Two years before seeking surgical evaluation for her scars, the patient suffered severe burns due to a flash incident. Her clothes caught fire when spirits were accidentally poured on a lit barbecue (photo 1). The Medical Emergency Response Team (MERT) promptly provided first aid by removing her clothes and cooling the burned skin under a shower. She was then transferred to a Burn Center after a primary survey at a regional hospital, as she had burns on her face, neck, trunk, both arms, and left hand. The affected area accounted for 20% of her total body surface, with 9% being deep burns.

The patient was extubated after five days, and within two weeks, the superficial burns had healed. A delayed, staged grafting approach was employed, successfully performing a split skin graft on the neck burns 15 days post-burn. Ten days later, the remaining small defects, including a portion of the neck, were treated with another split skin graft. Due to hypertrophic scarring, scar treatment was initiated, and conservative management involving pressure garments and neck splinting with a silicone collar proved beneficial.

Despite these interventions, the patient continued to experience limited mobility in her neck 2.5 years after the burn (photo 2). Her primary concern was the inability to look up and backwards, which hindered activities like biking and obtaining a driving license.

Upon examination, limited extension and rotational movements were observed in the neck. The hypertrophic scars had flattened but remained non-elastic, with raised and hypervascularized areas. At the outpatient department (OPD), preoperative Doppler sonography was utilized to locate a supraclavicular perforator that could be utilized for a perforator-based interposition flap.

The surgical procedure involved the release and reconstruction of the neck contracture. A local flap with a sufficient perforator was designed and carefully dissected, while ensuring closure of the donor site. The contracture was released, and the flap was successfully sutured in place (Photo 4).

Following the surgery, a light dressing with Vaseline gauzes was applied. The wound was inspected the next day, revealing good vascularization of the flap (Photo 5). Over the subsequent months, the scars showed improvement with the help of massage therapy, gradually becoming less active (Photos 6 & 7).

After a year, it became evident that the contractures were not fully resolved. As a result, a second surgery was performed to release the neck and reconstruct it using a full-thickness graft from the abdomen. The procedure proved successful, with the graft fully taking and resulting in satisfactory mobility of the neck. Five years later, the remaining scars were treated with cupping, a non-evidence-based conservative approach that the patient found beneficial. Presently, the patient experiences minimal limitations in neck movement.

The purpose of surgery is to release the contracture in order to improve function. Releasing a contracture leads to a defect that requires closure, and various surgical techniques are available for reconstruction after the release. In this case, both a FTG and a perforator-based interposition flap were good options. 

In less experienced hands, a FTG is a good first choice as it is a relatively simple and safe option. Although FTGs shrink less than SSGs, FTGs are still subject to shrinkage, which can potentially cause a new contracture. Perforator-based interposition flaps do not shrink and even possess the ability to increase in surface area. It is for this reason that the team opted for this technique for this patient as a first choice. However, as it did not provide enough mobility a second procedure was required, and the remaining contracture was successfully treated with release and FTG reconstruction. 

A large and deep burn has long term consequences. Due to scar formation, a patient will need medical care for a long period of time, with aftercare being equally as important as surgery. The burn injuries and the aftermath had significant consequences for this patient’s social life and professional career. She was advised to seek help from a personal-injury lawyer which resulted in financial compensation, helping her to commence studying once she had sufficiently recovered. 

It is important to bear in mind that burn patients recovering from large burns are often not mentally sound during recovery; this may be due to trauma, pain, or medication. Therefore, it is even more important to be aware that a patient may only be ready for “the next steps” such as physiotherapy or a legal process years later.

As a general rule, normal local flaps should be designed with a length that is approximately 2-3 times the length of the base of the flap. As shown in photo 3, a flap with a sufficient perforator can be longer (photo 3). 

During the procedure, the flap was first dissected and the donor site subsequently closed. Finally, the contracture release was performed and the flap was sutured in place (photo 4).