|Year : 2020 | Volume
| Issue : 1 | Page : 36-43
The postburn severe flexion contracture neck correction with split-thickness skin graft: Our experience
Ankur Bhatnagar, Anupama Singh
Department of Plastic Surgery and Burns, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
|Date of Submission||18-May-2020|
|Date of Decision||31-May-2020|
|Date of Acceptance||04-Jun-2020|
|Date of Web Publication||21-May-2021|
Dr. Anupama Singh
Department of Plastic Surgery and Burns, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: One of the most common burn sequels is postburn contracture (PBC) neck. These contractures affect the patient significantly causing both functional limitations and distorted aesthetic appearance. Therefore, the reconstruction of the head-and-neck area is a challenge for surgeons to restore not only the function but also to improve the esthetic appearance.
Materials and Methods: We conducted a tertiary hospital-based prospective study in 12 patients with cases of severe PBC that underwent split-thickness skin graft (SSG) cover as a treatment modality and evaluated the results after the operative procedure in terms of function and appearance of the neck and its complications. Result of the function evaluated with respect to the range of extension movement of the neck –good 120°or more, fair 90°–120°, and bad <90°. Esthetic appearance evaluations were done on the patient's opinion with consideration of color match; maintenance of contour of the neck is good, fair, and not acceptable.
Observation and Results: In our study, nine of cases were of thermal burn. All cases were presented with flexion contracture neck, while in seven cases were presented with 0° extensions of the neck. The neck contracture was released in two cases by excision of the scar and in rest of cases by incision methods. The defect was resurfaced with an unmeshed sheet of SSG in six cases, while in six of cases, the defect was resurfaced with a combination of an unmeshed and meshed sheet of SSG. Good functional recovery in terms of extension of the neck >120° in nine cases and fair esthetic appearance in eight cases and good in four cases.
Conclusions: The excision of all scar tissue is possible only in few cases, but the incision releases were required in the majority of severe neck contractures. The STS grafting is a simple, reliable, and safe operation. Sheets of unmeshed SSG in the neck and lower face resulted in better postoperative neck function, the cosmetic appearance in terms of color match, and cervicomental angle.
Keywords: Aesthetic, cervicomental angle, difficult intubation, postburn contracture, split-thickness skin graft
|How to cite this article:|
Bhatnagar A, Singh A. The postburn severe flexion contracture neck correction with split-thickness skin graft: Our experience. Indian J Burns 2020;28:36-43
|How to cite this URL:|
Bhatnagar A, Singh A. The postburn severe flexion contracture neck correction with split-thickness skin graft: Our experience. Indian J Burns [serial online] 2020 [cited 2021 Jun 19];28:36-43. Available from: https://www.ijburns.com/text.asp?2020/28/1/36/316585
| Introduction|| |
The neck contracture and deformities as consequences of burns are one of the greatest challenges to plastic surgeons in reconstructive surgery. The head-and-neck area is commonly exposed to various injuries, such as flame, scalds, electrical flashes, and splashes. Contractures of mentosternal or even cervicothoracic areas cause serious problems, both functional and esthetic. Anterior neck contractures are characterized by the limitations in the range of neck movement, most obviously extension. The scar may extend to involve the face and the chest; thus, burn scar contracture may pull by traction forces and cause insufficient neck extension, incomplete oral occlusion, cicatricial lower lip eversion, cicatricial lower lid ectropion, distorted airway anatomy, and distortion of the cervical spine. Distorted airway anatomy and the cervical spine results in difficult intubation in a patient with neck contracture that can be the life-threatening situation of “cannot ventilate cannot intubate” and can result in multiple serious complications and sequels. Physical limitation and esthetic disfigurement resulting from scar and contracture in exposed areas, such as the face and neck, can cause significant depression, which affect quality of life of the patient. Esthetic reasons alone would place neck contractures as a priority for reconstruction. In the review of literature, the severity of postburn contracture (PBC) neck contracture and functional impairment includes three degrees – mild (scar appears only during neck extension with the loss of the cervicomental angle and the neck extension from 95° to 110°), moderate (scar appears in the resting position, which hinders any more neck extension and the neck extension from 85° to 95°), and severe (neck is already in the flexed position and the scar is limiting any neck movement and the neck extension is <85). Even in this modern era of well-equipped hospitals and skilled reconstructive surgeon, severe PBCs are dreadful conditions to reconstruct. In our study, the aim of management of severe postburn neck contractures is to restore the function and esthetic appearance to its normal form. As the neck contractures cause major functional and esthetic problems, which affect patient economically and psychosocially. Therefore, operative correction is generally recommended, mainly in children in whom these scars and contractures also can cause a growth imbalance in the head-and-neck area. The primary objectives of surgical intervention are releasing the scar and restoring neck movements, appearance up to near-normal profile and prevent recurrence of contracture.
