Contracture scars tighten the skin and affect the individual’s mobility. Areas below the skin, ranging from muscles to nerves, are also affected.  Contracture scars are more common with deeper burns.  Contracture scars are normal responses to burns and they must heal completely before being surgically altered.

 

Keloid scars are growths that result from the formation of excessive scar tissue.  They are typically raised and have a puffy appearance.  Keloid scars do not affect one’s health. However, its appearance may make individuals feel self-conscious. Ogawa R. (2017). Keloid and Hypertrophic Scars Are the Result of Chronic Inflammation in the Reticular Dermis. International journal of molecular sciences, 18(3), 606. doi:10.3390/ijms18030606

Upon contact with the acid, nerves can be permanently damaged. As a result, specific body parts may face restricted movement. If the nerves of the mouth are affected, eating and speaking may be difficult.

When acid comes into contact with the eyes, it can lead to blindness, blurred vision, and scarring. Survivors may experience watery eyes for a long time due to a deformation in the tear ducts. Eyelids may be burned off as a result of the acid. It is common that the eyelids no longer close properly, resulting in dry eyes. Furthermore, pain, redness, and irritation (itching) may occur. When a weaker acid is used, the outer parts of the eye such as the eyelids, sclera, cornea, and conjunctiva are affected. When a stronger acid is used, the inner parts of the eye such as the lens and the retina are affected. Source: https://www.webmd.com/eye-health/chemical-eye-burns#1

Acid can melt the skin layers (epidermis and dermis), the lower layer of fat muscles (hypodermis), and in severe cases, the muscles and bones. Acid may also affect cartilage in the ear or nose, both of which can be partially or completely destroyed. A survivor's teeth and nails may also be damaged.

There are two main types of skin grafts. A split-thickness graft is when a dermatome, a surgical tool, is used to take off the epidermis and only part of the dermis for transplantation. A full-thickness graft is when all of the epidermis and dermis are removed and placed at the site of the wound. If the skin used for the graft is from the same person receiving the graft, then it is called an autograft. An allograft is transplanting skin from one person to another. A xenograft is transplanting skin from a different species to a human.

Source: Shimizu, R., & Kishi, K. (2012). Skin graft. Plastic surgery international, 2012, 563493. doi:10.1155/2012/563493  

Contracture releases are done when the skin becomes so tight that one is not able to bend or straighten the limbs. Initially, contracture scars are highly vascularized, meaning that they have a lot of blood vessels transporting the necessary nutrients to the area to heal quicker. If surgery were done at this point, there would be more complications since the scar would bleed more. However, after approximately one year, contracture scars start to mature and become softer. At this point, surgery can be done.  However, there are exception to this rule. Surgery can be done immediately if the contracture is located in the following areas: eyelids (if the individual cannot close their eyes), neck (if the individual cannot move their head properly), knees (if the individual cannot be stand properly and has to be on all fours), and hands (if the individual loses the ability to flex the hand).

Sources: Goel, A., & Shrivastava, P. (2010). Post-burn scars and scar contractures. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 43(Suppl), S63–S71. doi:10.4103/0970-0358.70724 & Hayashida, K., & Akita, S. (2017). Surgical treatment algorithms for post-burn contractures. Burns & trauma, 5, 9. doi:10.1186/s41038-017-0074-z

In some cases, survivors lose their entire eye after the attack and a prosthetic eye is implanted. Though not functional in terms of restoring vision, prosthetic eyes can help improve one's appearance. There are two types of corneal transplant surgeries. A traditional corneal transplant surgery is when a tool is used to cut out the cornea in the shape of a disk, taking out all five layers and then replacing the void with new tissue from a donor.   Endothelial keratoplasty is a another type of transplant surgery. During this procedure, a small incision is made on the surface of the cornea and a small disk of a healthy endothelium is implanted. This procedure leaves the first four layers of the healthy cornea untouched. There is also no need of sutures since the incision is usually self-healing. In cases of visual impairment due to cataracts, surgery may be recommended. Usually, an artificial lens is placed within the eye as a replacement of the damaged and clouded lens.

