Burn Contracture Release | Release and tissue replacement

Z-plasty is used when a contracture has a mainly linear component and relatively lax, vascular tissue beside it. The central limb follows the scar; equal side limbs are transposed to break up the band, reduce longitudinal tension and narrow the scarred area. It can camouflage the scar by making borders less regular. It can separate scar islands in diffuse hypertrophic scarring and restore elasticity; contour abnormalities may be corrected at the same time. Relief of tension can improve scar maturation. Unlike larger releases that may need grafting, this local rearrangement is simpler and less morbid, and the scar may continue to soften and loosen over months to years. Repeat surgery may be considered later for scars that become noticeable.

Skin grafts are commonly used for burn contractures, especially when donor sites are limited or several areas are involved. A local flap is more suitable when healthy surrounding tissue is available for small or medium defects, when release may open a joint or later tendon or nerve surgery is planned, or when a moderate cosmetic defect needs better appearance. Local flaps can also avoid prolonged splinting, but they are usually limited to mild linear or webbed contractures and may necrose in scarred tissue; severe or extensive defects need regional rather than local coverage, and vital structures may need protection with careful assessment of scar quality and blood supply by the operating surgeon.

The thicker graft has more dermis, which inhibits myofibroblast-driven secondary contraction; a split-thickness graft has less dermis and therefore more secondary contraction. Full-thickness grafts are also more pliable and durable and may match texture and color better, but they have lower take and survival and are limited by donor skin, so they are often reserved for face, hands and joint surfaces. Split-thickness grafts allow donor sites to heal spontaneously and are useful when many contractures or limited donor skin exist. Postoperative splinting and pressure are especially important after split-thickness grafting to limit secondary contraction. Thicker split-thickness grafts can reduce, but not fully stop, wound contraction.

After release, raw areas are commonly covered with split skin grafts, while flap covers are used in special situations only. If tendon or bone is exposed, flap cover becomes mandatory. Choices depend on contracture duration, involved joint or surface, cosmetic goals and functional rehabilitation. Flaps may be local, regional, distant, free or pedicled; a free groin flap is an alternative when standard flaps are unavailable. In axillary contracture, flap-based reconstructions showed greater abduction gain than skin grafting. A systematic review found flap-based techniques improved abduction by about 82 degrees versus about 52 degrees with skin grafting. The same review pooled a 13.0% recurrence rate across 855 reconstructions, mostly observational studies.

Tissue expansion works like pregnancy skin stretching: a balloon-like expander is placed under nearby skin and gradually filled with saline over several weeks, so the skin stretches and grows. In burns, this can provide sensate, like-for-like skin and may improve appearance and function of many scars without damaging a donor site. It can be repeated for major sequelae. However, expanders have higher extrusion rates in limbs, and wound dehiscence or extrusion may require premature removal and a repeat procedure. Contracture release may also use splinting, Z-plasty, skin grafts, local flaps or free flaps, depending on duration, joint involvement, cosmetic goals and rehabilitation.

Skin release alone may not correct the deformity; deeper structures can then be evaluated for possible release, including fascia, contracted or damaged muscles, adherent tendons, or contracted volar plates and joint capsules. In long-standing contractures, neurovascular bundles shorten, so release can stretch or even tear blood vessels or nerves; intraoperative examination helps determine the safe extent. Severe cases may need staged partial release, and bones or joints may require orthopedic input. The surgeon also checks joint mobility, strength, sensation and perfusion before deciding. Complete release in one operation is not always possible when deeper structures are shortened. Skin cover is usually provided after adequate release.

Severe burns often leave limited donor skin, so planning matters. Split-thickness grafts from buttocks, thighs and postaxial trunk suit trunk and limb releases; full-thickness grafts from behind the ear, cervicopectoral area and upper inner arms suit head and neck. Lower abdomen and groin are excellent full-thickness sites and usually allow primary closure. In extensive burns, surgeons use available healthy skin; thighs are excellent, lower back is often hidden, and buttocks may suit children in diapers. Grafts may also come from legs, upper limbs, abdomen, back or scalp. Large sheets are usually needed for neck, axilla and face; smaller pieces may suffice for fingers or eyelids. Multiple contractures are often released in stages.

Burn scars can tighten across joints and limit movement; surgery releases that tightness and restores flexibility, sometimes with full-thickness skin grafts. The approach varies with contracture duration, joint or surface involved, cosmetic goals and functional needs, and may be staged when several areas are affected. Immature scars may recur after early release, so timing and nonoperative care matter. Nonoperative options such as splinting, stretching and exercises can help, and surgery is considered when these do not restore useful movement. Release may use Z-plasty, grafts, flaps, tissue expanders or free flap reconstruction depending on the case and goals. Recurrence is common, so postoperative therapy, splinting and regular follow-up are vital; release may need to be staged for safety.

Severe burns can significantly reduce circulation through fluid loss, swelling and circumferential scarring, so pulses must be checked hourly and any diminished or absent pulse reported to the physician immediately. Fluid shifts can lower blood pressure and organ perfusion, while edema can compromise distal areas. Circumferential burns may need escharotomy or fasciotomy to restore limb circulation. Before lower-extremity release, neurovascular status is documented; during surgery, bundles are carefully identified and excessive stretch avoided, and the procedure may be staged. In severe longstanding contractures, release may be staged to protect nerves and vessels, and long-term follow-up with close clinical monitoring after surgery remains especially important over time because recurrence is common.

In severe long-standing contractures, musculotendinous units and neurovascular structures shorten. Their exposure can limit further release, and forceful extension may cause vessel spasm, especially in limbs. If joints are subluxated or dislocated, immediate complete release may not be possible. Multiple contractures also cannot all be released in one stage, and donor-site availability may limit reconstruction. The correction achieved at surgery is likely the maximum; postoperative splinting and therapy help maintain gains but rarely increase range beyond what was obtained on the table. Immature scars can recur, so timing and scar maturation also influence planning. Serial splintage, traction or distractor systems may then achieve full correction gradually over up to a couple of weeks before skin cover is provided.