2. JOURNAL - IJP- 2010 SEPTEMBER
Dr Arun Goel, Dr Prabhath Srivatsava
This article gives an overview of the post burn scars and
scar contractures, especially their prevention,
minimization and principles of management.
3. INTRODUCTION
Burn trauma constitutes the second most common cause of trauma related
deaths after vehicular accidents, both in developing as well as the
developed nations.
It is the restoration to pre-injury status and return to society that becomes
important for the victim and the treating team.
A healed burn patient may be left with scars with varying degrees of
functional and aesthetic components.
Proportional to the standards of initial treatment with patients receiving
best of care having minimum number and severity of problems
4. POST BURN SCAR
Post-burn scars are inevitable even with the best of treatment because they
depend upon the depth of burn injury.
Except for the superficial dermal burns, all deeper burns (2nd degree deep
dermal and full thickness) heal by scarring .
This scarring can only be minimized by various physical therapy measures
and plastic surgical procedures, but not be eliminated completely.
The appearance of even the best split-skin grafted areas and the donor sites
of these grafts is also a scar by the patients definition of a scar.
6. BURN WOUND HEALING AND DEVELOPMENT OF
SCAR AND SCAR CONTRACTURE
The healing of a burn wound is accomplished
either by Restitution (complete regeneration)
or Substitution.
7. RESTITUTION
Restitution is possible only if the skin is burnt as deep as the
stratum papillare and all the specialized cells of the organ are
preserved.
The epithelial cells, in these cases, are derived from the epithelial
appendages such as pilo-sebaceous units and sweat glands in the
central portion and wound edges at the periphery.
These appendages extend into the deeper dermis and may even
penetrate into the subcutaneous fat (as in beard area in males) and
survive in partial thickness injuries.
8. RESTITUTION
Sequence of cellular events that comprise epithelialization is
Cellular detachment
Migration
Proliferation
Differentiation
n
9. SUBSTITUTION
If the skin is affected deeper in the zone of stratum reticulare, the
defect is covered by substitutive unspecialized connective tissue.
The final result is demonstrated by a lesser or more extensive
formation of the cicatrix
With full thickness loss of skin, wound contraction and
epithelialization from the margins occurs leading to contractures.
10. CONTRACTION
Contraction is an active biological process by which an area of skin
loss in an open wound is decreased due to concentric reduction in the
size of the wound.
The reduction in size of wound causes lesser degree of connective
tissue deposition and the amount of epithelialization needed is
decreased.
Wound contraction involves an interaction of fibroblasts,
myofibroblasts and collagen deposition .
A satisfactory mechanism when the tissue loss is small, in a non-
critical area and surrounded by loose skin.
Scar contracture, on the other hand, is the end result of the process of
contraction.
11. VANCOUVER SCAR SCALE / BURN SCAR INDEX
PIGMENTATION
0- normal colour that closely resembles the colour of the rest of the
body
1- hypopigmentation
2- hyperpigmentation
VASCULARITY
0- normal- colour that closely resembles the colour of the rest of the body
1- pink
2- red
3- purple
12. PLIABILITY
0 normal
1- supple- flexible with minimal resistance
2 yielding giving way to pressure
3 firm- inflexible, not easily moved, resistant to manual pressure
4 banding rope like tissue that blanches with extension of the scar
5 contracture permanent shortening of the scar, producing deformity or
distortion
HEIGHT
0- normal flat
1- <2 mm
2 - <5 mm
3 - >5 mm
14. CLASSIFICATION OF SCAR
Immature and mature scars
Linear and widespread hypertrophic scar
Minor and major keloid
Contractures
Superficial macular scars
Ice pick scars
Rolling scars
Boxcar scars
15. Mature scar - light colored, flat scar
Immature scar- red, sometimes itchy or painful and slightly
elevated scar in the process of remodeling. Many of these will
mature normally over time and becomes flat
Linear hypertrophic scar (surgical/ trauma scars)- red, raised,
sometimes itchy scar confined to the border of original surgical
incision occurring within weeks following surgery and can
regress of its own
Widespread hypertrophic scar (eg burn scars)- a widespread
red, raised, sometimes itchy scar that remains within the borders
of burn injury.
