Double reverse V-Y-plasty in postburn scar contractures: a new modification of V-Y-plasty

Several techniques have been defined to use in surgical treatment of postburn scar contractures. However, distal flap necrosis is frequently seen since most of these techniques require random-pattern flaps and there is often poor vascular supply to scar tissue. In the Z-plasty, V-Y-plasty and their analogues, excess tissue requires excision of the dog-ear. A new modification of V-Y-plasty, called "double reverse V-Y-plasty", is discussed. Nineteen postburn scar contractures were successfully treated with double reverse V-Y-plasty. The postoperative results represent the versatility of this technique in the surgical treatment of postburn scar contractures, especially neck and extremities. There was no distal flap necrosis. Double reverse V-Y-plasty is effective and alternative to the current techniques in surgical treatment of every kind of postburn scar contractures with one or more contracture lines. It does not need any surgical knack. Advantages: (i) double reverse V-Y-plasty is safely useful, when skin tension across the contracture line is too great to use any local flaps; (ii) when superficial scarring is localized in the contracture site, it is superior to other local flaps because of rich vascularity and mobility; (iii) double reverse V-Y-plasty is advised to the inexperienced surgeon, since it is easy to use; (iv) color and texture matches are cosmetically acceptable, and the resultant contracture is as much as with other techniques; (v) there is no necessity to use excision of the dog-ear; (vi) it can be utilized under local anesthesia almost in all cases; and (vii) it requires a shorter period of operation, and hospitalization.     

The correction of postburn contractures of the second through fourth web spaces

The release of postburn contractures in the hand is one of the most commonly performed procedures in burn injuries. Contractures of the web space may involve palmar, dorsal, or both sides of the web skin and require various surgical techniques. In this report we provide general guidelines for the release of these contractures, with special emphasis on reconstruction of the second through fourth web spaces.     

The surgical treatment of postburn cicatricial contractures of the knee joint extensors

In the recent 3 years operations were carried out in 8 patients with postburn extension contractures of the knee joints, which accounted for 12.9% of all cicatricial contractures of this joint. The anatomical essence of the contracture was ascertained. A method of surgical treatment was developed, which consisted in restoration of the cutaneoadipose layer in the region of the knee with a cutaneofascial graft taken from the contralateral leg and subsequent excision of the scars on the thigh, by freeing of the muscles extending the joint, and restoration of the skin surface with a split nonperforated autodermal graft. The operation restores knee joint movement and removes trophic ulcers of pathological postburn scars.     

A new method in the treatment of postburn and post-traumatic scar contractures: Double-opposing Z- and V- (K-M-N) plasty

BACKGROUND:

To date, many techniques for the surgical treatment of postburn scar contractures have been described. Some of the most popular techniques are Z-plasty, V-Y-plasty and their analogues. A major limitation of these techniques is that the excess tissue requires excision of the dog ear. The current study presents a new modification of the double-opposing Z- and V-plasty, called ‘K-M-N plasty’.

METHODS:

Twenty postburn scar contractures were successfully treated with K-M-N plasty. The postoperative results depict the versatility of this technique in the surgical treatment of postburn scar contractures, especially in the upper and lower extremities.

RESULTS:

There was no distal flap necrosis, and postoperative recovery was uneventful in all operated patients. K-M-N plasty is an effective and alternative method for the surgical treatment of postburn scar contractures. In addition, drawing and flap transpositions were not complicated.

DISCUSSION:

There are many advantages to using this technique: K-M-N plasty can be safely used when skin tension crosses the contracture line; it is superior to other local flaps because of its rich vascularity and mobility for superficial scars; it can be recommended to the inexperienced surgeon because it can be performed with ease; it is also an effective procedure for the pericontracture area due to its V limb (it can prevent recontracture); the colour and texture matches are more cosmetically acceptable, and the resultant contracture release is similar to other techniques; the dog ear formation is not seen; it can be performed under local anesthesia in most cases (not in children); and it has a shorter period of operation and hospitalization than other techniques.     

Burn scar contractures of the feet: efficacy of bilateral simultaneous surgical correction

Children who sustain large total body surface area (TBSA) burns with involvement of the lower extremities frequently sustain injuries to the dorsum of the feet. Burn scar contractures of the feet can develop as a sequela of the burn injury. Such contractures frequently require surgical correction. Many surgeons proceed with staged unilateral corrections when both feet are equally in need of operative intervention. The purpose of the study is to determine if the morbidity for correction of bilateral dorsal foot contractures is different from that for the correction of unilateral dorsal foot contractures.