| Materials and Methods|| |
This hospital-based prospective study was conducted on patients admitted in our institution with proven cases of postburn neck contracture from January 2015 to March 2020. Twelve patients of severe postburn neck contracture who underwent operative treatment were included. We included cases of postburn neck contracture of severe degree with neck extension of 0°–40°, of all ages and both male and female [Figure 1]. Previously operated contracture neck cases and patient with infected raw area were excluded from the study. A brief relevant history (including details of the burn injury), along with clinical examination, data of patient were taken. Local examination included evaluation of scar, severity of contracture, range of neck movement, skin texture and contour of the neck. Evaluation of neck extension (cervicomental angle) was performed by having the patient sit straight and asked to extend the chin (mentum) as far as possible. In this prospective study all patients underwent contracture release and split thickness skin grafting (SSG). Postoperative results were evaluated for function and appearance of the neck. Complications like the recurrence of contracture and loss skin graft were also noted. Result were evaluated with respect to range of neck extension – good if the angle is 120° or more, fair if the angle is in between 90° and 120°, and poor if the angle is less than 90°. The esthetic appearance evaluations were done according to the patient's opinion as good, fair, and not acceptable with consideration of color match and maintenance of contour of the neck.
Surgical planning and operative procedure
After endotracheal intubation oral or nasal, the patient was placed in supine position and neck in extension by keeping sandbag below the shoulders. The lines of contracture and proposed incisions were marked on the patient preoperatively with fishtailing at the ends of incision line to prevent recontracture in future. Incision or excision release of the contracture neck was done till full extension neck was obtained and the defect was created by dissection through the scar to underlying normal tissue. SSG sheets were taken; defect was immediately covered with unmeshed SSG sheets or with the combination of unmeshed and meshed SSG sheets. These SSG sheets were held in position with sutures and tie over, while the neck was immobilized with a bulky dressing in the extended position.
In postoperative period, patients were nursed in the supine position and the neck was maintained in extension with pillow under the shoulder. A small rolled sheet was placed transversely beneath the neck. The first dressing was changed 5–7 days after surgery. At the next dressing, if the graft was well settled, locally lubricating antibiotic ointments were advised along with the soft cervical collar. After 15 days of surgery, the chin neck pressure garment was applied. The cervical collar and pressure garments were given for 6–8 months or till as per the requirement of patients. In case of graft loss, the area was resurfaced with autograft after few dressings or dressed regularly till the wound heals. As soon as the grafts were adherent, i.e., after 2–3 weeks, the patient was allowed to start an active and passive dynamic and static self-exercise. The extension of the neck was the primary exercise and later on, patients were allowed for alternate flexion, lateral rotation, and flexion on both sides and circumduction movements as per requirements.
