J Gandhara Med Dent Sci

ORIGINAL ARTICLE

SURGICAL MANAGEMENT AND LONG-TERM OUTCOMES OF POST-BURN NECK

CONTRACTURES

Muhammad Mudassir Mahboob

, Adeeba Ahmad

, Muhammad Shadman

, Fahimullah Khan

, Shahzad

Adil Rehman

, Iqra Bakhtawar Zafar

ABSTRACT

OBJECTIVES

The study aimed to assess the range of motion and graft recipient site

complications in post-operative burns patients.

METHODOLOGY

This descriptive cross-sectional study was conducted at the Burns and Plastic

Surgery Centre in Peshawar over a period from January 2019 to December

2024. A total of 40 patients diagnosed with post-burn mento-sternal neck

contractures were included in the study. Participants of all age groups, both

male and female, were considered, while patients with infected contractures,

sinus, or stula burns, or those who had undergone previous surgeries

elsewhere were excluded. Range of motion of neck and graft recipient site

complications were recorded from the patient records. Data were analysed

using SPSS version 25.

RESULTS

The study included 40 patients, with 30 (75%) males and 10 (25%) females.

The mean age of the patients was 22.20 ± 10.12 years, with an age range of

10 to 45 years. Most burns were ame-related (80%), while scalds caused

20%. For those treated after 12 months, 24 (60%) underwent skin grafting,

while 10 (25%) exhibited poor skin texture. Good range of motion was found

in 24 (60%) patients while 10 (25%) patients had fair ROM at 12 months

follow-up.

CONCLUSION

Post-burn neck contractures are a common and challenging complication of

burns, typically managed with surgical interventions such as skin grafts, local

aps, and Z-plasty. The overall outcome of these procedures is greatly

inuenced by early and consistent physiotherapy. A well -structured follow-up

program for up to 18 months is essential for ensuring optimal functional

recovery and improving long-term outcomes.

KEYWORDS: Burns, Post-Burn Neck Contractures, Physiotherapy, Surgical

Management, Skin Grafts, Z-Plasty

How to cite this article

Mahboob MM, Ahmad A, Shadman

M, Khan F, Shahzad, Rehman A, et al.

Surgical Management and Long-Term

Outcomes of Post-Burn Neck

Contractures. J Gandhara Med Dent

Sci. 2026;

13(1

32-36.

Date Submission: 24-03-2025

Date Revised: 13-07-2025

Date Acceptance: 24-07-2025

Specialist Registrar, Burns & Plastic

Surgery Center, Hayatabad Medical

Complex MTI

Assistant Professor, Burns & Plastic

Surgery Center, Hayatabad Medical

Complex MTI

Junior Consultant, Burns & Plastic

Surgery Center, Hayatabad Medical

Complex MTI

Resident Burns & Plastic Surgery

Center, Hayatabad Medical Complex

MTI

Correspondence

Muhammad Shadman, Assistant

Professor, Burns & Plastic Surgery

Center Hayatabad Medical Complex

MTI

+92-300-5876918

shadmanch@gmail.com

INTRODUCTION

Post-burn contracture is common and very frustrating

sequel of burn injury aecting form and function.

Amongst these, burn contracture of the neck aects the

patients signicantly, causing both functional

limitations and aesthetic disgurements.

1,2,3

Burns and

fires result in more than 300,000 deaths. Almost 11

million people each year require burn-related medical

attention all over the world.

It not only aects the

movements of the neck, but also can aect the function

of the lower face as well as result in possible tracheal

alteration and distortion of the cervical spine. As these

contractures cause signicant functional and cosmetic

problems with resultant economic and psychosocial

implications, operative correction is generally

recommended, particularly in children in whom they

can cause growth imbalance in the head and neck area.

Contracture is dened as inability to perform the full

range of motion of a joint. The development of

contractures after burn injury depends on many factors

including areas involved, depth of burn, initial

management, duration of immobilization, and soft

tissue and bony problems.

In developing countries

their incidence are mainly due to lack or unsuitable care

because they almost didn't see a specialist medical

doctor to evaluate the need of skin grafting of acute

burn and physiotherapy after healing.

Major

improvements in burn care in the 20th century brought

in a shift in attention from mortality towards reduction

of morbidity.

