REVIEW Open Access

Surgical treatment algorithms for post-burncontracturesKenji Hayashida1* and Sadanori Akita2

Abstract

Burn contractures produce restrictions in motion and unacceptable aesthetic results, frequently with persistentwounds. Proper planning and tissue selection are essential to minimize donor site morbidity optimizing outcomes.The principle of burn reconstructive surgery requires that the defects after release should be replaced with donortissues which have matching texture and color as well as enough pliability. Autologous skin grafting or flap surgeriesmeet these criteria to replace scar tissues and resurface the subsequent to post-released scar defects. Despite thebenefits, the use of flaps is often limited in burn patients for many reasons. If a surgeon intends to release completelyand reconstruct in one-stage operation, a large defect may result in large donor site morbidity, necessitating flapsurgery including free flap surgery. A lot of different methods and procedures are available for resurfacing the defects,and these are reviewed. In this article, algorithms for the release of burn contractures and reconstructive methods arepresented. These treatment algorithms should aid in achieving significant improvement in both joint motions andaesthetic deformities.

Keywords: Burn Contracture, Algorithm, Donor site morbidity, Perforator flap, Surgical treatment

BackgroundBurn injury is still the common cause of trauma espe-cially in low- and middle-income countries [1]. Deeppartial-thickness and full-thickness burns that are nottreated with early excision and grafting can be disabling,as these deep injuries often lead to burn scar contrac-tures unless provided with adequate positioning andsplinting. Burn scar contractures are severely disfiguring,painful, and itching. As such thing, patients with burnscar contractures which interfere with activities of dailyliving are often marginalized and experience difficultiesin receiving education and securing work [2].There are a number of therapies to reduce contrac-

tures including intra-lesional corticosteroid injection, an-tihistamines, hydrotherapy, dynamic or static splinting,laser therapy, compression therapy, and surgical excisionand reconstruction; yet, it is still unknown which ther-apy should be chosen for which contracture, when theyshould be initiated, and how long should be the periodor how often they should be continued [3–6].

Generally, contractures arise where adequate burn carehas not been applied. Even though scar management hasbeen instigated in a vigorous manner, the contracturemay also occur secondary to split-thickness skin graftingto the burn wounds. Another point, the contracture doesnot only occur due to skin loss but also may result fromthe differential growth pattern between burn scar andsurrounding tissues [7].The most powerful treatment option for contracture

release is a surgical procedure. The defect should be re-placed with the donor tissues matching texture, color,and pliability. Skin flaps including free flaps meet thesecriteria to replace scar tissues and repair the resultingdefect post release, providing superior functional out-comes [8–10]. Indeed, the gold standard for burn scarreconstruction is to use adjacent skin flaps to minimizedifferences in skin characteristics. However, achieving abalance between scar resurfacing and minimizing donorsite morbidity is a challenging problem that depends onthe size of the area involved, the region of involvement,and the availability of the non-scarred tissue for use asskin flaps. Many surgical treatments are available forburn scar contracture release. However, a recent system-atic review showed that it is still unclear which surgical

* Correspondence: tokimayu122710130311@gmail.com1Division of Plastic and Reconstructive Surgery, Department of Dermatology,Faculty of Medicine, Shimane University Hospital, 89-1 Enya-cho, Izumo,Shimane 693-0021, JapanFull list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Hayashida and Akita Burns & Trauma (2017) 5:9 DOI 10.1186/s41038-017-0074-z

http://crossmark.crossref.org/dialog/?doi=10.1186/s41038-017-0074-z&domain=pdfmailto:tokimayu122710130311@gmail.comhttp://creativecommons.org/licenses/by/4.0/http://creativecommons.org/publicdomain/zero/1.0/

procedure is the most effective [11]. Thus, surgeons arefacing with clinical problems. The purpose of this reviewwill be to outline the use of skin grafts, flaps, and devicescurrently used in burn scar contracture as well as pro-vide insight into flap surgery that might make a futureimpact in burn patients.

