Anatomically, the head and neck, along with upper limbs, are the most frequently burned areas.1 Contractures inherently arise due to the extensive, contractile nature of the scar tissue resulting from the burn. Vascularity and hypertrophy gradually increase over time, while pliability of the dermis decreases. Burn contractures are functionally debilitating and often lead to a poor cosmetic appearance.
We report the successful use of artificial dermis and vacuum-assisted closure in the release of an anterior neck contracture in a 14-year-old boy. He was admitted with burns over 70 percent of his body, involving the face, neck, thorax, both arms, abdomen, back, buttocks, and thighs. All of the burns were full thickness, including the circumferential neck burn. Four months after the initial injury, severe anterior neck contracture necessitated fiberoptic intubations and day-to-day activities proved very difficult.
His contracture was released through a standard anterior fishmouth incision under general anesthesia, which left a 25 × 8-cm defect. Integra (Integra Life Sciences, Plainsboro, N.J.) was used (Fig. 1) and held in place using vacuum-assisted closure at continuous suction (KCI, San Antonio, Texas) for 2 weeks.
The contracture was successfully released, which improved the neck range of movement. Cosmetically, this was also more acceptable for the patient. At 6-month follow-up, there was no recurrence of the neck contracture (Fig. 2).
The objective in releasing a contracture of the anterior neck is to improve both function and appearance by restoring the anatomic profile and contour of the neck.1 A number of methods have been reported in the literature for the treatment of anterior neck contractures,1,2 including split-thickness skin grafts, full-thickness grafts, local flaps, Z-plasty, and free flaps. Tissue expansion is also an optional adjunct to reconstruction.
Integra has a role to play in contracture release.3 It consists of a biosynthetic dermis of porous collagen and glycosaminoglycan, with a thin silicone epidermal substitute. The silicone layer retains moisture and essentially closes the wound. The superficial silicone layer is removed after 2 weeks and replaced by a thin split-thickness skin graft. Histologically, the Integra is incorporated by fibroblast migration, revascularization, and remodeling. The dermal template is eventually replaced by normal dermal collagen. Integra is supple and has a thick dermal layer. It is an effective method for release of the anterior neck contracture in this case, as graft contraction and dermal thickness are inversely related.
Vacuum-assisted closure therapy was first described in 1997 by Argenta and Morykwas.4 This simple device facilitates graft take by preventing movement of the graft and protecting it from shearing forces.5 When securing a skin graft, continuous vacuum-assisted closure therapy is applied for 4 days at a low pressure of 50 mmHg. In this case, the therapy was used to secure the Integra in place at a higher pressure of 75 mmHg, which was well tolerated by the patient. This case reports the use of a novel technique to release an anterior neck contracture using Integra and vacuum-assisted closure.
Jenny B. Lynch, M.D.
Thamir S. Ismael, M.D.
Jack L. Kelly, M.D.
Department of Plastic, Reconstructive, and Hand Surgery
University College Hospital
1. Ninkovic, M., Moser-Rumer, A., Ninkovic, M., et al. Anterior neck reconstruction with pre-expanded free groin and scapular flaps. Plast. Reconstr. Surg.
113: 61, 2004.
2. Chan, E. S., Lam, P. K., Liew, C., et al. The use of composite biodegradable skin graft and artificial skin for burn reconstruction. Plast. Reconstr. Surg.
105: 808, 2004.
3. Frame, J., Still, J., Lakhel-LeCoadou, A., et al. Use of dermal regeneration template in contracture release procedures: A multicenter evaluation. Plast. Reconstr. Surg.
113: 1330, 2004.
4. Argenta, L. C., and Morykwas, M. J. Vacuum-assisted closure: A new method for wound control and treatment: Clinical experience. Ann. Plast. Surg.
38: 563, 1997.
5. Schneider, A. M., Morykwas, M. J., and Argenta, L. C. A new and reliable method of securing skin grafts to a difficult recipient bed. Plast. Reconstr. Surg.
102: 1195, 1998.
Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria:
Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/. We strongly encourage authors to submit figures in color.
We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.