Reconstructive Management of a Severe Mentosternal Contracture in a Resource-Limited Setting: A Case Report from Ghana, West Africa

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Post-burn injury mentosternal contractures can lead to significant functional and aesthetic problems.¹ A Nigerian study classified 4 types of mentosternal contractures. Type 1 is a mild anterior contracture with subtypes 1a-c depending on band width. Type 2 is a moderate anterior contracture (patient can bring the neck and jaws to anatomic position while erect) with subtypes 2a-c depending on band width. Type 3 is a severe anterior mentosternal contracture (patient is contracted in the flexed position, chin is occasionally restrained down to the anterior trunk, and patient is unable to bring neck and jaws to anatomic position), with subtype 3a having enough local supple neck skin to cover the defect after excision and subtype 3b not having enough local supple neck skin to cover the defect. Type 4 is a posteriorly located contracture with subtype 4a being a single band with adjacent supple neck skin flaps available for adjacent tissue transfer, subtype 4b being single or multiple bands without enough local supple neck skin for an adjacent tissue transfer, and 4c being the presence of both posterior and anterior neck contractures.² Patients frequently have difficulty in moving their neck and lower face, which can impair their ability to perform daily tasks. Intubations can be especially difficult in patients with anterior neck contractures.³ Surgical management focuses on restoring the range of motion of the cervical region as well as the cosmetic appearance of the injured area. Typically, this is accomplished through a series of skin grafts, local flaps, or a combination of the two.^1,2,4,5 In this report, we describe a case of a severe mentosternal contracture in a Ghanian survivor of an acid burn. As far as we know, this is the first case report detailing a reconstructive approach to treating a severe mentosternal contracture in a resource-limited environment under purely local anesthesia with no oral, inhaled, or parenteral anesthetic or sedating agents.

The patient was a 49-year-old female from Ghana, West Africa, and sustained an acid burn injury affecting her right neck, shoulder, axilla, and cheek in December 2020. As per the patient and her family, she spent 3 days at a local burn intensive care unit in Accra, Ghana, and was then treated with 1 month of conservative management. She received twice-weekly dressing changes and wound care during this time as she could not afford surgical management. The mentosternal contracture developed due to inaccessibility to definitive surgical care. In September 2023, she presented to our team with severe mentosternal (Type 3b) and right axillary contractures (Figure 1). The mentosternal contracture was causing a large impact on quality of life, so we addressed this contracture alone during this initial encounter. The injury led to substantial functional limitations including the inability to turn her head or lift her right arm. Ultimately, this impacted her employment, self-care, and ability to care for her family to the extent that her daughter had to quit school to care for her mother. The patient gave signed informed consent to publish her story and photographs.

Figure 1: Type 3b contracture with neck contracted in a flexed position, unable to return neck or jaw to natural anatomic location.

Given the limited resources available, the decision was made to perform a skin graft rather than a flap. The procedure involved release and excision of the mentosternal portion of the contracture and coverage of the defect with a full thickness skin graft harvested from the lower abdomen (Figure 2). Due to lack of monitored anesthesia availability, the case was completed with the use of local anesthesia alone; no oral, inhaled, or parenteral anesthetics or sedating agents were administered. The patient did receive 975 mg of oral acetaminophen the morning of the case. A local anesthetic solution of epinephrine (2 mcg/mL), lidocaine (0.8 mg/mL), and bupivacaine (0.15 mg/mL) was prepared in lactated Ringer solution. The donor site on the lower abdomen and the mentosternal contracture were infiltrated with 60 mL and 150 mL, respectively, of the solution prior to incisions. The patient tolerated this very well. She did not complain of any pain during the procedure and no technical or positional challenges occurred during the case. The skin graft laid flat and filled the entire defect. The graft was sutured in place with 5-0 Monocryl and then bolstered with xeroform-wrapped gauze, which was sutured to the surrounding skin. The donor site defect on the lower abdomen was closed primarily with a running 3-0 Monocryl suture. In the immediate postoperative period, the patient reported 0 out of 10 on the pain scale. The patient showed significant functional improvement postoperatively, with increased mobility of the neck. She was sent home the same day and followed up in the clinic with our team on postoperative day 5 with excellent results (Figure 3; Video 1). Upon in-person follow-up, the patient stated that her postoperative pain was well controlled with acetaminophen and ibuprofen. Postoperative care included return for wound care at the local clinic twice weekly and home self-physiotherapy. Long-term follow-up has been successful through the web-based messenger, WhatsApp, and the patient has maintained excellent functional and cosmetic improvements since her surgery, with minimal to no re-contracture thus far (7 months out). She reports that her range of motion remains much improved, and all wounds are well healed. The lower abdominal donor site healed well with no complications. Unfortunately, the current photos sent by her daughter are too poor quality to submit for publication.

Figure 2a: Preoperative marking of the contracted scar tissue border from healthy skin of jaw; 2b: Intraoperative exposure of soft tissues deep to the excised scar contracture; 2c: Postoperative view of the application of single full-thickness skin graft harvested from the lower abdomen.

Figure 3: Postoperative day 5 showing healthy skin graft with near complete adherence and marked improvement in neck mobility.

Video 1. This video shows the improvement in patient mobility at the initial follow-up visit on postoperative day 5.

Typically, severe mentosternal contractures are treated surgically with skin grafts, flaps, or a combination of the two.^1,4 Tissue expansion can also be utilized in the treatment of larger injuries with flaps.⁵ These reconstructive options involve multiple operations while the patient sometimes remains hospitalized between procedures. In this case, we were treating a patient in a resource-limited environment in which we could only perform a single operation involving a full-thickness skin graft. Despite these constraints, the patient made remarkable improvements during her recovery and was able to regain significant range of motion in her neck.

Skin graft harvesting and mentosternal contracture release are typically performed under general anesthesia. In resource-limited environments, cases utilizing conscious sedation with benzodiazepines or ketamine in addition to tumescent local anesthesia have been reported.^6-8 As far as we know, ours is the first documented case of a severe mentosternal contracture reconstruction under local anesthesia alone without additional anesthetic or sedation. Despite this, our patient reported satisfactory pain control immediately after the procedure and at follow-up. We suggest that in extremely resource-limited settings that lack access to monitored anesthesia care, it is possible for mentosternal contracture reconstruction to be accomplished via the use of the local anesthetic technique we have described.

This case underscores the challenges faced in managing complex burn injuries in resource-limited settings. The choices to reconstruct with skin graft alone and to use only local anesthetic were necessitated by the lack of monitored anesthesia care and limited availability of perioperative care. The highly satisfactory outcome highlights the importance of adaptable surgical and anesthesia techniques and comprehensive care in such contexts.