ReviewPrinciples of surgical contracture release andreconstructionGenerally, release of burn contracture is considered oncethe scar forming of the contracture is thought to be ma-tured. This is based on the conventional idea that inter-fering with an active scar will lead to further contractureformation. This waiting approach is representative ofwhat the contracture release and split-thickness skingrafting was the most widely performed procedure untilrecently. If split-thickness skin grafting is applied to awound, this wound would contract with the potentialityof recurrent contracture again. Additional procedureswould be required to normalize subsequent contrac-tures. These include physiotherapy to mobilize the jointsand splints to preserve the range of motion (ROM) [12].Since contracture and hypertrophic scarring increase upto the first 6 months, patients should be followed upfrequently.Recent studies and articles have questioned this wait-

ing period. As an example, full-thickness skin graftinghas been shown to reduce the incidence of subsequentectropion in the acute phase of lower eyelid burns [13].The important thing is that this timing restriction is notcapable of being applied when the defects are planned tobe covered by full-thickness skin or flap [14]. De Lorenziet al. [15] have reported waiting for 2 or 3 weeks acutely,prior to considering release and free flap covering, andtheir success rates of 94%. The procedures providedgood functional and aesthetic results with low morbidityon both acute deep burns and delayed reconstructions.As described in a number of articles [16, 17], flap sur-

geries are preferable to a full-thickness skin graft. Be-sides, the concept of “perforator flap” allows us toharvest thinner flaps like full-thickness skin [18]. Tissuethat does not re-contract and will grow with the patientsshould be used for the release of scar contractures. Forthis purpose, locally available tissue is preferred becauseit provides tissue of superior quality and containshealthy adjacent skin and subcutaneous adiposal tissue.A first study published in 2017 compared the perforator-based interposition flaps and the full-thickness grafts inthe management of burn scar contractures [19]. Theopen randomized controlled trial revealed thatperforator-based interposition flaps resulted in a moreeffective scar contracture release than full-thickness skingrafts. They observed an increase in surface area of the

flaps to 123 percent after 3 months and a further in-crease to 142 percent after 12 months. In contrast, full-thickness skin grafts showed a significant contraction;the remaining surface area decreased to 87% after3 months and 92% after 12 months. The versatility andsafety of local flaps has been improved by incorporatingperforator vessels, because the vascular supply is securedand perforators are located in throughout the body.Perforator-based propeller flaps and so-called ad hocperforator-based flaps provide well-vascularized skin andsoft tissue which has reliable pliability [20, 21]. As themulticenter randomized study excluded scars of the faceand scalp, it seems that these methods are especially ef-fective in reconstruction of burn contracture of extrem-ities and trunk to preserve ROM across joints.

Surgical treatment optionsExtremitiesThe contracture must be fully released whether a bandor a sheet of scar tissue exists. The incision for contrac-ture release should be done at the meridian of the jointand fish-tailed at both ends of the scar, extending intonormal medial tissue and lateral tissue (Fig. 1). Thisprocedure will increase the size of the defect to becovered. Then, reconstructive procedures include thefollowing (Fig. 2).

In mild contractures (>50% joint range of motion)For extremity contracture, Hudson et al. divided theminto mild and severe type by less or greater than 50%ROM on the basis of their much experience in this field[14]. The classification is a simple judging method to de-termine the severity of post-burn contractures. Local tis-sue rearrangement such as Z-plasty can be used tolengthen and transpose the scar. Transposing the flapsof Z-plasty lengthens the central limb and narrows theinvolved scar by the medial transposition of the flaps.And then, the flap tips should be incised perpendicularto the central limb for a short distance to supply moreenough skin and soft tissue. Following transposition, the

Fig. 1 Inadequate incision cannot release the contracturesufficiently. Bilateral fish-tailed incision should be made atappropriate points

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irregular borders could help to camouflage the scars(Fig. 3). Many variations of Z-plasty and YV-plasty in-cluding the opposite running YV-plasty [22] have beendescribed such as W-plasty, 5 or 4 flap-plasty, and mul-tiple Z-plasty. When the scar around a band is mature,these variations are more easily applied. Unless the scaris mature, these local tissues around inflammatory scarsmay result in flap necrosis.