16. Minor keloids- focally raised, itchy scar extending over the
normal tissues and may develop upto 1 yr after injury and does
not regress on its own
Major keloids- large , raised scars, possibly painful, pruritic
extending over normal tissue often resulting from minor trauma
and can continue to spread over years.
Contractures- restrict movements due to skin and underlying
tissues that pull together during healing and can occur when there
is a large amount of tissue loss or where a wound crosses a joint
17. Superficial macular scars- occurs only if epidermis and superficial
dermis are involved, appears as erythematous or pigmented macules
Ice pick scars (cone shaped) narrow, deep and sharply marginated
epithelial tracts extend vertically to deep dermis or subcutaneous tissues
Rolling scars (wavy scars)- occur from dermal tethering of otherwise
relatively normal appearing skin, abnormal fibrous anchoring of dermis
to subcutis lead to superficial shadowing and rolling or undulating
appearance to the overlying skin
Box scars ( chicken pox scar like)- round to oval depressions with
sharply demarcated vertical edges , similar to varicella scars, clinically
wider at the surface than ice pick scars and tapers to a point at the base
20. IMMATURE SCAR----MATURE SCAR
Itching over the healed burn and split-skin donor sites --- antihistaminic drugs
(pheniramine maleate, promethazine,etc).
Itching must be prevented not only to make the patient comfortable but also to break
the cycle and ulceration.
Massage with steroid containing creams also can be advised for short periods on areas
which can be protected from exposure to sunlight as otherwise hyperpigmentation can
result.
21. IMMATURE SCAR----MATURE SCAR
Exposure to sunlight till they are mature should be prevented, to prevent
hyperpigmentation.
Coverage with clothes, caps, sun screen lotions with SPF of at least 2025,
decreasing outdoor activity during daytime or even using an umbrella.
The maturation of scars is also greatly helped by using custom-made pressure
garments, especially for deep dermal burns and donor sites of intermediate and
thick split-skin grafts which involve reticular dermis.
Deep dermal burns - develop hypertrophic scars. These unsightly scars are
hyperaemic, raised above the surface of skin, firm to hard in consistency and
itchy.
23. IMMATURE -----MATURE SCARS-
PRESSURE GARMENTS
Compression garments prevent the development of hypertrophic
scars.
The effectiveness of these garments decreases after the
development of hypertrophic scars.
Before prescribing commercial pressure garments, the newly
healed skin must be preconditioned to accept the stress and
pressure exerted by the garments.
24. COMPRESSION GARMENTS
Initially gentle pressure is applied with crepe bandages.
As the skin toughens, the commercial pressure garments may be prescribed.
These are to be worn 24 hours a day (except during bathing and massage)
For a period of at least 912 months.
The ideal pressure required is also not clear but it must be more than 24 mm hg
for capillary pressure to be countered.
25. COMPRESSION GARMENTS HOW IT ACTS
Pressure therapy diminishes the number of myofibroblasts, erythema,
thickness and firmness of hypertrophic scar and accelerates its
maturation.
The various explanations put forward for these changes are hypoxia of
the scar tissue by occlusion of the microvasculature, increased
collagenase mediated collagen breakdown due to pressure induced
decrease in capillary blood flow, reduction in tissue oedema, etc
26. SILICONE SHEETS
Silicone gel sheets have been shown to be useful for treatment of
hypertrophic scars.
They have to be worn for 24 hours a day with particular care to be
taken of local hygiene to avoid the development of contact
dermatitis
27. SILICONE GEL SHEET- HOW IT ACTS
Exact mechanism of action of silicone gel is not known.
It may exert its effects by increasing the temperature of the scar, thereby
enhancing the activity of collagenase.
Other effects of silicone gel, such as increased pressure, lowered oxygen
tension and occlusion may be less important.
