateral or bilateral based on perforators of supraclavicular arteries. Expanded flap were prepared with expansion of expanders in the neck under the healthy skin and flap is advanced to cover the excised scar area. Necks with severe contractures were released with excision of unhealthy, hypo- or hyperpigmented/or hypertrophied scar, and covered with split skin graft (SSG).
Table 2: Surgical procedures

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Table 3: Surgical procedures done in different patients in different types and subtypes

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In the postoperative period, neck splints were applied and continued till grafts were stable, soft, and pliable. Plaster of Paris (POP) splints were replaced with custom-made splints after 2-3 weeks and continued for a period of 4-6 months. Patients were discharged on 8-18 days (average 14 days) with advice to use splints and chin straps, and daily care of the grafted skin with massage and application of moisturizing cream [Figure 3]. The patients were followed-up on 1, 3, 6, and 12 months and 2 years. We provided long-term compression garments and aggressive rehabilitation after surgery in all type 3 contractures. The postoperative extension angles (cervicomental) achieved were measured and recorded in follow-up visits. The esthetic quality of the neck is judged by the patient, operating team, and patient's relative.
Figure 3: Post-operative care with neck splint and chin strap

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  Results Top


In this study out of 40 patients, there were seven patients in type-1 contracture with five patients in type-1a and two patients in type-1b. All type-1a patients were treated with only Z-plasty. One patient in type-1b was treated with expanded flap; the other patient was treated with unilateral supraclavicular flap along with full thickness skin grafting. The preoperative extension angles ranged from 92-100° (average 98°). On follow-up visit at 6 months, the postoperative neck extension angle ranged from 114 to 116° (average 115.29°). The average improvement in extension angle was 17.29°, which was found within the normal range of neck extension angle.

In type-2 there were 23 patients where four patients were males and 19 females. Seven patients in type-2a contracture were treated with Z-plasty. One patient was treated with only Z-plasty, and six patients were treated with Z-plasty along with full thickness skin grafts.

Seven patients in type-2b contracture were treated with flap surgery. The different procedures used are shown in [Table 4]. Supraclavicular flap were used in three patients. There were one patient with unilateral and two with bilateral flap cover. Local advancement flaps were used in four patients. Split thickness skin grafts were used in two patients of supraclavicular flap and in three patients of local advancement flap.
Table 4: Improvement of extension angles in different
types of post-burn contracture of neck


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Nine patients in type-2c were treated with split thickness skin grafts.

The preoperative extension angles in type-2 were ranged from 86 to 90° (average 87.74°). Follow-up at 6 months, the postoperative extension angles were ranged from 105 to 116° (average 110.30°). The improvement of extension angle was average 22.56°.

In type-3, there were 10 patients with five male and five female. There were no patient in type-3a, only one patient in type-3b, and nine patients in type-3c contracture. All contractures were released with excision of the scars; and the defects were resurfaced with split thickness skin grafts. The average preoperative and postoperative extension angles were 69.30 and 104.4°, respectively. The improvement of extension angle was 35.1°. The esthetic results of the grafted areas were acceptable. But there were recurrence of contractures of three patients at 2 years of surgery. These three patients have been under follow-up with continuous splinting

Details of extension angles and their improvement with respect to the type of contracture [Table 4] and with respect to the surgical procedure done [Table 5] have been tabulated.

The esthetic quality of the neck was judged by the patient, operating team, and patient's relative. The result of postoperative scar neck was also found esthetically fair to good.

The cervicomental angle of 100-125° was attained in our cases.
Table 5: Preoperative and postoperative extension (mentosternal) angles

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Case photographs : [Figure 4], [Figure 5], [Figure 6], [Figure 7] [Figure 8]
Figure 4: (a) Preop photograph. (b) Expander placed. (c) Expanded flap advanced

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Figure 5: (a,b) Preop photograph. (c,d) postop photograph

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Figure 6: (a,b) Preop photograph. (c,d) Postop photograph

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Figure 7: (a,b) Preop photograph. (c,d) Postop photograph

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Figure 8: (a) Preop photograph. (b) Postop photograph

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  Discussion and Summary Top


In reconstruction of PBC of neck, both functional and esthetic look of the neck is considered for final outcome. Each esthetic unit is considered separately during reconstruction. Undue tension should be avoided in all possible circumstances.