A retrospective review from January 1994 to July 1999 was undertaken. Forty-five patients with photographic record of burn scar contracture of the feet were identified. Twenty-five patients underwent staged unilateral surgical correction and twenty patients underwent simultaneous bilateral correction of the feet. All patients underwent surgical correction with split thickness skin grafts (STSG). No statistical difference was found in terms of mortality, development of contracture, or number of reconstructive procedures. However, the length of stay revealed the efficacy of the bilateral simultaneous release of the dorsal feet.     

Epidemiology and risk factors for pathologic scarring after burn wounds

OBJECTIVE: To describe the clinical characteristics of postburn scars and determine the independent risk factors specific to these patients. While burns may generate widespread and disfiguring scars and have a dramatic influence on patient quality of life, the prevalence of postburn pathologic scarring is not well documented, and the impact of certain risk factors is poorly understood. METHODS: A retrospective analysis was conducted of the clinical records of 703 patients (2440 anatomic burn sites) treated at the Turin Burn Outpatient Clinic between January 1994 and May 15, 2006. Prevalence and evolution time of postburn pathologic scarring were analyzed with univariate and multivariate risk factor analysis by sex, age, burn surface and full-thickness area, cause of the burn, wound healing time, type of burn treatment, number of surgical procedures, type of surgery, type of skin graft, and excision and graft timing. RESULTS: Pathologic scarring was diagnosed in 540 patients (77%): 310 had hypertrophic scars (44%); 34, contractures (5%); and 196, hypertrophic-contracted scars (28%). The hypertrophic induction was assessed at a median of 23 days after reepithelialization and lasted 15 months (median). A nomogram, based on the multivariate regression model, showed that female sex, young age, burn sites on the neck and/or upper limbs, multiple surgical procedures, and meshed skin grafts were independent risk factors for postburn pathologic scarring (Dxy 0.30). CONCLUSION: The identification of the principal risk factors for postburn pathologic scarring not only would be a valuable aid in early risk stratification but also might help in assessing outcomes adjusted for patient risk.     

Reconstruction of extensive postburn scar deformities and contractures of the neck using expanded and nonexpanded free tissue transfer

The treatment of postburn scar deformities and contractures of the neck is one of the most complicated and unsolved challenges in reconstructive surgery. This paper is based on the experience of treating 63 patients with extensive postburn scar deformities and contractures of the neck. The supraclavicular and anterolateral chest wall skin was damaged, and the authors therefore used expanded and nonexpanded free flaps. This method allows the release of contracture, creates a natural skin cover of this part for the body, and provides good functional and cosmetic results.     

A new method in the treatment of postburn scar contractures: double opposing V-Y-Z plasty

PURPOSE: Postburn scar contractures are fairly often seen in many parts of the body, and are still a considerable problem for reconstructive surgeons. Although the mild to moderate contractures can easily be managed by numerous surgical methods, serious contractures usually require more comprehensive surgical solutions including multiple Z plasties and rhomboid flaps, each of which have disadvantages. We used a new method called "double opposing V-Y-Z plasty" in this study. This technique is a combination of V-Y plasty with Z plasty in double opposing fashion, both ensuring primary donor site closure. MATERIALS AND METHODS: The technique was applied to 21 postburn scar contractures in 14 patients (9 males and 5 females). The localization most often seen was in the hand. RESULTS: The mean follow-up time was 7.6 months. All flaps healed uneventfully. An adequate lengthening and functional recovery were achieved in all cases. The donor site scars were acceptable in all cases. None of the patients developed contracture recurrence in our series. CONCLUSIONS: Double opposing V-Y-Z plasty, as a good alternative to multiple Z plasties and multiple rhomboid flaps, is a very useful technique to insure more lengthening and to prevent recurrence in the treatment of serious postburn scar contractures.     

The scar band rotation flap

This study presents cases in which postburn scar contractures of finger joints and interdigital spaces have been reconstructed using a scar band rotation flap. The scar band rotation flap is a subcutaneous pedicled skin island flap consisting of a contracture-causing scar band, the graft surface and normal skin. After flap rotation, the normal skin in the flap divides the scar band, thus releasing the scar contracture. In the past 10 years, we have used this reconstruction method to treat seven patients (three males and four females) ranging in age from 4 to 72 years. In all patients, the cause of the scar contractures was marginal scarring of a life-saving skin graft that was used to treat extensive burns. We reconstructed four finger joints and eight interdigital space contractures and obtained favorable results with no flap loss. We have found this method to be useful for the reconstruction of small scar contractures in locations such as finger joints and interdigital spaces after skin grafting to treat extensive burns.     