Hydration of the stratum corneum and direct release of low molecular
weight silicone fluid into the scar are other possible modes of action.
However, silicone does not appear to enter scar tissues.
29. STEROIDS
Intralesional injections of triamcinolone, every 4 weeks, have
been found to be effective for control of hypertrophic scar.
However, the dose and amount injected at any one time is limited
and is useful for very small lesions only.
30. DEALING WITH PIGMENTATION
hypopigmentation and hyperpigmentation following maturation of
scar , heals spontaneously in due course of time or can be treated
with skin grafts
little is known about their causation.
For depigmented or vitiligo patches
The treatment involves excision/ dermabrasion of vitiligo area and
coverage with thin split thickness skin graft.
31. DEALING WITH SCAR BREAK DOWN
This scar or neoepithelium is usually single-celled and highly fragile
and bound to break due to minor trauma especially if present on
extremities and other areas of stress (unstable scars).
It needs excision/ dermabrasion and coverage with intermediate or
thin split thickness skin grafts
Any associated contracting element should also be released along
with.
32. POST BURN CONTRACTURE - SEQUELAE
Any unstable area may also be associated with a Marjolins ulcer
Deeper tissues may be affected either due to their involvement in the initial burn
injury (e.g., electrical burns) or secondary to the presence of a skin contracture
over a prolonged period of many years.
Shortening of musculotendinous units and neurovascular structures.
Joints may be subluxated or dislocated, with joint capsule and ligaments
becoming tight in the direction of the contracture
The bones may be deformed, especially in growing children, e.g., mandibular
deformity in cases of post-burn contractures of the neck
33. PBC
An unstable scar or chronic non-healing ulcer(s) will not heal
without surgical release of the contracture. Massive raw areas need
wound closure with skin grafting before contracture can be subjected
to physical therapy.
Wide excision of Marjolins ulcer has to be combined with release of
contracting bands.
A post-burn contracture associated with a hypertrophic or an
atrophic scar or a depigmented area may all need excisionrelease to
achieve best results not only functionally but also aesthetically.
34. PBC DEEPER TISSUE INVOLVEMENT-
CLINICAL SIGNIFICANCE
Shortening of deeper structures has great clinical significance.
Neurovascular structures and musculotendinous units may stand
out as bowstrings, limiting any further release.
Moreover, the vessels may also go into spasm with compromise
of distal limb or digit circulation due to excessive stretch.
35. PBC- DEEPER INVOLVEMENT
The muscles / tendons may resist any lengthening by forceful pull
even under general anesthesia.
Such contractures need gradual release by sustained traction using
various methods for complete correction. This can generally be
achieved within 2 weeks. When bones and joints are also affected,
orthopedic consultation may be needed.
When mandible is deformed along with loss of normal dental
occlusion in severe and untreated post-burn contractures of neck in
children orthodontic orthognathic measures are needed after the
contracture is fully released
36. WHY EARLY SSG ?
The most important and effective method of controlling the wound
contraction is to close the wound at the earliest using split-skin grafts in
deep dermal and full thickness burns.
Contraction can be inhibited by applying grafts to fresh wounds (as in
early excision) or over healthy granulating areas (after eschar separation).
It is widely believed that thicker the graft, greater will be the inhibition of
contraction.
37. TIMING OF SURGERY IN PBC
As a general rule, surgical intervention for post-burn contractures
should not be undertaken during the active phase of healing and
scarring, i.e., as long as the scar is immature and highly vascular.
This usually takes 1 year or so.
One must allow the scar to become mature, soft and supple and
avascular before undertaking surgery for contractures.
This is because a highly vascular scar bleeds more during operation,
with difficulties in achieving perfect haemostasis resulting in poor graft
take leading to healing by further contraction.
38. TIMING OF SURGERY IN PBC
Operation on an active, highly vascular scar with wound bed still in active
phase of contraction, adds insult to already traumatised tissues with
vigorous local response in the form of further contraction.
an immature scar is amenable to physical therapy measures resulting in
significant improvement even non-surgically.
