This is the treatment of what is left after a burn: contractures that limit movement, thick or distorting scars and areas of skin with altered appearance and texture.
A burn scar is not just a mark: it contracts. As it pulls back it drags the neighbouring skin, and when it crosses a crease — the neck, the armpit, the elbow, the hand, the knee — it limits the movement of the joint. In growing children it can also distort the area, because the scar does not grow at the same rate as the body. Surgery for burn sequelae deals with that: first with what limits, then with what shows.
The order matters and it is worth stating clearly: treatment is in stages, prioritising function. First the contractures that prevent movement, closing the eyes, opening the mouth or using the hand are released; afterwards the appearance is worked on. And the result is measured in improvement, not restoration: burn sequelae improve a great deal, sometimes in ways that change a person's daily life, but they are not erased. Anyone promising to give back the skin you had is not telling the truth.
It usually helps when there is
- A contracture limiting the movement of a joint.
- A scar preventing the eye from closing, the mouth from opening or the neck from moving.
- A contracture that is distorting with growth in a child.
- A hypertrophic or keloid scar that is painful, itchy or breaks down.
- A mature scar, at least a year old, in non-functional areas.
Worth discussing first if
- A scar still immature: generally twelve to eighteen months are allowed.
- An area with open wounds or active infection.
- Expecting to get the previous skin back.
- No availability for the physiotherapy afterwards, which is essential.
- Current smoking, relevant if flaps are going to be used.
None of these rules the procedure out on its own; all of them change the conversation.
How it is resolved
The technique depends on whether the problem is a narrow band or a wide surface of contracted skin.
Z-plasties
They change the direction of a band and lengthen it by rearranging the neighbouring skin. They resolve linear contractures very well, with no need for a graft.
Release and graft
The contracture is cut and the defect that opens is covered with a graft. It is the option for wide surfaces, and it demands splints so that it does not contract again.
Expansion and flaps
Healthy neighbouring skin is grown with an expander and used to replace the scarred area. It gives the best result, with a longer process.
First what limits, then what shows
That is the order and it is not reversed. A contracture preventing the eye from closing, eating, moving the shoulder or using the hand is operated on before any visible scar, however visible it is. With two exceptions: on the face, appearance is also social function and is weighed accordingly; and in children, a contracture that is distorting with growth does not wait.
The timing is chosen by the maturity of the scar. Operating on an inflamed, red, active scar gives worse results and more recurrence, so generally twelve to eighteen months are allowed. The exception is a contracture that is progressing or compromising a function: that is released whenever necessary.
The physiotherapy and splints afterwards are not an add-on, they are part of the surgery. A contracture release without rehabilitation closes up again, and that is the most frequent cause of failure. When a patient cannot commit to that stage, it is worth discussing before operating.
What the process is like
The whole is planned and carried out in parts, in a defined order.
Consultation and staged plan
All the sequelae are assessed, ordered by functional priority, and how many operations are foreseeable and over what timescale is explained.
First operations
Release of the contractures limiting function, with Z-plasties, grafts or flaps according to the case.
Rehabilitation
Splints and physiotherapy after each stage. It is what stops the contracture coming back, and it is as decisive as the surgery.
Appearance stages
Once the functional side is resolved: scar improvement, fat grafting to soften the area and contour corrections.
What to expect per stage
These timings correspond to one operation; the complete treatment covers several.
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Weeks 1 to 2
Immobilisation of the released area and dressings. If there was a graft, the first dressing change on the fourth or fifth day decides the take.
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Weeks 3 to 6
Physiotherapy and splints begin, usually at night. It is the stage that decides whether the gain in movement is kept.
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Months 2 to 6
Compression garment, daily moisturising and sun protection. The operated area goes through its own red, firm phase.
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Months 12 to 18
Consolidated result of that stage and time to consider the next one, if it was planned.
Risks, and what is not promised
Those of each technique — loss of a graft, loss of a flap, infection, wound breakdown — and one specific to this surgery: recurrence of the contracture, which happens above all when the rehabilitation is not kept up. Hypertrophic or keloid scarring in the operated area is also possible, more frequent in patients who already developed it before, as are changes in pigmentation.
It is a long treatment. Most significant sequelae need several operations months apart, and that burden — surgical, financial and emotional — is part of the decision and is explained from the first consultation.
Giving back the previous skin and erasing the scar are not promised. What is promised is working to make the area function better and look better, with an improvement that in many cases is considerable. These risks are reduced by operating on a mature scar, with strict rehabilitation and compression. They are not eliminated. The ones that apply to your case are set down in writing in the informed consent.
The information on this page is for guidance and does not replace an in-person medical consultation. Medical practice is an obligation of means, not of result.
The questions we are asked most about burn sequelae
No. A burn scar improves — sometimes a great deal — but it does not disappear, and anyone promising otherwise is not telling the truth.
What does change significantly is function: recovering movement in a shoulder, being able to close an eye or using a hand again transforms daily life more than appearance does.
Generally between twelve and eighteen months, until the scar matures: operating on a scar that is still red and active gives worse results and more recurrence.
There are exceptions that do not wait: a contracture preventing the eye from closing, eating or moving a joint, and in children a contracture that is distorting with growth.
It depends on the extent, and with significant sequelae there are usually several, months apart. The whole is planned from the start and carried out in parts.
Function always comes first: what limits movement or an essential function, then what shows.
Because the contracture comes back if the area is not kept stretched while it heals. A release with no splints and no physiotherapy closes up again within a few months.
It is the most frequent cause of failure in this surgery, and it depends on the patient. If you are not going to be able to keep it up, it is worth saying so before operating.
Question not answered here? There are more answers in the frequently asked questions.