There are very few classification system for PBC neck. [2],[3],[4] Tsai et al., [4] used a classification based on reconstructive zones of anterior neck. The classification given by Onah [1] is more convenient for measurement of the PBC neck. We measured the cervicomental angle using Onah's system with little modification.

Cervicomental angle is of utmost importance for the contour of the neck. Excision of scar tissue should include underlying platysma muscle. Z-plasty offers good results in contracture bands, but it alone may not be enough in broad bands or diffusely scarred neck.

The color, appearance, and quality of the skin after using full thickness skin graft were better than in cases after split-thickness skin graft. Full-thickness grafts are not useful for very large defect. Local flaps offer the best color and texture match, but may not be available in all cases. We found good color and contour of neck with single or double (from both sides) supraclavicular flaps surgery.

Expanded flap from the neck or chest to cover the anterior neck can provide good results in burn contracture. Free flaps give superior functional results in the reconstruction of scar contractures, especially thin cutaneous perforator flaps. [5] The microsurgical burn reconstruction [6] is a one-staged procedure giving good quality and quantity of tissue for esthetic neck. We have not used any free flaps in our series.

SSGs are very good for contouring, but one major disadvantage is the requirement for prolonged splintage. For horizontal/submental plane, single sheet Split Skin Graft (medium thickness) is our choice and for vertical/cervical plane SSG or flap (subject to the condition of surrounding tissues). Quilting of grafts was done to attain the landmarks, elevations, and depressions. Sometimes, deep sutures and thinning of flaps was done for attaining the landmarks. Few patients came back to us with recurrences due to noncompliance to physiotherapy and splintage. In our study, five patients with recurrent linear bands were reoperated with Z-plasty and/or SSG. Three patients with mild early recurrence were managed with physiotherapy and continued splinting programs.

Onah [1] quoted that the surgery should be regarded as successful or satisfactory if patients with anterior contractures after surgery were able to reach type 1. We got acceptable functional angles in type 3 also treated with skin grafting. The use of skin graft still has a role in treatment of post-burn neck contracture. It is simple, reliable, and safe procedure. We provided long-term compression garments and aggressive rehabilitation after surgery in all type 3 contracture to get good esthetic neck. Also patients are advised for specific dresses to avoid exposure of scars. The patients are also advised regarding their posture during sleep (e.g., avoid pillows) to reduce the chances of recontracture on follow-up. The patients were guided and instructed about regular physiotherapy. The cervicomental angle ranging from 100 to 125° was attained in our cases. The esthetic quality of the neck is judged by the patient, operating team, and patient's relative. The result of postoperative scar neck was also found esthetically fair to good.

 
  References Top

1.Onah II. A classification system for postburn mentosternal contractures. Arch Surg 2005;140:671-5.  Back to cited text no. 1
[PUBMED]    
2.Achauer BM. Neck reconstruction. In: Achauer BM, editor. Burn Reconstruction. New York: Thieme Medical Publishers; 1991. p. 79-89  Back to cited text no. 2
    
3.Aranmolate S, Attah AA. Bilobed flap in the release of post burn mentosternal contracture. Plast Reconstr Surg 1989;83:356-61.  Back to cited text no. 3
[PUBMED]    
4.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.  Back to cited text no. 4
[PUBMED]    
5.Yang JY, Tsai FC, Chana JS. Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn anterior cervical contractures. Plast Reconstr Surg 2002;110:39-46.  Back to cited text no. 5
    
6.Masser MR. The preexpanded radial free flap. Plast Reconstr Surg 1990;86:295-301.  Back to cited text no. 6
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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