Contractures
About Contractures
Scar contracture is a process that occurs due to an increased and prolonged wound healing response. During the final stage of wound healing (matrix remodelling), the persistent activation of myofibroblasts is a big contributing factor to the formation of scar contracture. Scar contractures will typically appear as fixed, rigid scarring that is confined to the area of trauma. The skin will feel tight and constricted, which can lead to pain, permanent physical disabilities and functional limitations. Deep burns (which lead to greater scarring), especially when over or near a joint can cause contractures. Contractures can be quite common after burn injury. Prevention of scar contractures involves surgery (skin grafting) and wound management to speed wound healing times, and therefore reduce scarring. In combination with this lots of active movement, maybe splinting and other advice given by a physiotherapist is important to prevent and treat contractures. Surgical technique is also important: incisions that are placed parallel to relaxed skin tension lines or that may have irregular angles are more likely to heal satisfactory without functional or cosmetic problems.
Burn contractures may be visible by around 4 weeks post burn, but they can continue to improve or worsen over many months post injury and require longer term care to monitor, prevent or minimise them.
Recommendations
Scar contracture must be treated as soon as possible since this type of scarring can result in restriction of movement around the injured area. If your scar is pulling at a feature e.g., your eyelid is being pulled down or your movement is feeling tight or limited, please see a specialist. The management of the scar contracture can include one or a combination of the following treatment options:
- Silicone-based products
- Massage
- Splinting
- Stretching and exercise
- Lasers
- Surgical intervention
Treatment will typically begin with non-invasive methods (silicone products, pressure therapy, exercise, or splinting); more invasive options such as laser or surgical release may be required if non-invasive options do not achieve the maximum benefit. After contracture surgery, the non-invasive treatment options help to maximise surgical results and prevent anymore loss of movement.
Treatment options for Contractures
Silicone Therapy
Scars and skin graft donor sites need regular creaming (moisturisation) to prevent the area from drying, cracking and becoming sore. The oil glands in your skin which usually provide moisture can be damaged or destroyed by the injury. The surface layer of the skin which prevents water loss is damaged. Therefore, the healed skin lacks the moisture needed. Silicone works by sealing in the moisture and hydrating the scar. Through providing occlusion (covering) and hydration to the outer layer of the epidermis evaporation of water is reduced from the skin. Silicone treatment aims to flatten, soften and reduce the redness and discomfort of your scar over time. Silicones possess many skin-friendly properties; they are easy to use and remove, painless, can be worn for long periods, are resistant to microbial growth, and are waterproof.
Scar Massage
Scar massage is a non-surgical technique used in day-to-day scar and burn care. There are multiple techniques that can be used and that are quite easy to apply.
Vacuum Massage
Vacuum massage is also known as depressomassage, vacuotherapy or Endermologie®. It is a non-invasive mechanical massage technique. It is performed with a mechanical device that lifts the skin by suction and creates a skin fold which can be mobilised. In the late 1970s, Louis-Paul Guitay developed the Endermologie® system (or LPG), this uses both suction (negative pressure) and mechanised rollers to mimic manual massage. LPG can provide consistent and effective treatment in a shorter time. Treatment sessions are painless and vary from 10 minutes to longer depending on the state and size of the scar.
Scar Taping
Elastic taping (kinesio tape) is an acrylic adhesive that is often used as a physiotherapeutic tool for the treatment of various musculoskeletal problems and other clinical conditions in athletes and patients.
Exercise and Splinting
People who sustain burn injuries can experience reduced activity performance due to periods of immobilisation, ventilator dependence, the burn-related catabolic response, pain, limiting scars, muscle weakness and reduced fitness levels. High levels of fatigue may also be experienced. Many of these problems can be more noticeable after discharge from hospital.
Micro-Needling
Micro-needling is a semi-invasive technique that can be used on the face and body to achieve collagen induction (production). In this technique the skin or scar is pricked with needles to cause percutaneous collagen induction, this builds up connective tissue underneath retracted (contracted/stuck) or hypertrophic scars and wrinkles.
Non Ablative Fractional Laser (NAFL)
A Non-Ablative Fractional Laser (NAFL) is a non-wounding laser, it does not damage the integrity of your epidermis. NAFL uses a wavelength that does not evaporate the water in the tissue, and the energy from the laser heats the tissue in a controlled manner. Therefore, many patients prefer NAFL to ablative laser treatment. The rise in temperature stimulates the production of new collagen. By producing new collagen, the remodelling of the scar tissue is improved. Although NAFL is less invasive, requires less recovery time and has less complication risks, is not as effective as ablative laser resurfacing.
Ablative Fractional Laser (AFL)
The Ablative Fractional Laser (AFL) is a wounding laser, which delivers micro fractional columns of laser light to the top layers of the skin. This treatment works by creating thousands of microscopic areas, through heat, where the top layer of the skin is ablated (removed). These tiny areas of damage are surrounded by untreated skin, this allows healing of the skin. Traditional ablative laser resurfacing can take on average up to three weeks to heal. Types of ablative treatments include the carbon dioxide (CO2) laser and the erbium laser. AFL is performed under local anaesthesia.
Surgical Scar Revision
Annually, 200 million incisions (surgical cuts) are performed worldwide. The treatment of aesthetically unacceptable scars can be challenging, although several options are available. These options vary from non-invasive options to invasive scar revision. As there are lots of options along this spectrum it is important that you seek advice for your specific concerns from a surgeon specialised in scar.
Patients often see a plastic surgeon once they have tried lots of other non-invasive options. However, sometimes there are non-invasive options that could be more appropriate than surgery; again, an assessment by your scar specialist is important.
While various surgical options exist, all surgery carries risk and therefore a full assessment is important so that you can let the surgeon know what your concerns are. The surgeon can explain all the possible procedures, the pros and cons of each one and what can or can’t be achieved with surgery. Sometimes more than one surgery will be needed and follow up after surgery is also important.