In severe contractures (

compromised in the intended position, the flap was con-verted to an islanded flap. This was a clinical decisionthat allowed for greater angles of rotation where neces-sary. Low recurrence rate is the most important advan-tage of the flap transferring. The wide variety of flapchoice allows the surgeon to make judgement dependingupon each individual case. One limitation of perforator-based local flaps is that sufficient adjacent normal skinhas to be available. In that case, free flap transfer is agood option especially in the extremities, when only onejoint has a severe contracture from broadened sheet ofscar. Since perforator vessels are usually protected inmost burn cases, the vessels can be used as recipientvessels for free flap transfer. However, free flaps fre-quently result in importing tissue of different color, tex-ture, and thickness. This may lead to unacceptableaesthetic result. Furthermore, the flap must be the samesize as the defect. This should lead to a large donor de-fect requiring coverage with split-thickness skin graft.

FaceThe long-term results showed confidently that flapsperform better than full-thickness skin grafts in provid-ing a safe and effective method to resurface post-burnscar contractures in the face. Understandably, the aes-thetic results are better as well. However, a randomizedcontrolled trial for the scars of the face has not beenperformed to determine which technique has the besteffectiveness in post-burn contracture release. Besides,because of the relative lack of objective data on out-comes, individualized reconstructions pertaining toeach unique aesthetic region of the face should be per-formed. The most problematic late outcomes thatPhilip et al. identified after facial burns included gapsbetween grafts and hairline, eyelid ectropion, noseasymmetry, and marked hypertrophic scarring aroundthe lip [35]. In our algorithms, we chose these three

areas in the face to improve the post-burn patients’quality of life (Fig. 4).

Eyelids Late complications of eyelid burns includeectropion and lagophthalmos as a result of secondaryburn contractures [35]. Significantly, this may resultin further corneal damage and risk to sight [36].However, total visual loss is thankfully rare. The goalin management of eyelid burn contractures is preser-vation of eyesight, prevention of future complica-tions, and aesthetic restoration [37]. There are anumber of operative procedures and methods formanaging periorbital burn scar contractures. To cor-rect ectropion, the upper eyelid should be releasedat the level of the supra-tarsal fold, and the lowereyelid should be released at the sub-ciliary margin.And then, they are reconstructed using full-thicknessskin grafts or local flaps such as laterally based cuta-neous flaps or reverse flow nasolabial flaps [38].However, the surrounding tissue is usually not avail-able because of severe burn scarring, in addition tothe added facial scarring. Therefore, temporoparietalfascial flap based on temporal arteries in periorbitalreconstruction has been widely accepted includingeyebrow reconstruction with hidden scars [39]. Theisland flap including a reverse flow flap provides anoptimal result for the eyelid contracture with min-imal donor site morbidities. Elbanoby TM [40]described two skin paddles based on a single superfi-cial temporal artery to reconstruct the upper andlower eyelids simultaneously. There were some caseswhose flap may be hairy, but the patients canundergo laser hair ablation to correct and solve thisissue. This technique may be innovative and usefulfor the reconstruction of three different unique aes-thetic facial units (eyebrow, upper eyelid, and lowereyelid) with one-stage island flap.

Fig. 4 In the face, an algorithm for the defect after release of burn scar contracture

