Postburn Neck Contractures Research Articles

Supraclavicular Artery Perforator Based Flap in Reconstruction of Neck Soft Tissue Defects: Our Experience.

Neck reconstruction is challenging task as it requires achievement of both function and aesthetic form as it is exposed and visible part of body. Various reconstruction modalities like Skin graft to free flap has been described in literature (Achauer and Sood's Burns Surgery, edition 2006). We used Supraclavicular artery perforator based island Flap for resurfacing defect in Five patients. After localization of Supraclavicular artery perforator with hand held Doppler; flap was raised in subfascial plane and inset was given under anesthesia. Out of five patients, there were two males and three females. Three patients had Postburn neck contractures, one had post electrical burn defect, and one had post infective defect over neck region. All flaps survived well without any complications. Supraclavicular artery perforator based island Flap is a reliable soft tissue cover for neck defects from various etiologies.

Managing difficult airway in a post burn neck contracture: A case report

Post burns neck contracture is always considered a difficult airway and requires meticulous planning for proper management. Awake fiberoptic intubation (AFOI) have been gold standard for managing difficult airways [1]. Here we will discuss a case of difficult airway due to post burn contractures at the neck posted for debridement and Split Skin Grafting (SSG) for Marjolin’s ulcer at the nape of the neck. Internal changes in the airway due post inhalational injury fibrosis proved the major cause of difficulty and following traditional clinical teachings helped in successful management of airway.

Role of split thickness skin grafting in post burn contracture neck

Optimizing functional and aesthetic outcomes in post burn head and neck reconstruction remains a surgical challenge. Recurrent contractures, impaired range of motion, and disfigurement because of disruption of the aesthetic subunits of the face, can result in poor patient satisfaction and ultimately, contribute to social isolation of the patient. Despite advancements in post burn head and neck reconstruction, such as the advent of free-tissue transfer, split thickness skin graft remains the mainstay of cover in most burn care institutions around the world. Usually skin graft is required to cover raw area after release of contracture. But in case contracture is associated with non-healing ulcer which may become source of infection then skin grafting for non-healing ulcer should be done before release of contracture. In this study we are sharing our experience of post burn neck contracture associated with non-healing ulcer in which first skin grafting was done for ulcer & then release of contracture & skin grafting was done.

Improvement in functional and aesthetic outcome in postburn contracture of neck following split skin grafting using goniometer

Introduction: Although the mortality and morbidity from burns have diminished significantly over the last few decades, these do not truly reflect whether the victim could lead a normal life, owing to postburn contractures (PBCs) and other deformities, which have functional and aesthetic implications. Objective: The main objective of this study was to compare the improvement in cervico-mental angle after surgery, using a goniometer; and to assess the postoperative complications, cosmetic outcome and patient satisfaction after contracture release and split-thickness skin grafting. Methods: In this prospective study, we have studied a total of 20 patients with PBCs of neck, who underwent contracture release and split skin grafting. The preoperative cervico-mental angles were compared to postoperative measurements using a goniometer. Results: In this study, we observed that the mean cervicomental angle before the surgery was 85.5° ± 12.8° and after the surgery was 106.4° ± 7.8°. The percentage improvement was 24.3% which was found to be statistically significant (P < 0.001). Patients were also classified based on age, gender, mechanism and classification of burns, time elapsed since burn injury. Postoperative complications, cosmetic outcome and patient satisfaction were also studied. Conclusion: PBCs can affect a patient's life functionally, aesthetically, and psychologically. Split-thickness skin grafting is a safe and reliable option for PBC neck. This causes improvement in cervicomental angle and thus range of movements of the neck in different axes (as measured by a goniometer). lthough the mortality and morbidity from burns have diminished significantly over the last few decades, these do not truly reflect whether the victim could lead a normal life, owing to postburn contractures (PBCs) and other deformities, which have functional and aesthetic implications. In this prospective study, we have studied a total of 20 patients with PBCs of neck, who underwent contracture release and split skin grafting. The preoperative cervico-mental angles were compared to postoperative measurements using a goniometer, and a significant improvement was noted. Overall patient satisfaction was also very good. Hence, split thickness skin grafting is a safe and reliable option for PBC neck.