With the passage of time, some mild contractures may improve with a
better final result than if they had been surgically managed.
39. EXCEPTIONS
Ectropion of the eyelids, especially the upper eyelid with constant danger of
keratoconjunctivitis, corneal ulceration, scarring or perforation with loss of
vision
Incapacitating contracture of the neck with inability to look forwards
Severe microstomia causing interference with adequate nutrition and
maintenance of orodental hygiene
Crippling contractures of hand, especially dorsal contracture with
metacarpophalangeal joints going in hyperextension leading to permanent
damage to extensor mechanism with various deformities
40. EXCEPTIONS -
Contractures of both the knees , which force the patient to be on
all the fours and endangers the very dignity of being an upright
human being
Post-burn contractures with associated adjoining chronic raw areas
needing skin cover
Contractures with infected hypertrophic scars and abscesses, which
need excision/drainage for their recovery
Any severe, incapacitating contracture unlikely to improve at all
with physical therapy measures
41. PRIORITY OF RELEASE IN CASE OF
MULTIPLE CONTRACTURE
1) Ectropion of the eyelids, especially the upper eyelid, with its attendant risks
needs to be dealt with first to prevent irreparable damage. It may even be
managed under local anaesthesia in the case of an adult.
2) Severe contracture of the neck or microstomia leading to difficulties in
intubation should be corrected before planning any other contracture release or
reconstructive procedure requiring general anaesthesia.
Additionally, the complete release of a neck contracture removes the extrinsic
pull on facial structures (lips, chin and even lower eyelids) and contractures of
the axilla and the breast.
43. PRIORITY OF CONTRACTURE RELEASE
3) Dorsal contractures of the hand need to be addressed after the neck is
treated. They are not only crippling but may also cause permanent damage
to the delicate balance of tendon movements (extensor apparatus) when
metacarpophalangeal joints go into extension.
Both hands should NOT treated together (except in small children) to
allow the patient his/her daily needs of feeding and toilet care
When axilla, elbow and hand are all affected on one side, ---- axilla and
elbow are released.
Popliteal fossa contracture
44. SURGICAL INTERVENTION-RELEASE
Release of contracture
Complete release of contracture should be done, avoiding damage to any
important underlying structure, e.g., arteries, nerves, tendons, etc.
Incision begins across the point of maximum tension, i.e., where the contracture
is most tight.
This point is usually opposite the joint line. The incision is deepened all the way
to the unscarred tissues.
45. No attempt should ever be made at undermining the surrounding
healthy/scarred skin and advancing it to decrease the defect. Incision
line can be infiltrated with 1:200,000 adrenaline solution to have a
relatively bloodless field.
The limb contractures can be released under tourniquet which
should be deflated after complete release and haemostasis achieved
using bipolar cautery.
46. SURGICAL INTERVENTION- RELEASE
Incision vs. excision
In general, a contracture should be released by incision rather
than by excision.
This is especially true for patients who have received adequate
pre-operative physical therapy and their scars have become soft
and pliable.
Incision alone decreases the requirement for skin cover. When the
scars are extensive-excision is not preferred
47. SURGICAL INTERVENTION
Excisional release - may, however, be required in certain circumstances
(a) small adjoining depigmented or hypertrophic areas, excision of which will add
to the final aesthetic result
(b) atrophic/unstable scars/chronic non-healing ulcer(s)/ discharging sinuses should
be excised along with release of contracture to obtain healthy bed for split-skin
graft take
(c) scars may also be excised so as to apply the graft/flap in accordance with
principles of aesthetic units.
Partial excision of hypertrophic scars may sometimes be done, e.g., in a case of post-
burn contracture of neck, the scars may extend from chin, neck onto the chest and even
abdomen. Here, only neck scars are excised.
48. SURGICAL INTERVENTION-RELEASE
Immediate vs. gradual release:
Released completely on the table in one go.