Discharge and follow-up
At the time of discharge, instructions to the patients regarding the care of the local area, the position of the neck, splintage (cervical collar), pressure garment, [Figure 2] and physical therapy were given. The patient was advised to attend the outpatient department regularly. During this period of follow-up, the results were evaluated with respect to the range of extension, overall cosmetic appearance in terms of color match, maintenance of contour, and donor-site morbidity.
|Figure 2: Follow-ups. (a) Pressure garment. (b) Pressure garment with a cervical soft collar|
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| Observations and Results|| |
Of 12 cases, 7 were male, 5 female, and the 5 cases were at or below 10 years of age. About 75% (9) of cases were of thermal burn, while 8% (1) and 16% (2) were of acid burns and electric flash burn, respectively. Three patients presented with history of epilepsy. Eleven patients belonged to rural area, lower socioeconomic and educational status. Lack of facilities for managing acute burn cases cumulatively resulted in severe postburn neck contracture. The average time interval between burns injury and contracture release is 3 years and 7 months [Table 1]. All cases were presented with flexion contracture neck which is dense type, while 58.33% (7) of cases were presented with 0° extensions of the neck. The lower lip was totally engulfed to the neck in 75% (9) of the cases [Figure 3]. Prognathia and increased interdental space of front teeth of the lower jaw was observed in 75% (9) of the cases [Figure 4]. All cases were operated under general anesthesia. The difficult intubation was managed with the help of fiber-optic endoscope in 58.33% (7) of the cases, video endoscope in 41.66% (5) cases, while one case required incision and release under local anesthesia before video endoscope-assisted intubation [Table 2]. The neck contracture was released in 16% of the cases by excision of the scar and in rest of cases by incision methods. The defect was resurfaced with an unmeshed sheet of SSG in 50% (6) cases, while 50% (6) of the cases were resurfaced with a combination of an unmeshed and meshed sheet of SSG [Figure 5]. Small area of graft loss was in three cases, of which one case required regrafting while rest healed by regular dressing, one patient had reccurance of contracture [Figure 6]. The average time of follow-up in our study was 13 months. In 83% of cases, postoperative hospital stay was of 15 days or less. The good functional recovery in terms of extension of the neck (angle >120°) was in 75% (9) of cases, while fair esthetic appearance in 66.44% (8) of the cases and good in 33.33% (4) of cases [Table 3] and [Figure 7].
|Figure 3: Severe neck contracture with lower lip engulfed in neck. (a, c and d) Front view. (b) Left profile view. (e) right profile view|
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|Figure 4: Cases with prognathia with interdental gaping of front teeth lower jaw. (a) Left lateral view. (b) X-ray head and neck lateral view shows prognathia, interdental gaping of front teeth lower jaw. (c) Front view, right lateral view. (d) Left lateral view|
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|Figure 5: Defect after release of contracture neck in full extension and resurface of defect with split-thickness skin graft. (a) Defect from the front view, defect from a right lateral view, defect from a left lateral view, resurface with split-thickness skin graft (meshed + unmeshed) front view, resurface with split-thickness skin graft right lateral view resurface with split-thickness skin graft left lateral view, bulky dressing of neck. (b) Defect from a right lateral view, resurface with split-thickness skin graft (unmeshed) front view, resurface with split-thickness skin graft right lateral view|
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|Figure 6: Complications (a) Partial loss of skin graft, (b) Recontracture with edge hypertrophy|
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|Figure 7: Function and aesthetic appearance. (a and b) Skin graft take at 7th postoperative day. (c) Patient after 2 months of follow-up with a good extension of the neck and well-defined contour of the neck, left and right profile view, front view. (d) Patient after 6 months of follow-up with well-defined contour of the neck and a good extension of the neck, front view, right profile view. (e) Patient after 11 months of follow-up with well-defined contour of the neck, good color match of skin and a good extension of the neck, front view, left profile view, right profile view|
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| Discussion|| |
The burn patients are usually treated by a variety of medical professional who aims at the healing of the raw wounds and this leads to invariable development of wound contraction and scarring. PBCs are unpleasantly very common and severe in developing and also considered as a significant problem in developed countries too. Serghiou et al. stated that the main causes of burn contractures are mostly inappropriate initial burn management and inadequate physical therapy. 91% of our patients were of the lower socioeconomic group and were residents of villages.