Postburn neck contracture reconstruction by interval skin grafting

Introduction: Delayed burn wound healing, due to lack of proper initial treatment, especially in deep partial-thickness and full-thickness burns leads to the formation of burn scar contracture. Because of the loose tissue in the anterior neck and also due to habitual and ignorant use of a pillow in burnt patients during the postburn recovery phase, contracture of the neck is a common sequela. Many reconstructive modalities have been described in the literature which include skin grafting, pedicle flap with or without expansion, and free flap. Keeping the esthetic concern in mind, we modified the method of contracture release and skin grafting into two stages. Materials and Methods: This is a prospective study conducted on 15 patients with extensive postburn contracture of the neck during the period ranging from January 2020 to August 2021. Results: In our study, 80% of the patients were females. The mean age was 25.9 years. The number of type 2 and type 3 neck contractures was 7 and 8, respectively. The mean duration of contracture was 8.26 months. Graft loss was the only complication seen and that too was < 10% in all cases (mean - 4.46). At 6 months, mandibular border and thyroid bulge were distinctly visible, and cervicomental angle was within the normal range (mean - 110.46) giving a youthful and appealing esthetic appearance. The mean of the Patient and Observer Scar Assessment Scale score was 2.06 for the observer component and 3 for the patient component. Conclusion: Interval skin grafting can be undertaken following postburn neck contracture release for better functional and esthetic outcomes.

ALT free flap as a crucial tool in management of post burn neck contracture

ALT free flap as a crucial tool in management of post burn neck contracture

Pre-shaped supraglottic airway devices offer an alternative to endotracheal intubation for airway management of postburn neck contracture: A case series.

Background and Aims:Moderate to severe postburn contractures (PBCs) of the neck lead to multiple areas of difficulty in airway management. Awake flexible fiberscope guided intubation with cuffed endotracheal tube (ETT) is considered the “gold standard” for securing the airway in these cases. Supraglottic airway devices (SADs), if at all used, are used either as rescue devices or as conduits for ETT. This case series looks at the possibility of using SADs as a planned airway securing device in these cases.Material and Methods:We managed 24 cases of moderate to severe PBC neck using six types of pre shaped SADs as the first choice airway device. These SADs were placed after either airway topicalization (19 cases) or general anesthesia (GA) (5 cases). Once SAD placement was confirmed, all the patients received GA and muscle relaxant. Tests for proper placement and function and fiberscopy (conducted in four cases) were performed at various times during the procedure. The SADs were removed once the patients were fully awake.Results:SADs could be placed in one attempt in all the cases. The time taken to hand over the patients to surgeons was 12–20 min. SADs maintained their proper placement and function in spite of changing airway dimensions during contracture release. The patients tolerated the SADs well right until the time they were fully awake. The SADs could be successfully removed on the operation table in all the cases.Conclusion:Pre shaped SADs secure the airway quickly and are free from the risk of intraoperative displacements and allow uneventful emergence in moderate and severe PBC neck cases and need to be considered as the first choice in these cases.

Our Experience of Tie Over bolster and Quilting Sutures Versus Stapler fixation for Split thickness skin graft in post burn neck contracture – A Comparative study

Background: Traditional method to fix Split thickness skin graft in post burn neck contracture is Tie over Bolster dressing and Quilting sutures. We used staplers to fix split thickness skin graft. Materials & methods: A comparative study conducted in 30 patients with post burn neck contracture at Dr. Vasantrao Pawar Medical College, Nashik, during January 2015 to December 2020. Time required for fixation of split thickness skin graft, outcome in terms of graft uptake and patients comfort level while removing sutures and stapler recorded. Results: Total 30 Patients were included in our study. Mean time required for Tie over and quilting suture was 10.53 ± 0.88 min, significantly higher than the mean time in stapler fixation 4.87 ± 0.81 min. (p<0.001). Graft take was 95% in stapler and 93% in Tie over and quilting suture. Conclusion: Fixation of Split thickness skin graft with stapler is more rapid, less time consuming also results in decreased surgical and anaesthesia time. More patient friendly while removing staplers with comparable skin graft uptake.

MANAGEMENT OF POST BURN CONTRACTURE OF NECK IN A TERTIARY BURN CARE CENTRE

Background: Post burn contracture is one of the most common problems in our country and usually seen in lower socio-economic people. Burn contractures of the neck can produce a signicant impact on quality of life by reducing a patient's ability to perform activities of daily living Methods: A prospective study was conducted with a sample size of 30 patients with post burn neck contracture conducted for a duration of 24 months. After meticulous surgical planning, patients underwent contracture release and split skin grafting/z-plasty followed by rigorous splintage and physiotherapy. Majority of the patients were in the age group of 11-30 years (63%).70% of the Results: patients sustained burns in the range of 21-40% and 80% were due to ame burns.46.66% (14) of patients had severe contracture while 13.33% (4) had extensive mento-sternal adhesions. 90% of the patients underwent release + SSG while 10% underwent z-plasty. Postoperatively cervico-mental angle of 100-120 degrees was achieved Skin grafting is a simple, reliable and safe operation however postoperative splinting is n Conclusion: ecessary. The use of skin grafts continues to deliver excellent results with adequate restoration of cervico-mental angle.