In severe long-standing contractures, there is considerable shortening of
musculotendinous units and neurovascular structures. Hence, it may not
be possible to achieve complete release.
When the joints are subluxated or dislocated
49. SURGICAL INTERVENTION -RELEASE
Immediate complete release may not be possible in all cases
As much release as possible is done and then, full correction is
achieved gradually over a couple of weeks using serial splintage,
skin/skeletal traction or the modern distractor systems (e.g.,
UMEX, JESS, etc).
Once full correction is achieved, the skin cover is provided.
50. POST RELEASE COVERAGE
Skin graft
sheet grafts are to be preferred and no attempts should be made to expand the
graft by meshing .
try to feed in more graft than the size of the defect to take care of the
postoperative, inevitable secondary contraction
The junction line of the sheets of the grafts should be parallel to the axis of
joint motion.
The skin grafts are applied immediately after complete release. Sometimes,
delayed application after 5 days, once the granulations form, is done.
51. POST RELEASE--- SSG
The delayed approach is required when release of contracture results in
exposure of fat which is a poor bed for graft take.
When the raw areas are oozing a lot, or when the contracture is
associated with infected areas, delayed application can give a better
result.
When skin grafts have been used, they are immobilised by one or more
of the various techniques, viz., tie-over dressings [Figure plaster of
Paris splints, crepe bandages, elastoplasts, etc.depending upon the site.
52. POST RELEASE SSG
In general, all contractures should be treated with splitskin grafts of
intermediate or thick variety.
This allows the donor site to heal spontaneously. extensively burnt patients
with multiple contractures have a paucity of donor sites.
Full thickness grafts, although better than the split-skin grafts in most of the
properties, have poorer chances of take and their donor sites in turn need
split-skin grafts.
Their use is limited to very small defects resulting after release of contracture
in aesthetically important areas, e.g., ectropion of the upper lip, lower eyelid,
etc.
53. POST RELEASE COVER- FLAPS
flaps:
If the contracture release is likely to open up the joint, especially
of the hands and feet, or tendon/ nerve surgery is planned at a
later date, e.g., old healed electrical burns, a flap cover must be
provided after release of contracture.
If release of contracture results in a moderate defect in a cosmetic
area, which if covered with a flap will give a better aesthetic
appearance, a flap cover may be provided..
54. POST RELEASE- COVER -FLAPS
an ectropion of the upper lip in an adult male can be released and
covered with a flap from the scalp or upper neck to restore
moustaches.
In a female, the same ectropion requires a graft cover.
A groin contracture may be treated using a tensor fascia lata flap
with graft on the flap donor site.
This decreases the need for postoperative splintage to prevent
secondary graft contraction
55. POST RELEASE-COVER- FLAPS
If a local flap in the form of Z plasty (for linear/webbed contractures), V-Y plasty,
V-M plasty, etc., is available and will be sufficient in itself to treat the contracture
these flaps are always in danger of necrosis when raised in scar tissues.
they are possible only in very mild cases. They are also useful when massive
diffuse contractures are treated with split skin graft (SSG) and later on, after graft
maturation, contracting bands form at the graft-surrounding skin junction.
The flaps used for provision of cover may be loco-regional or distant. They may
be free or pedicled.
56. POST OP- FOLLOW UP
Postoperative care
Maintenance of released/corrected position is mandatory until the graft has
become stable (usually 3 weeks) or till the flap margins have healed.
Post-operative use of static or dynamic splints, interspersed with a routine of daily
physical therapeutic exercises is required to keep the joints in full range of motion
especially if static splintage is used.
This therapy is continued till the grafts have matured and complete range of
motion is achieved. Care of the grafted areas is done as detailed above till the graft
loses its tendency to contract and can be pinched and moved over the recipient
area (usually 1 year or so).
57. Post op follow up
This therapy is continued till the grafts have matured and complete range
of motion is achieved.
Care of the grafted areas is done as detailed above till the graft loses its
tendency to contract and can be pinched and moved over the recipient area
(usually 1 year or so).
