Home Print this page Email this page Users Online: 266
Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
IDEA AND INNOVATION
Year : 2021  |  Volume : 29  |  Issue : 1  |  Page : 104-106

ARC technique – An innovative method to assess true defect in postburn contracture release


Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, India

Date of Submission07-Dec-2020
Date of Acceptance18-Mar-2021
Date of Web Publication03-Feb-2022

Correspondence Address:
Dr. K T Ananda Murthy
Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijb.ijb_34_20

Rights and Permissions
  Abstract 


Most commonly, skin grafts are used to resurface the raw areas resulting after the release of postburn contractures but in the extensively burned patient, donor sites may be limited. There is no accurate technique described in literature for the assessment of the true defect preoperatively. We describe a technique to accurately assess the true defect which helps to determine the amount of skin graft required preoperatively.

Keywords: Apparent defect, contracture release, split skin grafting, true defect estimation


How to cite this article:
Sarabahi S, Ananda Murthy K T, Arumugam PK, Babu MR. ARC technique – An innovative method to assess true defect in postburn contracture release. Indian J Burns 2021;29:104-6

How to cite this URL:
Sarabahi S, Ananda Murthy K T, Arumugam PK, Babu MR. ARC technique – An innovative method to assess true defect in postburn contracture release. Indian J Burns [serial online] 2021 [cited 2022 Nov 28];29:104-6. Available from: https://www.ijburns.com/text.asp?2021/29/1/104/337210




  Introduction Top


Incisional or excisional release and skin grafting are the mainstays of treatment in postburn contracture.[1] Incisional release is preferred in patients with soft, pliable scars and limited donor areas. Excisional release is preferred in patients with hypertrophic, atrophic, unstable scars and depigmented areas with adequate donor areas.[2] In former linear incision through the scar tissue overlying the affected joint at the point of maximum tightness is done, which is oriented perpendicular to the line of contracture with added fishtailing.[3] In latter, part of the scar tissue is excised, which depicts an apparent defect, along with multiple darting is used to release the contracture. True defect is the actual raw area created after release of the postburn contracture. To the best of our knowledge, there is no established technique described in literature for the exact assessment of true defect preoperatively.

Prior assessment of defect size helps the operating surgeon to plan the amount of skin graft/flap to be harvested. Since postburn flexion contracture of the neck and elbow is common in India, they have been taken as prototypes to explain this arc technique.


  Technique Top


Postburn contracture of neck

With the patient in standing or sitting position, first a transverse line is marked over the contracture depicting the line of incisional release. This would span between the neutral lines of the neck anteriorly. Three points are marked over the incision line, one at the center and others are at the ends of marking (Points A, B, and C). Fishtailing at the both ends of the transverse line is marked, about one-third length of incision and two limbs placed at an angle of about 45°–60°. Then, four points are marked at the ends of the fishtailing bilaterally (Points D, E superiorly and Points F, G inferiorly). This gives us a total of 7 points.

In the superior aspect, three fixed bony points are marked, one at the symphysis menti at the lower border of mandible (Point H) and two points marked at the angle of mandible bilaterally (Points I, J). In the inferior aspect, the center point is marked at the sternal notch or center of  Angle of Louis More Details (Point K) and two points at the tips of acromion process on both sides (Points L, M) [Figure 1].
Figure 1: Incisional release markings with fishtailing, for postburn contracture of neck

Click here to view


For the true defect, markings are made over a normal person of similar age, sex, build, and stature, with neck in full extension using measuring tape or thread. From the symphysis menti, a point is marked of length HB (Point B). From the angle of the mandible, an arc is drawn with radius of ID, and from the symphysis menti, an arc is drawn with radius HD intersecting the previous arc giving us Point d. Similarly, measurements from other bony landmarks help us to obtain Points b, e, g, and f. Arcs drawn with radii DA and FA intersect to give the Point a. Similarly, EC and GC intersect to give us Point c. Joining all these points give us the shape of two trapezoids (deca and acgf). The area of this shape is derived by doubling the area of each trapezoid, given by bb'x (ac + de) [Figure 2].
Figure 2: True defect markings (area) obtained after representing the corresponding points over normal person neck

Click here to view


Postburn contracture of elbow

Measurements are taken with shoulder in adduction and neutral position. Three points are marked over the incision line, one at the center and others are at the ends of marking (Points A, B, and C) with fishtailing. Then, four points are marked at the ends of the fishtailing bilaterally (Points D, E superiorly and Points F, G inferiorly).

In the superior aspect, 2 fixed bony points are marked, one at the clavicle (at the junction of medial two-third and lateral one-third) and the other at the tip of acromion. These are marked H and I, respectively. In the inferior aspect, Points J and K are marked at radial and ulnar styloid processes, respectively [Figure 3].
Figure 3: Incisional release markings with fishtailing, for postburn contracture of elbow

Click here to view


For the true defect, markings are made over the opposite elbow in extension and shoulder in adduction. Arcs drawn from Points H and I with radii HD and ID intersect to give Point d and with radii HE and IE intersect to give Point e. Midpoint of line de is marked b. Similarly, we can obtain Points f and g. Midpoint of line fg is marked b' and de as b. Arcs drawn from Points D and F with radii DA and FA meet to give Point a. Similarly, we can obtain Point c. The area of this shape is derived by doubling the area of each trapezoid (deac and acfg), given by bb'x (ac + de) [Figure 4].
Figure 4: True defect markings (area) obtained after representing the corresponding points over contralateral limb or normal person limb

Click here to view


A similar technique can be used for excisional release in both the regions, which constitutes the same bony points and with darting of apparent defect at the four angles represents the total 6 points. Resultant true defect shape resembles a rectangle with limbs slightly concave toward defect, area of which can be calculated by length × breadth.


  Discussion Top


In patients with multiple postburn contractures, there is limited normal donor area for harvesting skin grafts which would be used to resurface the raw areas after release of the contracture. Harvesting the skin graft by considering the apparent defect is unwise because true defect is always more than that of apparent defect. In literature, true defect in postburn contracture of elbow was estimated by single bony points on either side of contracture using scale, which gives rough estimate of actual defect.[4] Arc technique uses two bony points to mark a single point of the defect border, using tape or thread, which is very accurate to assess true defect. Mody et al. have described estimating the mentosternal distance to assess the true defect preoperatively but this may not be very accurate.[5]

This technique can be used for other areas of contractures such as axilla and knee in which the unaffected side is utilized for the true defect assessment.


  Conclusion Top


It is a refined, simple, easy, accurate technique which is very helpful in estimating the true defect beforehand in postburn contracture patients which helps to plan the amount of skin graft/flap required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hayashida K, Akita S. Surgical treatment algorithms for post-burn contractures. Burns Trauma 2017;5:9.  Back to cited text no. 1
    
2.
Goel A, Shrivastava P. Post-burn scars and scar contractures. Indian J Plast Surg 2010;43:S63-71.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Wainwright DJ. Burn reconstruction: The problems, the techniques, and the applications. Clin Plast Surg 2009;36:687-700.  Back to cited text no. 3
    
4.
McCarthy Plastic Surgery. 2nd ed.Vol. I. Introduction to Plastic Surgery; 'True Defect'. Philadelphia and W.B.Saunders company; 1990 p. 24-6.  Back to cited text no. 4
    
5.
Mody NB, Bankar SS, Patil A. Post burn contracture neck: Clinical profile and management. J Clin Diagn Res 2014;8:NC12-7.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Technique
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed1318    
    Printed54    
    Emailed0    
    PDF Downloaded49    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]