SUPRACLAVICULAR ARTERY FLAP: A SAFE, VERSATILE AND A RELIABLE FLAP A NEW WORKHORSE IN HEAD AND NECK RECONSTRUCTION OUR CLINICAL EXPERIENCE

Background: Anterior cervical contractures of the neck represent a great challenge for plastic and reconstructive surgeons. Necks can be reconstructed with a wide range of surgical techniques. The supraclavicular flap is easy to harvest without the need for free tissue transfer. It provides a relatively large flap for neck resurfacing with tissue very similar to that of the neck. Material and Methods: This study was carried out in the Plastic Surgery Department of GMC Srinagar between November 2015 and October 2019. It involved 50 patients (40 females and 10 males), in whom supraclavicular artery flap was done to reconstruct head and neck. Follow-up period ranged from 2-27 months (average 12.3). Results: The study involved 50 patients. Mean age was 26.5 years (range 57-12 years). Thirty five patients had post-burn neck contractures, five patients had portwine stain face, three had marjolin ulcer, four patients had post traumatic and three had post bear maul defect. We harvested unilateral flaps in all of patients. In thirty five patients the flap was pedicled, three had adipofascial pedicle and twelve were islanded. The size of the reconstructed defect ranged from 23x10 to 14x6, and the size of the flap varied from 16x7cm to 25x11. Mean length was 21.7 cm. We used a partial thickness skin graft for donor site closure in 41 cases and closed primarily in 9 cases. Flap was used to resurface neck in 35 patients, face resurfacing in 10 patients, as intraoral lining in 3 patients. The following complications occurred: hematoma in 3 cases, partial distal necrosis in 2 cases, and donor site graft loss in 3 cases. Follow-up period ranged from 2-27 months Conclusion: The supraclavicular artery island flap is a thin, malleable fasciocutaneous flap that is easily and rapidly harvested, with a reliable pedicle and minimal donor site morbidity. It constitutes an alternative to local flaps, while providing equivalent functional results, and must be an integral part of the head and neck reconstructive surgeons therapeutic armamentarium.

Tumescent local anesthesia as an alternative to general anesthesia in release of post-burn neck contracture and skin graft harvesting: A comparative study

Background: Anesthetic management of severe post burn neck contracture is difficult, demanding due to fixed flexion deformity of neck, incomplete oral occlusion and insufficient mouth opening leading to difficulty in intubation. Patients undergoing contracture release, skin graft harvest under general anesthesia (GA) were compared with patients undergoing the same surgery under tumescent local anesthesia (TLA) technique.
 Methodology: Twenty-one patients with post burn neck contracture undergoing contracture release with split skin grafting under GA were compared with twenty-one patients undergoing the same surgery under TLA. Post-operative pain and satisfaction were assessed using 10 cm VAS (Visual Analogue Scale).
 Results: Demographic profile was comparable in both groups. Changes in intra-operative vital parameters remained insignificant. The average volume of tumescent solution used was 254.76 + 49.05ml. Blood loss was significantly decreased, postoperative pain relief was more than sixteen hours in thirteen patients and extended beyond twenty-four hours in six patients in the TLA group. Time for the first rescue analgesia was significantly lesser in the GA group and the average dose of injection tramadol used in the GA group was significantly higher within the first 24 h. Overall satisfaction in the TLA group was significantly higher than in the GA group.
 Conclusion: TLA can be used as sole technique for release of post burn neck contracture and harvest of split skin grafts with less blood loss and significantly better postoperative pain relief avoiding complications of general anesthesia.
 Key words: Tumescent local anesthesia; Post burn neck contracture; Skin graft harvest; General anesthesia
 Citation: Prasad MK, Jain P, Varshney RK, Khare A, Jheetay GS. Tumescent local anesthesia as an alternative to general anesthesia in the release of post-burn neck contracture and skin graft harvesting: A comparative study. Anaesth. Pain intensive care 2021;25(1):34–39.
 DOI: 10.35975/apic.v25i1.1434
 Received: 18 February 2020, Reviewed: 16 March 2020, Accepted: 30 April 2020

Outcome of successful graft take of Integra and split thickness skin graft after the release of post-burn neck contracture.