4,7,8

Burn scar contractures involving the

anterior cervical neck present a unique set of problems

compared with the rest of the body. The thin and pliable

https://doi.org/10.37762/jgmds.13-1.709

January - March 2026

J Gandhara Med Dent Sci

skin of the neck is a region with multidirectional

activity, and post-operative scar contractures tend to

form there easily.

Best way to treat post-burn

contracture is to prevent them, as once they are formed,

they are not easy to deal with, especially in children.

There are various methods to treat contractures

depending on the type of contracture and donor site

availability. Splintage and physical therapy are as

crucial in post-burn contractures as in early burn

management.

2,11,12

The burn scar contracture has been

classified into dynamic (early phase) and static (late

phase).

However, early reconstruction of dynamic

scar contractures could decrease rehabilitation time and

improve life quality, before proceeding to static

complex scar contractures. Achauer in 1991 classied

anterior neck contractures into mild, moderate,

extensive, and severe depending on what fraction of the

anterior part of the neck involved in the contracting

band. The goals of treatment for neck contractures are

to release the contractures thoroughly; to regain the

natural prole, contour, and color match; and to restore

the normal mobility. Recently, numerous methods for

releasing the complex scar contracture have been

developed; the most common procedure being scar

excision and coverage with split- or full-thickness skin

grafts.

4,14

Although skin grafting is a commonly used

treatment, its major disadvantages are

hyperpigmentation and contracture.

10,15

Local aps

such as the deltopectoral ap, supraclavicular and

transverse cervical artery perforator ap, can be

advanced into burn defects.

These local aps can

obtain contour and color match with the nearby tissue.

Complex scar contractures are also resolved with

multiple Z-plastics and local or pedicled cutaneous

flaps; however, there are often limitations of local

injured donor tissue.

4,16

This study is conducted to

assess the outcomes of various treatments for post-burn

neck contractures, to provide critical data for the

development of standardized treatment protocols. By

focusing on the ecacy of surgical approaches, this

research intends to contribute to improving

management strategies in burn centers, particularly in

regions where specialized care is limited. Additionally,

the ndings will establish baseline data for further

studies and the formulation of comprehensive follow-up

protocols, enhancing the long-term care of burn

survivors. The objective of this study is to assess the

range of motion and graft recipient site complications in

post-operative burns patients.

METHODOLOGY

This descriptive cross-sectional study was conducted

from January 2019 to December 2024 in the Burns and

Plastic Surgery department of a public sector teaching

hospital in Peshawar, after obtaining permission from

the Institutional Board. Informed written consent was

obtained from all participating patients. The sample size

was calculated to be 25 using an 80% power of the test

and a 5% signicance level, based on a 94% prevalence

of post-burn neck mento-sternal contracture in patients

who underwent successful operative treatment.

However, due to small sample size, the number of

patients was increased to 40 in this study. Patients

diagnosed with proven post-burn neck mento-sternal

contracture, including both males and females of all age

groups, were included in the study. Exclusion criteria

included patients with infected mento-sternal neck

contracture, those with sinus or stula burns, patients

who had undergone surgery elsewhere or presented

with recurrence, and those with additional conditions

such as cervical spondylosis or achondroplasia. A

detailed history was obtained, followed by a thorough

local examination to assess the extent of contracture, as

classified by Achauer and Salisbury. The examination

also included assessment of bevin, skin texture, color

match, and the range of neck movement. The evaluation

of atlanto-occipital extension was performed with the

patient sitting straight, head erect, and facing directly

forward, as described by Bellhouse and Dore. The lines

of contracture and proposed incisions were marked,

with reference points including the mandibular angle,

mid-clavicle, mental tubercle, and sternal notch. The

vertical extent of the contracture was measured using

the mento-sternal distance. The availability of

surrounding skin and its suppleness were also assessed.

If the distance between the mentum and thyroid

prominence was less than 6 cm, dicult intubation was

anticipated. Postoperatively, physiotherapy was

initiated 2-3 weeks after surgery. The primary exercises

included extension, alternate anterior exion, lateral

rotation, exion on both sides, and circumduction. The

range of motion at the donor and grafted sites was

checked. The patient was sent home with instructions

on positioning, splintage (Watucci), local care,

massage, and physical therapy. Results were evaluated

in terms of the range of motion (ROM), especially

extension, and aesthetic appearance, including color

match, texture, contour, and donor site morbidity.

