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Research Article | Volume 5 Issue 1 (None, 2019) | Pages 101 - 107
A Clinical Study of Post Burn Contracture Neck in a Tertiary Care Teaching Hospital
 ,
1
Associate Professor, Department of Plastic Surgery, Narayana Medical college, Nellore, Andhra Pradesh
2
Associate Professor, Department of Plastic Surgery, Osmania Medical college, Hyderabad, Telangana.
Under a Creative Commons license
Open Access
Received
Jan. 28, 2019
Revised
Feb. 12, 2019
Accepted
March 27, 2019
Published
March 30, 2019
Abstract
Background: Introduction: Post burn contracture continues to be a problem in plastic and reconstructive surgery. After release of the contracture the resulting raw area needs a suitable covering. The conventional methods range from the use of split-thickness skin graft, local manipulation of tissue by advancement, transposition, fasciocutaneous, myocutaneous flaps and free micro vascular flap. Aim and Objectives: To assess the extent of restoration of Cervico-Mental angle and the range of cervical movements. To assess the compliance of patients in usage of splint and to assess the complications in patients while undergoing surgery and post-operatively. Materials and methods: This study was planned with twenty cases of post burn contracture of the neck where correction has been done with excision and cover with thick split skin grafting supported with a molded cervical splint. The extent of improvement of movements of the neck after surgery is measured and reported. Results: Nineteen patients had contractures of the neck following flame burns and one patient had chemical burn with acid. Sixteen patients had a good graft take (95-100 %) and improved further with splint, massage and physiotherapy. Four patients had graft loss in patches which were significant enough to receive supplementary graft. They also healed and showed good improvement with ancillary treatment. There has been a satisfactory improvement in the range of motion at the neck following treatment with skin grafting with a good take supplemented with pressure assisted simple splint (80-100 %). Conclusion: The graft take was excellent with FTG, with high color and texture match. The graft take, the color match and texture was equally good with 14 of the remaining patients. Four patients had patchy graft loss which was re-grafted with stored graft in two and fresh SSG in the other two to obtain a good result. A ready made cervical collar was used by all the twenty patients irrespective of the procedure. This splint was easily obtained from the splint-maker, inexpensive and had the highest patient compliance.
Keywords
INTRODUCTION
Post burn contracture continues to be a problem in plastic and reconstructive surgery. After release of the contracture the resulting raw area needs a suitable covering. The conventional methods range from the use of split-thickness skin graft, local manipulation of tissue by advancement, transposition, fasciocutaneous, myocutaneous flaps and free micro vascular flap. VAC assisted closure or reduction of the wound coupled with use of artificial dermis is reported 1. Tissue expander to generate more local skin also has its role. Each of these techniques has its advantages as well as its hazards and limitations. The ideal material for coverage of defects created by neck contracture release is thick, supple, large, healthy tissue with same texture, color and thickness without the possibility of subsequent contracture, available in abundance and easy to harvest with least donor site morbidity. This should be supported with a suitable molded splint with pressure on the graft. A thick split skin graft serves as an adequate cover for the post excision raw area. This should be well splinted to restrict motion and shearing of the graft to ensure a good take of the graft. Pressure technique with the splint will give a smooth finish to these grafts and obtain a wrinkle-free graft. Such a grafted neck gives adequate functional result by way of extension, lateral movements, and fulfills reasonable cosmetic appearance. This study was planned with twenty cases of post burn contracture of the neck where correction has been done with excision and cover with thick split skin grafting supported with a molded cervical splint. The extent of improvement of movements of the neck after surgery is measured and reported. Most scar contracture of the neck results from thermal burns. Less frequently they are caused by electrical, radiation or chemical burns. The proper treatment of severe contractures of the anterior neck has been a challenging problem from time immemorial. For the same reason, multiple procedures are being still tried with variable result. No single procedure fulfills all the criteria. Various flaps have been advocated by surgeons all over 2-8. This involved a number of procedures spread over many days and yet patient had no satisfaction as these were bulky, insensitive and cosmetically less appealing. There have been advances made in the anatomy of flaps after understanding of Angiosomes. With the advent of various flaps like fasciocutaneous flaps, myocutaneous flaps, fascial flaps, free flaps, the scope for re-surfacing of the post excision defects are wider now. Others recommended full thickness skin graft 9-13. If it takes well, offered a smooth surface and had the least recurrence rate. Skin grafts were developed as a way to prevent such consequences as well as to correct deformities. As early as the sixth century B.C., Hindu surgeons (Sushrutha) were involved in nose reconstruction, grafting skin flaps from the patient's nose. Gaspare Tagliacozzi, an Italian physician, brought the technique to Western medicine in the sixteenth century. Split-thickness skin grafts have been advocated by many 14-21. As ordinarily used they have been disappointing due to high incidence of wrinkling of the graft and post operative recurrence of contracture. Splinting-pressure techniques as preventive measures to avoid these two have been advocated by Cronin et al and this has gone a long way to make SSG as the treatment of choice in post burn contracture of the neck. The accomplishment of safe anesthesia was the important advancement and contributed in a big way to a good outcome. Equally important has been the use of splint and pressure technique. The role of controlled tissue expansion and VAC assisted closure contribute a forward step in the treatment of reconstruction of a mento sternal contracture. AIM & OBJECTIVES: 1. To assess the extent of restoration of Cervico-Mental angle and the range of cervical movements. 2. To assess the compliance of patients in usage of splint. 3. To assess the complications in patients while undergoing surgery and post-operatively. 4. To study the Re-Contracture rate and redo surgery.
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