Multicenter plastic surgery outreach services for underserved Ghanaian communities

This paper describes the efforts of one plastic surgery team composed of Ghanaians from one of the major metropolitan areas in Ghana to meet the plastic surgery needs of rural Ghanaian communities. The aim was to analyze retrospectively the cases managed by the team, the difficulties which arose over a 14-year period, and the provision of recommendations for such future work. This study reviewed the medical records of patients treated during 86 outreach visits to nine centers from October 1995 to September 2009. The team, drawn from three hospitals, comprised a plastic surgeon and surgical support staff. They mostly treated Buruli ulcers, postburns scar contractures, chronic ulcers, facial clefts, tumors, and breast diseases. In all, 2,284 patients were managed during the period under review, giving an average of 163 patients per year and 254 per center. Buruli ulcers accounted for the largest group of cases treated during the outreaches (41%). Other common diagnoses were postburn scar contractures and cleft lip and palate deformities. This paper provides an example of the possibilities for surgical outreach work that exist and how challenges that come up during surgical outreach visits can be handled effectively. It also highlights the need for outreach medical work in developing countries like Ghana, especially since there is a reduction in foreign outreach medical missions. The authors encourage all stakeholders involved in health care delivery to initiate and support local medical outreach teams to provide care to rural communities.     

Use of rhomboid flap and double Z-plasty technique in the treatment of chronic postburn contractures

BACKGROUND: Multiple reconstructive methods have been used for the treatment of postburn scar contractures including skin grafting, geometric relaxation techniques, local flaps and free flaps. PURPOSE: In the present study, the authors evaluated efficiency of the use of rhomboid flap and double Z-plasty technique in the treatment of chronic postburn contractures. METHODS: Twelve white male with postburn scar contracture were treated using rhomboid and double Z-plasty technique. The cause of burn, duration of contracture, postoperative follow-up period, preoperative and postoperative motion lag of joints and improvement in motion were recorded. CONCLUSIONS: All operations were successful. Severe contracture lines crossing flexion folds can be released effectively by using rhomboid flap and double Z-plasty technique without distorting the specialized flexion areas and with broken scar lines which is essential to avoid from recurrence.     

Postburn contracture of the neck--our experience with a new dynamic extension splint

Twenty-eight examples of postburn contracture of the neck managed during the last 5 years gave us a better understanding of the problems of anaesthesia, contracture release, skin grafting, splintage and maintenance of the fully release state. The severe contracture should be incised before intubation under a local anaesthetic agent. The release should include the adjoining contractures of mandibular and pectoral regions lest the skin graft is pulled by the existing contracture. Haemostasis should be meticulously secured to avoid graft loss. Splintage should be a static splint for 4-6 weeks followed by a dynamic splint until the applied graft becomes soft, supple and wrinkle free. Ideally, however, contractures should be prevented by nursing the patient with a neck extension in the acute phase and wearing a cervical collar during the subacute phase of wound healing.     

Use of free dorsoulnar perforator flap in the treatment of postburn contractures of the fingers

BACKGROUND: Burns of the hand cause not only the impairment of hand function but also cosmetic deformity. Cases with dysfunctional hands with severe contractures increase if rehabilitation of the acutely burned hand is not done properly. PURPOSE: We present the use of free dorsoulnar perforator flap in the treatment of postburn contractures as an alternative when local flaps cannot be used. METHODS: Free dorsoulnar perforator flap was used in the treatment of seven hands with postburn contracture. Five of them had multiple digital postburn flexion contractures. Combined use of cross-finger and side finger transposition flaps was preferred when the adjacent finger was suitable for being cross-finger flap donor. When the adjacent finger was not suitable for being cross-finger flap donor, the free dorsoulnar perforator flap was preferred. Two of the patients had postburn web contractures. Free dorsoulnar perforator flap was used to release the web and to form a new web commissure. CONCLUSION: The free dorsoulnar perforator flap could be a good alternative to cover the defects created with the hand contracture release.     

延期皮肤移植术在烧伤后重度关节畸形整复中的应用

目的　探索治疗重度瘢痕挛缩性关节畸形简便有效的整复技术。方法　Ⅰ期手术整复关节畸形 ,创面延期 3～ 5天 ,Ⅱ期手术植大片中厚皮。观察皮片成活质量及远期整复效果。结果　延期植皮法皮片成活率达 1 0 0 % ,关节畸形经分期整复可达到完全复位 ,远期整复效果良好。结论　延期植皮技术是一种简单有效的重度关节畸形整复方法。     

V-N plasty for the release of severe postburn contractures.