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Nose Secondary nasal reconstruction is based on an as-sessment of the residual functional and aesthetic prob-lems. Airway narrowing or nasal valving are managedusing internal nostril splints and standard rhinoplastyprinciples. The forehead flap with or without expansionis usually used for reconstruction of non-graftable nasaldefect. However, it is difficult for local flap options to beused because the adjacent tissue may be damaged as wellas eyelid reconstruction. The forehead is often involvedin a full-thickness burn, and conchal cartilage may belimited for graft material. As such thing, there are anumber of articles of the use of free flaps to reconstructthe nose [41]. Reconstruction of the nasal tip, columella,and alae by free flaps derived from the base of the helixseems to give good functional and aesthetic results. Thestructural similarities between the nasal alar and the aur-icular helix have allowed the use of free helical compos-ite grafts to reconstruct small nasal defects of less than2.0 cm. Although relatively easy to perform technically,they are restricted by problems such as viability, dimen-sions, and atrophy. A free tissue transfer harvested fromthe ascending helix has been used to repair defects ofthe distal part of the nose [42]. As a non-microsurgicaltechnique, based on the well-documented anatomy ofthe superficial temporal vessel, Li et al. described amicrovascular auricular flap by a reversed superficialtemporal vessels pedicle to surgically treat the distal de-fects of the nose [43]. The presence of vascular commu-nications between the anterior frontal branch of thesuperficial temporal system and the supraorbital andsupratrochlear arterial systems allowed this flap to beused in a reverse blood flow fashion. Krastinova et al.described a simple and reliable procedure [44]. They re-ported their experience of nasal alar reconstruction by ascar tissue remodeling technique using a rolled dermalflap with overlying full-thickness skin graft according toaesthetic units in a single operation. Taylor et al. haveused an inferiorly based nasal turndown flap in 28 pa-tients [45]. In their article, contraction of local scar tis-sue created bulk and support for nasal tip and alar,eliminating the need for distant tissue transfer or cartil-age grafting. The flap consists of the dorsal surface ofthe nose, usually made up of skin graft and scar. Dissec-tion is carried down to the periosteum with care to pre-serve a broad blood supply. The flap is then foldeddown on itself, and the resulting defect is resurfacedwith a medium to thick split-thickness skin graft. Thissimple technique has been outstandingly successful forthe post-burn patients with nasal deformities.

Lip The lip deformity after burn injury may be complexsuch as a functional disfigurement interfering witheating, airways, and speech, and/or an appearance.Hypertrophic scar contracture of the lip and chin area

frequently causes eversion of both the upper and lowerlip. There is an intrinsic lip contracture which cannot becorrected by a neck scar release alone. Also, associatedscarring at the oral commissures may limit the ability toopen the mouth. In that case, sufficient skin and soft tis-sue are needed by transplant to the lip and chin area. Alot of reconstructive methods for burn deformities anddefects of the lips have been developed [46–51]. The ef-fective technique Saadeldeen WM [46] introduced forcheiloplasty in burn scar management creates natural liplines and natural lip red substance without any aggres-sive undermining or adding any more scars. His surgicaltechnique for upper lip cheiloplasty was performed asfollows: excision of the scarred Cupid’s bow and upperlip vermilion lifting to augment the vermilion and re-draw the lazy M-shaped Cupid’s bow. Lower lip cheilo-plasty was designed for bordering, using a full-thicknessskin graft for the chin area. After 12 months follow-up,the end result was assessed by patient satisfaction, whichwas fairly good in 89.1% of cases. However, it needs skingraft. The take rates of full-thickness skin graft aroundthe mouth should be low, significantly because of diffi-culties of complete rest and prevention from food andfluid. Regarding the lip reconstruction in burn cases, freeflap covering based on an aesthetic unit is frequentlybetter than local flaps in the aspect of its texture. Recon-struction of labio-mental sulcus relatively seems to bedifficult. For a free flap, the thickness of the flap shouldbe reduced mostly and the cervico-mental angle tends tobe dull, causing unnatural contour as well. Forearm flapand other thin flaps can solve these problems. In flapsetting, Lee JW [47] defatted the forearm flap base par-tially, and incision was done to the dermis about 2–3 cmin length. Then, they adhered the dermis of the defattedflap to the lower lip muscle to produce an acceptablesulcus. Oh SJ [51] described a hairy preauricular free flapto correct a moderate defect of the upper lip for male.The flap was harvested from hairy posterior sideburnskin of preauricular area including superficial temporalvessels. The procedure resulted in an acceptable appear-ance with normal hairy skin.

