Post Burn Contracture Neck:Classification and management MOHAMED OSAMA KOTB,M.D. The department of plastic surgery,Ahmed Maher teaching hospital,Cairo.
Post burn neck contracture is a devasting functional and cosmetic deformity for patients and a challenging problem for reconstructive surgeons. Severe contractures are more commonly seen in the developing world,where primary and secondary burn care is often inadequate and options are limited for primary excision and grafting,splinting or physiotherapy. When burns are allowed to heal spontaneously,hypertrophic scar formation is prevalent,particulary in young,dark skinned patients with deep second and third degree burns.
A variety of reconstructive techniques have been described to manage neck contracture like: A:(Surgical procedures):excision of the scar and grafting,splitting of the scar and grafting,Z-plasty.local fasciocutaneous flaps,myocutaneous flaps,free flaps,and tissue expansion. B:(Non surgical procedures):skeletal traction,serial splinting and distraction lengthening.
Neck contracture can be classified as follows: A-according to shape of the contracture into linear band and broad web B-according to the degree of mentosternal angle which is normally around 90 degree. C-according to extent of injury into intrinsic type which affect only the neck tissue and the extrinsic type which affect also the nearby tissue like chin,perioral,nasaolabial and lower eyelid region.
PATIENTS AND METHODS This study included 25 patients with moderate to severe post burn neck contracture.Fifteen patients were females and ten were males.Their ages ranged between 10 and 55 years.The time between burn injury and reconstruction ranged from 5 months and 3 years.
Operative Techniques (a)Contracture release and split thickness skin graft:this technique was used in 10 cases and followed by splinting for 6 months to avoid recurrence of the contracture (b)Release and supraclavicular fasciocutaneous flap(epaulet flap):This technique was used in 7 cases with broad web neck contracture.The donor site must be free from burns.The posterior border of the flap coincide with the superior edge of the trapezius muscle while the anterior border is parallel to the posterior border of the flap starting at the anterior edge of sternomastoid muscle passing through midclavicular point.
The length of the epaulet flap ranged between 15 to 20 cm while the width was from 7 to 10 cm.The blood supply of the epaulet flap is the supraclavicular artery(a branch from the transverse cervical artery).The donor site was closed directly after wide undermining,2 drains were left,one at the neck and the other at the donor site.No need for post-operative splintage (c)Release and Z-plasty: this technique was done in 8 cases with linear neck contracture.Single or multiple Z-plasty can be used.The Z-plasty flaps must be thick including the platysma muscle to insure their viability.A rubber drain was left for 48 hours.Post operative splinting was not necessary as the thick flaps does not shrink compared to the skin grafts.
RESULTS The overall complication rate was 20% in the form of -partial loss of skin graft in the first modality(2 cases)-partial grapping of the donor area in second modality(2 cases)-and distal necrosis in Z-plasty(1 case)
Complications of Contracture neck: 1)Limit neck functions. 2)Abnormal posture. 3)Difficult intubation. 4)Restrict eating and swallowing. 5)Pull down the mouth and lower eyelids. 6)Pull up the breast tissue
Disadvantages of the split skin graft: 1)Recontracture. 2)Long hospital stay. 3)Painful donor area. 4)Long term splintage. 5)Not aesthetic. 6)Hypo or hyper pigmentation. 7)Possibility of graft failure.
CONCLUSION Prophylaxis must be done to prevent post burn contracture neck by splintage,early grafting and physiotherapy.But if the contracture was already formed,the coverage of the defect after the release is better reconstructed by a flap(Z-plasty-supraclavicular flaps)than to be reconstructed by split thickness skin graft.