The authors describe a technique for the release of severe postburn contractures of the web spaces by using all the available tissues in the web space as local flaps to avoid using skin grafts or distant flaps. We rely on the central part of the web to raise the main triangular flaps that may be used to create a functional web space. We called it the V-N plasty.     

Ankle dorsiflexion postburn scar contractures: anatomy and reconstructive techniques

Background

Postburn ankle scar contractures cause functional limitations of all lower extremities and create a serious cosmetic defect, not allowing patients to use normal foot wear, and, therefore, needing surgical reconstruction. The anatomic features of ankle dorsiflexion contractures and their treatment have been covered in the literature far less than other joint contractures, and their treatment is still a challenge for many surgeons. A common treatment method is incisional release of the contracture and defect resurfacing with skin graft. Rarely, distally based sural or free flaps and Ilizarov fixator are used.

Methods

Anatomy of postburn ankle scar contractures in 55 patients was studied and contractures were surgically treated using a specific approach and technique. Follow-up results were observed from 6 months to 16 years.

Results

According to the anatomic features, dorsiflexion scar contractures were divided into three types: edge, medial, and total. Edge contractures were caused by burns and scars located on the lateral or medial ankle surface and were characterized by the presence of the fold along the anterior edge ankle; the skin of the anterior ankle surface was not injured. Medial contractures were caused by scars located on the anterior ankle surface and were characterized by the presence of the fold along the medial ankle line. Total contractures were caused by scars tightly surrounding the ankle. In fold's sheets of edge and medial contractures there is a trapeze-shaped surface deficit in length (cause of contracture) and a surface surplus in width which allows contracture release with local trapezoid flaps. For total contractures, wide scar excision and skin grafting were indicated.

Conclusion

Three anatomic types of ankle dorsiflexion scar contractures were identified: edge, medial, and total. An anatomically justified technique for edge and medial contractures is trapeze-flap plasty; total contractures are effectively eliminated with scar excision and skin grafting.     

Flap choices to treat complex severe postburn hand contracture

Many regions of the hand are affected seriously in the patients with complex severe postburn hand contractures. Multiple flap choices should be in count to treat complex severe postburn hand contractures affectively. We preferred dorsal ulnar flap for palmar region, cross-finger flap, side finger flap, and combined use of both for flexion contracture of the fingers, and rhomboid flap for web contractures. Eight patients having complex severe postburn hand contractures were treated between November 2001 and February 2005. The maximum improvements of the joint extensions were 75 degrees for median of digits metacarpophalangeal joint and 105 degrees for proximal interphalangeal joint. Grasp function of the hand dramatically improved, and the bulk of the flap did not interfere grasping. Complex severe postburn hand contracture can be treated sufficiently with dorsal ulnar flap, combined use of cross-finger and side finger transposition flap, and rhomboid flap.     

Is the deltopectoral flap born again? Role in postburn head and neck reconstruction

After extensive use for head and neck reconstruction, the deltopectoral flap has been supplanted by alternative methods of reconstruction and relegated to historical references. However, it remains a very valuable skin flap and should keep its place in the armamentarium of reconstructive surgeons for postburn head and neck reconstruction. We report here five cases of head and neck reconstruction using the deltopectoral flap: one case of perioral reconstruction after ballistic trauma, one case of nasal reconstruction after burn and three cases of neck reconstruction after burn contracture. Technical simplicity and reliability are the main features of this flap. The skin paddle is thin and pliable, and its surface can be extended after a flap delay. Previous tissue expansion can minimize donor site morbidity. The flap division necessitates a second surgical procedure. The major burn contractures of the neck are, in our opinion, an excellent indication of the deltopectoral flap.     

Classification and management of burned thumb contractures in children

Based on the position of the thumb metacarpal, 102 burned thumb contractures in children were classified into four categories: adduction, opposition, extension and flexion. The contractures were further classified as mild, moderate or severe, based on the amount of motion lost. All thumbs were surgically released. Coverage was obtained with local flaps or Z-plasties, skin grafts or a combination of local flaps and skin grafts. Factors influencing the results were as follows: Classification category: Extension contractures generally did poorly, whereas flexion contractures did well. Severity of contracture: The more severe the contracture, the worse the final results. Complexity of contracture: Contractures with a subluxated or dislocated joint did not do as well as those with undisturbed bony alignment. Type of surgical release: There was a trend towards better results when skin grafts (as opposed to local flaps) were used, especially in the treatment of moderate and severe contractures.