The contractures were caused by thermal burns in 75% of our patients. Bhattacharya et al. found contracture in 24 patients followed thermal burns and four contractures resulted from scalds. Ahuja and Bhattacharya observed that in developing countries like India, thermal burns are most frequent in contrast to chemical and electrical burn injuries, the majority of them are accidental and occur in the kitchen with floor level cooking on kerosene pressure stoves. These accidents were related to malfunctioning stoves or moving about with loose flowing garments, for example, saris or dupattas, which contact the fire unknowingly.
Mosier and Gibran observed that the early excision and grafting, in deep second-degree and third-degree burns, decrease the length of hospital stay and also the development of burn contractures. Early aggressive physical therapy and splinting are the fundamental parts of burn management. Exercises must provide a full range of motion. While in our study, 91% of the cases were residents of villages where advance health-care system or physiotherapy centers were not available.
According to MacLennan et al., the neck contractures of severe degree, especially of the anterior neck, cause secondary deformities of the lip and eyes and lower jaw. The basic goal of treatment is obtaining enough cervicomental angles to permit functional movement of the neck. There are many classification systems for neck contractures, which mostly depend on the degree of extension. Makboul and El-Oteify classified his patients into three groups, i.e., mild, moderate, and severe contracture. Patients in each group were again classified into three subgroups, i.e., linear scar, band scar, and broad scar. Moustafa treated 264 patients with burn contractures of the neck and 23 had multiple webs, 139 partial, and 59 complete obliterations, i.e., 83.7 which appear to correspond to the latter three groups of B. M. Achauer's classification. Onah et al. described a classification system for PBC that included major categories of 1–4, which includes position, severity, and likely problems. Tsai et al. defined the classification of PBC by the zones of scar contractures in burn patients and the aim of this classification was to use it in microsurgical reconstruction. In our study, we included cases of severe flexion contracture neck with 0°–30° extension of the neck, while 58.33% of cases were with 0° extensions of the neck.
Severe facial and neck scars may predict difficult mask ventilation. The maintenance of spontaneous ventilation during induction and intubation and avoidance of muscle relaxants is a better and safer option in these cases. The difficult intubation should also be expected.,,, In our study, the difficult intubation was managed with the help of fiber-optic endoscope in 58.33% of the cases and video endoscope in 41.66% of the cases.
In our study, after the release of the neck, contracture defect was resurfaced immediately with an unmeshed sheet of SSG in 50% of the cases, in 50% cases resurfaced with a combination of an unmeshed and meshed sheet of SSG. The results were evaluated during follow-up, there was recontracture in 8% of our patients, small or patchy loss of skin graft was in 3 cases, and in one case regrafting was done. One of the studies reviewed 143 neck release procedures and documented a 17% rate of contracture recurrence following releasing incisions with skin grafting and use of a neck hyperextension brace for over 1 year. Saaiq et al. observed that majority of patients (83%) had satisfactory graft intake, while (8.9%) had poor graft intake. In a study of Rajan et al., 93.33% patients had good graft intake, while three patients had minor loss of graft, which healed with dressings.
The postoperative stay for 33% of our patients was around 10 days or less, and for 41% of patients around 15 days, a longer stay was required only for the patient who had to undergo repeat STSG. The hospital stay for Nath et al.'s patients who had been skin grafted varied from 1 to 3 weeks.
| Conclusions|| |
The excision of all scar tissue is possible only in few cases of severe burn neck contractures, but the incision releases were required in the majority of severe neck contractures without any effect on the outcome of the surgery. In our study, we found that the SSG grafting is a simple, reliable, and safe operation. The sheets of unmeshed SSG in the neck and lower face resulted in better postoperative neck function, the cosmetic appearance in terms of color match, and cervicomental angle. The only disadvantage of SSG grafting was hypertrophy and recurrence of contracture. We observed that the difficult intubation was also the major factor to cause delayed surgical management of severe PBC neck patients.
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], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]