Follow-up was conducted at 6-, 12-, and 18-month

post-surgery. Data were entered into SPSS version 23.

Continuous data, such as age, was presented as mean

and standard deviation. Categorical data, including

gender, duration of hospital stay, type of contracture,

and complications, were presented as frequency and

percentage.

RESULTS

In our study, a total of 25 patients were included,

comprising 19 (76%) males and 6 (24%) females. The

mean age was 22.20 ± 10.12 years, ranging from 10 to

Surgical Management and Long-Term Outcomes

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J Gandhara Med Dent Sci

45 years. Flame burns accounted for 20 (80%) cases,

while 5 (20%) were due to scalds. The severity of

contractures varied, with Z-plasty performed for 5

(20%) patients with mild contractures, local aps and

STSG used for 15 (60%) patients with moderate

contractures, and STSG alone used for 3 (12%) patients

with severe contractures (Figures 1 and 2). Scar tissue

was released until healthy underlying tissue was

exposed. Table: 1

Table 1: Demographic and clinical characteristics of patients with

neck contractures (including mean age, gender distribution, burn

etiology, and classication of contractures by severity and

surgical management techniques).

Age Mean +SD

Mean age 22.20+10.12

Gender (n) (%)

Male 30(75%)

Female 10(25%)

Etiology of Burn (n) (%)

Flame 32(80%)

Scald 08(20%)

Type of Contracture (n) (%)

Mild ( Z-Plasty) 08(20%)

Moderate (STSG with local aps) 24 (60%)

Sever (STSG) 05 (12.5%)

Extensive (graded release &STSG) 03(7.5%)

Table: 2 Summary of Anesthetic Techniques for Intubation,

Methods of Contracture Release, Hospital Stay Durations, Post-

Operative Complications, and Range of Motion (ROM) Outcomes

among

Patients with Neck Contractures

Anesthetic technique for intubation (n)

Awake 13

Controlled Anesthesia 22

Spontaneous release and

intubation

Method of release (n)

Incisional 32

Excisional 08

Duration of hospital stay (n)

Less than 5 days 24

7-14 days 10

Greater than 14 days 06

Complications (n) (%)

Poor Match Color 10 (25%)

Graft Loss 06 (15%)

Graft hypertrophy 06 (15%)

Range of Motion(ROM) (n)

Good 24

Fair 10

Poor 06

Figure 1: Neck contracture resulting from ame burns, treated

with release and split-thickness skin grafting (STSG).

Postoperatively, splintage was maintained using a Watucci splint.

The images depict the long-term outcome of the patient.

Figure 2: Severe neck contractures treated with release and split-

thickness skin grafting. The images illustrate both the early and

long-term outcomes of the graft in these patients.

Figure 3: A Case of Severe Recurrent neck contractures treated

with adequate release and Thickish split-thickness skin grafting.

The images illustrate early outcomes of the graft.

Surgical Management and Long-Term Outcomes

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J Gandhara Med Dent Sci

DISCUSSION

The head and neck are the most exposed parts of the

body to the external environment; disguring scars in

this region aect the function and aesthetics of various

parts. As the skin in this region is thin and pliable,

contractures can result in abnormalities of lip

competence, facial expression, and decreased neck

movements.

Initial management aects the depth of

burn but also causes hindrances in physiotherapy

because of late mobilization, pain, repeated anesthesia,

and nutritional problems. Initial adequate burn

management and aggressive physiotherapy and

Splintage have the leading role in prevention of

local plasties and staged excisions.

contractures.

The basic goals of neck reconstruction

are the restoration of appearance, including symmetry,

contour, texture, color match, and function. In our

study, we had 19 females and 06 males. Similarly,

another study was also seen by Kobus, where there

were 87 females out of 147 patients. This increased

incidence is mainly due to increased domestic exposure

due to kitchen work.

Many classication systems were

found in the literature; most of them were based on the

severity of the contracture, as Achauer in 1991, who

classified anterior neck contractures into mild,

moderate, extensive, and severe depending on what

fraction of the anterior part of the neck is involved in

the contracting band.