Objective: To determine the frequency of the successful graft take of Integra™ and split thickness skin graft after the release of post-burn neck contracture. Study Design: Descriptive Case Series. Setting: Department of Plastic Surgery, Jinnah Burn and Reconstructive Surgery Centre, Lahore. Period: 1st October, 2017 to 30th September, 2018. Material & Methods: A total of 70 cases, those who full filled the inclusion criteria were included in the study through non-probability consecutive sampling. Informed consent was obtained from all the patient. Integra was applied in all the patients after the release of contracture and excision of scar tissue and was inspected every 3-5 days. After 3 weeks, the outer layer of silicone sheet was removed and replaced by thin split-thickness skin graft. The graft was secured with skin staples, absorbent gauze and the crepe bandage. All the patients were followed up regularly and the final outcome was assessed at 6 weeks. Results: The mean age of the patients was observed as 34.51 ± 14.19 years with age range of 11to 59 years. Among these 70 patients 61.4% were male and 38.6% were females. The mean body mass index was observed to be 22.59 + 3.68 kg/m2. Out of these 70 patients, the outcome in terms of successful graft take with Integra treatment was achieved in 60 (85.7%) patients. On stratification, statistically insignificant difference was observed for the effect modifiers like age, gender and BMI. Conclusion: In our study we found that Integra and STSG can be considered as one of emerging and promising modality in burn management and reconstructive surgery with the significantly high success rate in terms of complete re vascularization and skin graft take.

Tips for management of postburn neck contracture

Postburn neck contractures are frequent sequelae after deep thermal burns. They are a significant cause of morbidity and pose a serious challenge for anesthesia. In developing countries, lack of adequate burn care infrastructure, training, and workforce leads to the occurrence of multiple postburn deformities. Wound healing can never occur without wound bed contraction. Therefore, the best treatment for any problem related to burn wound contraction is to prevent or at least reduce its severity. The same is the case with postburn contractures and deformities. The use of simple measures can prevent or at least limit the severity of deformities even when used by trained paramedics and nursing staff.

Supraclavicular Artery Flap versus Skin Graft: Which Is a Better Reconstructive Tool for Managing Post-Burn Contractures in the Neck.

BACKGROUNDBurn in developing countries still has high burden of inadequately managed severe burns. This study compared supraclavicular artery flap and skin graft in managing neck post-burn contractures.METHODSIn National Institute of Rehabilitation Medicine and Pakistan Institute of Medical Sciences, Islamabad, Pakistan, 30 patients with neck post-burn contractures were enrolled. Half of patients randomly underwent supraclavicular artery flap and half received skin graft. The outcome measures including initial improvement in neck extension, patient’s satisfaction with color-texture-match and recurrent contracture formation rate were assessed.RESULTSAmong patients, 80% were female and 20% were male. Preoperatively, each group had post-burn contractures of grade II among 26.66% of patients, grade III among 60% and grade III among 13.3%. Postoperatively after three months in the two groups, 86.66% improved to grade I and 13.3% improved to grade II. Patient’s satisfaction with color-texture was 84.66% in supraclavicular artery flap group, whereas it was 42.66% for skin graft group. Complications were hypertrophic scar at donor site (13%) and flap tip necrosis (6.66%) in supraclavicular artery flap group. In skin graft group, partial skin graft loss was noticed among 33% of patients and delayed healing of donor site among 20%. The recurrent contracture formation rate at one year was 73.33% in skin graft group, whereas there was no case of recurrent contracture in supraclavicular artery flap group. CONCLUSIONSupraclavicular artery flap was superior to skin graft in managing post-burn neck contractures. It provided better color-texture match and was associated with no recurrence of contracture formation.

Thoracic epidural anaesthesia – A promising alternative for a patient with difficult airway

A patient with post burn contracture of neck and Marjolin’s ulcer on anterior chest wall was posted for wide local excision and skin grafting. Skin graft was taken from lower limb under unilateral subarachnoid block and wide local excision of ulcer was performed under thoracic epidural anaesthesia. In the background of pre-formulated strategy in view of anticipated difficult airway, regional anaesthesia is a well established and safe alternative in expert hands. Keywords: Anterior chest wall surgery, difficult airway, Thoracic epidural, Post burn contracture (PBC).