Source: https://www.allaboutvision.com/conditions/cornea-transplant.htm

Tissue expansion is a cosmetic procedure that allows the body to grow extra skin. A silicon balloon expander is placed near the affected area. The balloon is then filled with saline. The skin will being to stretch and grow over time.

Silicone gel sheets (for example, ScarAway) work by applying pressure and prevent scars from growing. Mederma gel scar treatment can help reduce inflammation, can make the scar region softer, and can make the color of the scar lighter. Silvadene is another topical treatment that helps prevent infection. Source: Puri, N., & Talwar, A. (2009). The efficacy of silicone gel for the treatment of hypertrophic scars and keloids. Journal of cutaneous and aesthetic surgery, 2(2), 104–106. doi:10.4103/0974-2077.58527

Acid attack survivors may encounter physical limitations, such as limited joint movement, due to scarring. Physical therapy will work towards keeping all the affected joints moving. It involves different exercises such as splinting (securing a broken limb with splints) and strengthening. It can also aid in scar management through use of pressure garments and massage. The treatment time can vary. However, the average amount of time that an acid attack survivor will undergo physical therapy is about one to two years.

Source: OSullivan, Susan B., et al. Physical Rehabilitation. 6th ed., F.A. Davis Company, 2014, https://hsrc.himmelfarb.gwu.edu/books/85

Although there is no experimental evidence that shows that massage therapy can help against keloid and hypertrophic scars, it has been shown that it can help with scar pain, itching, and minimizing contracture scar formation. It also helps with range of movement and can have a positive effect on the individual's mental health. Massage therapy can help soften and flatten the scar region.

Source: OSullivan, Susan B., et al. Physical Rehabilitation. 6th ed., F.A. Davis Company, 2014, https://hsrc.himmelfarb.gwu.edu/books/85

Corticosteroid injections can be injected into a keloid or hypertrophic scar to reduce inflammation. The corticosteroid injections break the bonds between collagen fibers, which reduces the amount of scar tissue beneath the skin.

Lasers can be used to flatten keloid scars and help treat uneven skin. Pulse Dye Laser Therapy is primarily used to treat the redness and discoloration that is caused by the scar. The laser causes the blood vessels within the scar to decrease in size which results in a lighter color of the scar. Fractional Carbon Dioxide Laser Therapy uses a high-energy beam of light to speed up the skin’s exfoliation and repair processes. It also aids in removing scarred or discolored outer layers of skin.

Medical tattooing helps improve the appearance of scars from an acid attack. It involves coloring in the scarred areas to make the skin look all the same color. The tattoos are darker than the skin for four to six weeks after the procedure. Eventually, the darker pigment from the tattoo fades to blend in with the natural skin color.

Source: Batstone, M. D., Fox, C. M., Dingley, M. E., & Cornelius, C. P. (2012). Cosmetic Tattooing of Free Flaps following Head and Neck Reconstruction. Craniomaxillofacial trauma & reconstruction, 6(1), 61–64. doi:10.1055/s-0032-1330840

Compression garments are used to reduce the scar development. Compression garments benefit patients through protecting fragile skin, decreasing pain and itching, and allowing for better circulation of damaged tissues by reducing the production of collagen and realigning collagen fibers. Compression garments should be worn seven days a week and 23 hours per day until the scars are matured and pliable. This typically takes between eight months to two years. There are various types of compression garments, however custom-made garments allow for specialization of patient measurements.

Keloid scars are difficult to treat and have high rates of recurrence after treatment. One way in which surgeons treat these scars is surgical removal of them.

Source: Wilson A. M. (2013). Eradication of keloids: Surgical excision followed by a single injection of intralesional 5-fluorouracil and botulinum toxin. The Canadian journal of plastic surgery = Journal canadien de chirurgie plastique, 21(2), 87–91. doi:10.1177/229255031302100208