There are various options of

reconstruction for post-burn neck contractures. But

each option has its advantages and disadvantages. It

includes plasties, STSG alone or with local aps,

regional aps, and expanded local aps. In our study,

we only included release n z-plasties, STSG with or

without local aps, excision, and STSG.In our study,

five patients (20%) had z-plasties. Comparing this to a

study by Fehmina, 21.1% of pts underwent z-plasties. Z

plasties has the advantage of using local pliable skin,

good color and texture match, and is mainly for linear

bands. Disadvantage is that it needs non-scarred skin to

be available for transposition of aps.

Out of a total of

25 patients, 15 (60%) were treated with STSG+ z

plasties. And 02 patients (12%) with STSG alone.

According to KOBUS, 74 patients out of 147 were

treated with STSG, and 182 operations included both

Similarly, in

another study by Fehmina, 39.4% patients were treated

with STSG.

Treatment outcomes were assessed based

on the duration of stay in hospital. In our study, mostly

patients stayed in less than 5 days in the hospital, and

only four patients stayed more than 14 days in the

hospital due to graft scar. In the 2013 India study,

complication was seen in only 4 cases; as compared to

our study, complication was seen in 14 cases.

Scar

hypertrophy was the common complications seen in 4

patients. Range of motion or function good results were

seen in 15 patients, fair in 6 n poor in 4 patients.

Expanded neck skin has a better color match and

pliability their disadvantage is donor site morbidity and

availability of donor ap, options are free tissue

transfer that brings a well vascularized tissue but it’s a

prolonged surgery with risk of failure.

19,20

Other Need

of long pedicle, donor site morbidity but usually kept as

last option, which ever technique used the main

outcome depends on post op splintage and

physiotherapy early initial management had better post

op outcomes and post op physiotherapy and splintage

had a role in reducing recurrence.

6,21,22

As essential as

early intervention is in the treatment of burns, standard

precautions among healthcare workers are also just as

important. Just as prompt physiotherapy can prevent

contractures, proper precautionary practice prevents

healthcare-associated infections. Enhancing knowledge

and compliance through ongoing training and audits

will lead to improvements in patient outcomes and

general safety.

23,24

LIMITATIONS

The strengths of this study include explicit inclusion

and exclusion criteria, thus ensuring a homogeneous

patient group and a well-defined study protocol for

examination, treatment, and post-operative care.

Moreover, the study had a long follow-up period that

enabled the assessment of short- and long-term

outcomes. However, it had some limitations, as the

sample size was small with only 25 patients. Because

this is a descriptive cross-sectional study, causal

relationships could not be established. The lack of

control and subjective nature of aesthetic and ROM

evaluations may also introduce bias in this study.

Lastly, it limits generalizability since this study was

conducted only at a single center.

CONCLUSIONS

Post-burn neck contractures are a common

complication of burns. They are managed primarily

surgically by skin grafts, local aps, and z-plasty. Local

and loco-regional aps give better results because of

the use of similar skin quality and color and induce low

risk of recurrences. Overall outcome of any procedure

used for release depends on early and prolonged

physiotherapy for better functional results. A follow-up

program for a reasonable period is highly desired up to

18 months.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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January - March 2026

J Gandhara Med Dent Sci

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AUTHORS CONTRIBUTION

Muhammad Mudassir Mahboob - Concept & Design; Data

Acquisition; Drafting Manuscript; Critical Revision; Final

Approval

Adeeba Ahmad - Concept & Design; Data Acquisition;Drafting

Manuscript; Final Approval

Muhammad Shadman - Concept & Design; Data Acquisition;

Data Analysis/Interpretation; Drafting Manuscript;Critical

Revision; Supervision; Final Approval

Fahimullah Khan - Concept & Design; Data Acquisition;

Drafting Manuscript; Critical Revision; Final Approval

Shahzad – Concept & Design; Data Acquisition; Drafting

Manuscript; Critical Revision; Final Approval

Adil Rehman - Concept & Design; Data Acquisition; Data

Analysis/Interpretation; Drafting Manuscript; Critical Revision;

Final Approval

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

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