Early debridement with physiotherapy for prevention of postburn contracture of neck: a case series

Hypertrophic scars and contractures are well known sequelae after burns. They result in high morbidity in severely burned patients who are surviving. Present case study was done to establish the usefulness of early debridement and physiotherapy in preventing these sequelae. Present study was conducted on patients admitted in a tertiary care hospital on patients with alleged history of thermal burns to neck and upper chest over a period of 6 months. These patients were subjected to early debridement, daily dressings and early neck physiotherapy. They were assessed for neck mobility and development of neck contracture. Three patients were studied, two had a favourable outcome due to adherence to above measures while one developed contracture due to her late presentation and non-compliance to early physiotherapy. Post burn contractures are common sequelae of thermal burns involving the neck region. Early Debridement, daily dressing of the raw areas with starting of early neck physiotherapy are important and prove beneficial in preventing neck contractures with early return to normal daily activity.

Airway management of post-burn neck contracture: preshaped supraglottic airways should be the new ‘gold standard’

Airway management of post-burn neck contracture: preshaped supraglottic airways should be the new ‘gold standard’

Post burn neck contracture: an algorithm for choosing the ideal surgical method of management

Background: The aim of the study is to facilitate choosing the surgical technique that will be suitable for improving both function and aesthetics of each patient through this suggested algorithm system. Any post burn neck contracture usually causes severe impairment of function and aesthetics, which causes serous psychological and social problems. That’s why it is very important to sub-categorize this type of deformity by anatomical location and cause of burn to allow choosing the ideal method of surgical management.Methods: This is a prospective study which was performed in Plastic Surgery Department, Menoufia University Hospitals over the period from March 2017 to March 2019. The study included 30 patients suffering post burn neck contracture deformities.Results: Patients were carefully examined, and the post burn neck deformities were analyzed according to age, condition of skin at the contracture site, the range of sternomastoid muscles movement at both sides of the neck and patient's general condition. Patients were given scores and categorized into 4 grades. And according to each patient's grade, the suitable surgical technique was chosen and fulfilled. 25 patients showed great satisfaction to their post operative’s outcomes and the rest were poorly satisfied.Conclusions: Application of patients with post burn neck contractures to this algorithm system will make it easy to choose the ideal method of management and gain the best surgical results possible when performing surgical correction.

POST BURN CONTRACTURE OF NECK A CLINICAL STUDY.

20Aug 2019 POST BURN CONTRACTURE OF NECK A CLINICAL STUDY. K.V.N.Prasad. MS.MCh(Plastic Surgery),AsstProfessor,Dept of Plastic Surgery, Kurnool Medical College,Kurnool,AP,INDIA.

Comparative evaluation of three methods of skin graft fixation for split thickness skin graft after release of post burn contracture of the neck

ObjectivesSplit thickness skin graft is an essential component of release of post burn contracture of neck. There are many methods of fixation of skin grafts; however, there is lack of objective comparison between different techniques. This study has been designed to compare three commonly used techniques of split thickness skin graft fixation methods. Surgical time, advantages, cost factor and post-operative outcome have been compared amongst three techniques. MethodsA randomized interventional comparative study was conducted to compare three methods of skin graft fixation in patients of 10–50 years age group, with contracture of more than 3 month duration having more than 100cm2 skin defects after contracture release. Resurfacing of the defects after contracture release was carried out in all the groups using autologous split skin grafts. Patients were included in three groups; Group 1: tie over method, Group 2: skin stapler fixation and Group 3: Cyanoacrylate glue fixation. ResultsMean duration of fixation procedure was 34min in tie over group, in skin stapler group 7min and in cyanoacrylate group 12min. Mean cost of fixation material was 10.23 USD in tie-over group, 11.23 USD in stapler group and 40.06 USD in cyanoacrylate group. Mean score of pain/discomfort (visual analog score) on dressing removal in tie-over group was 3, for skin stapler group was 2.9 and that for cyanoacrylate glue group was 1.8. mean graft take was found to be 90.1% in tie-over group, 94.1% in skin stapler group & 93.8% in cyanoacrylate glue group. On logistic regression analysis, keeping all the variables constant in the groups the complications as the outcome variable, three groups are comparable. The need for regrafting remains inconclusive. ConclusionsSkin stapler method for skin graft fixation was least time consuming, affordable and highly reliable when graft take success was considered. Cyanoacrylate glue fixation method was least painful and reliable in terms of graft take success though costlier than other two