Growth factors: surgical applications to prevent scarcontractureGrowth factors are endogenous signaling proteins intim-ately involved in wound healing. These proteins are up-regulated in response to tissue damage and act throughautocrine, paracrine, or endocrine mechanisms to facili-tate re-epithelialization by binding to membrane-boundor cytoplasmic receptors. Even at low concentrations,growth factors can have a profound impact on thewound microenvironment, leading to rapid increases incell migration, proliferation, and differentiation. Applica-tion of human-recombinant growth factors has been

Hayashida and Akita Burns & Trauma (2017) 5:9 Page 5 of 8

shown to mimic these effects, allowing for externalmodulation of the healing process. This has led to anumber of applications in the surgical area where con-trolled delivery of growth factors holds great therapeuticpotential. In fact, perioperative delivery of exogenousgrowth factors is a routine adjunctive treatment in anumber of surgical specialties, including burn surgery.Growth factors are classified into several families

based on their characteristics. The most relevant growthfactor families for wound healing are the epidermalgrowth factor (EGF), transforming growth factor β(TGF-β), platelet-derived growth factor (PDGF), vascularendothelial growth factor (VEGF), and fibroblast growthfactor (FGF).In terms of scarring, some articles demonstrated that

FGF-treated scars showed a better process of skin re-modeling, which may avoid the subsequent developmentof fibro-proliferative disorders [52–57]. The FGF familycontains more than 20 members, of which, the mostrelevant for wound healing are FGF-2, FGF-7, FGF-10,and FGF-22. FGF-2, also known as basic FGF, is releasedfrom damaged endothelial cells, macrophage, or mono-cyte and is one of the most potent isoforms in FGF fam-ily. The bFGF is a mitogenic and chemotactic factor forfibroblasts and endothelial cells, and stimulates angio-genesis. In burn treatment, accelerated wound healing,maintenance of the complex system of melanization,and diminishing activity of erythema by bFGF will leadthe wound to a closer pliability and color to adjacentskins [53, 57]. Besides, bFGF treatment is effective toprevent scar contracture especially in pediatric palmarburns [58]. While current results are promising, add-itional clinical trials are needed before FGF becomeswidely accepted in surgical management for burn pa-tients to avoid scar contractures and hypertrophic scars.

Use of artificial dermisArtificial dermis as a scaffold has been used and devel-oped in reconstructive surgery, and now we can seesome reports of one-stage skin grafting with it [59, 60].There are several reports that this material is effective inskin defects, which are accompanied with exposure ofdeep structures and more brittle local tissue textures[61]. Artificial dermis allows for neodermis to form overthe surface of the wound and minimizes the number ofmigrating myofibroblasts. Besides, combined use ofbFGF is furthermore effective in order to facilitate theformation of good granulation tissue and to reduce post-operative contraction [62]. This resulted in less contrac-tion with fewer adhesions to the underlying bones,tendons, and nerves. However, dermal substitution inpost-burn surgery has not become practical, because asubjective and objective long-term follow-up studyshowed that no significant differences were found for

skin elasticity, scar contraction, Vancouver Scar Scale,and patient’s impression in both categories between acombination of the collagen substitute with an autograftand the conventional split-thickness autograft [63].Disadvantages include donor site morbidity from split-

thickness skin graft harvesting, lower take rates thanconventional autografts, and higher cost implications.Usually, it is a two-stage procedure. Soejima et al. foundthat areas of keloid cannot respond to artificial dermisand tend to lead to re-contracture [64]. Despite adequatesplinting, the results of artificial dermis over the jointsare on the whole disappointing [65]. For these reasons,treatment of burn deformity with artificial dermis maybe beneficial in selected cases including elderly patientswith a poor systemic condition.However, recent advances in the field of tissue engin-

eering and dermal substitution may create new optimalalternative methods for post-burn scar reconstruction inthe near future. Stem cell technology is one of the candi-dates toward the treatment with artificial dermis. Amongthese stem cells, adipose-derived stem cells (ADSCs) canbe harvested with a minimally invasive method by lipo-suction through small incisions. Akita et al. showedthat ADSCs mixed with fat tissue have potential in celltherapy together with an artificial dermis for neckcontracture. In the article, the injected subcutaneouslesion has still kept its soft texture and demonstratedthe thick and vascularized soft tissue in 6 months aftercell therapy [66].

