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Release of Anterior Neck Burn Contracture Using Artificial Dermis and Vacuum-Assisted Closure

Lynch, Jenny B. M.D.; Ismael, Thamir S. M.D.; Kelly, Jack L. M.D.

Author Information
Plastic and Reconstructive Surgery: January 2008 - Volume 121 - Issue 1 - p 352-353
doi: 10.1097/01.prs.0000300296.06731.74
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Sir:

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.

Fig. 1.
Fig. 1.:
Contracture released with Integra in situ.

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).

Fig. 2.
Fig. 2.:
View of the patient 6 months after contracture release.

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

Galway, Ireland

REFERENCES

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.

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