Burn scars are known for their poor cosmetic appearance and contracture formation, and patients may therefore require surgery.

Contracture formation often leads to functional impairment, requiring surgical reconstruction. Poor cosmesis and deformation anywhere, but especially of the face, can cause social rejection and isolation, so cosmetic reconstruction may also be important.

Contractures often reduce mobility and impair function. Most commonly, contractures involve one or more joints, but they can also form a constricting band around the circumference of an extremity, interfering with muscle function. If this is around the thorax or abdomen, it can debilitate respiratory function; if it is in the genital area, contracture can interfere with normal urogenital function.

A common misconception is that anything is possible in plastic surgery. Burn victims will often bear visible scars due to their trauma.

The main principle in reconstructive surgery is the restoration of function, with the ideal reconstruction restoring both form and function.

Functional improvement often also means aesthetic improvement. Although reconstruction for functional movement of the extremities is different from reconstruction of burn scars and defects of the face, the same principles apply.

Other features of burn scars, such as discoloration and itching, can cause functional impairment.

Principles of scar management.

General principles of burn scar contracture treatment

Contractures can be caused by deformities of bone, ligaments, tendons, muscle, and skin.

Often, burns and burn contractures are limited to the skin and subcutaneous tissue, and in these cases all the underlying tissues and structures are normal and functional. However, this is not always the case. Fibrosis of deeper layers or loss of functional tissue (nerves, tendons, arteries, veins, ligaments, and cartilage) can seriously impair the outcome of reconstructive surgery and should be taken into consideration.

Always evaluate the scar carefully before attempting reconstructive surgery.

After prolonged exposure to the cause of the burn (for example due to loss of consciousness or epilepsy), the burn wound can be particularly deep and may involve deeper functional structures. 

You can learn a lot about the affected area by examining it carefully. For example, if the joint is easily mobile within the limits of the contracture, it is less likely that the deeper structures are affected. If the joint is completely immobile, but the skin over it can be moved up and down, the contracture may reach the deeper structures and release of a skin contracture will not result in adequate functional improvement.

Assessing the potential of skin release surgery

In most burn contractures, the functional restriction lies in the skin, therefore surgical treatment often means releasing the skin contracture and closing the created skin defect with a flap or a graft.

If the muscles feel supple and normal upon palpation, you may achieve a good result with skin release surgery. But if the muscle feels hard and fibrotic, the functional gain of this surgery is likely to be limited.

Setting up a service for treatment of burn contractures always requires a multidisciplinary approach.

In general, surgery for contractures is only successful if the patient can be given the correct aftercare, such as splinting and physiotherapy.

Muscles and ligaments will shorten over time if their movement is restricted by a contracture of the skin, even when they are not primarily affected by the burn. These structures need to be gently stretched, trained, and sometimes even splinted over a long period of time to regain adequate function.

The longer a contracture has been present, the more difficult it will be to restore full range of motion (ROM) and the more important the aftercare becomes.