Use of tissue expandersThe reconstruction using stage transfer of expanded thinflaps is a relatively safe method. Expanded skin is thesame or very close in color, thickness, and texture asadjacent skins. The procedure using tissue expander iscommonly performed in the neck, chest, and scalp. Also,the use of pre-expanded scapular free flaps is a practic-able procedure to ameliorate the final aesthetic appear-ance and functional result for the reconstruction ofneck contracture by reducing donor site morbidity [67].Gao et al. [68] reported the expanded flap of “super-thin flaps.” The advantages of this type of flaps are thefollowing:

1. Very large flaps can be harvested because of theexpansion

2. Super-thin flaps can be employed with safety3. Texture and color match are good in the case of the

anterior chest wall near the recipient site4. Donor sites can be closed primarily5. Microsurgical operation is not required

However, in the burned extremity, on the contrary, thetissue expander seems to be difficult to use. This procedure

Hayashida and Akita Burns & Trauma (2017) 5:9 Page 6 of 8

requires two or three operations, and the multiple surgeriesshould be stressful for patients. Also, it is often difficult topredict the size of the defect at the time of organizing theexpansion. Infection, leakage, and skin ischemia may becomplicated by expansion. There is often a considerabledelay between diagnosis and treatment for the complica-tions, as multiple operations are required. Compliant andperseverant patients are needed, and multiple patients’visits are required to inflate the expanders weekly or so.In contrast to full-thickness skin grafts, flaps in the ex-

panded tissue contain subcutaneous adipose tissue. Itmay be hypothesized that the subcutaneous fat acts as afunctional gliding layer to prevent the skins from adher-ing to the underlying tissue. In addition, the presence ofsubcutaneous adipose tissue may also explain the factthat the flaps are found to be more similar to normalskin and softer than full-thickness skin.

ConclusionsFull-thickness skin grafts and local flaps produce satis-factory outcomes when performed for the reconstructionof burn contracture defects by experienced surgeons.Free perforator flap transfer with minimal morbiditiesmust be useful in patients who are willing to receive alonger operation and a longer hospital stay with thebenefit of improved aesthetic results at both recipientand donor site. In the future, interposition flaps basedon a perforator may become a mainstay in post-burn ex-tremity and trunk surgery.Beneficial algorithms have been invented which are

used to assist reconstructive surgeons in selecting appro-priate reconstructive methods following release of burnscar contractures. These algorithms are an attempt tosimplify the approach to burn contracture reconstruc-tion. Advantages and disadvantages of these differentmodalities should be considered and compared beforedeciding the treatment.

AcknowledgementsNot applicable.

FundingNot applicable.

Availability of data and materialsNot applicable.

Authors’ contributionsKH wrote the review manuscript and applied the reviewers’ comments andSA revised the article. All authors read and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Consent for publicationNot applicable.

Ethics approval and consent to participateNot applicable.

Author details1Division of Plastic and Reconstructive Surgery, Department of Dermatology,Faculty of Medicine, Shimane University Hospital, 89-1 Enya-cho, Izumo,Shimane 693-0021, Japan. 2Department of Plastic Surgery, Wound Repair andRegeneration, Fukuoka University, Fukuoka, Japan.

Received: 13 January 2017 Accepted: 6 March 2017

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Hayashida and Akita Burns & Trauma (2017) 5:9 Page 8 of 8

AbstractBackgroundReviewPrinciples of surgical contracture release and reconstructionSurgical treatment optionsExtremitiesFace

Growth factors: surgical applications to prevent scar contractureUse of artificial dermisUse of tissue expanders

ConclusionsAcknowledgementsFundingAvailability of data and materialsAuthors’ contributionsCompeting interestsConsent for publicationEthics approval and consent to participateAuthor detailsReferences