Use of seven-flap plasty for the treatment of axillary and groin postburn contractures

An Innovative Approach to Classifying and Treating Axillary Scar Contracture

BACKGROUND

Axillary cicatricial contracture is a debilitating condition that can greatly impair shoulder joint function. Therefore, timely correction of this condition is imperative. In light of Ogawa's prior classification of axillary cicatricial contracture deformities, we have proposed a novel classification system and reconstruction principles based on a decade of treatment experience. Our proposed system offers a more comprehensive approach to correcting axillary cicatricial contracture deformities and aims to improve patient outcomes.

METHODS

Our study included 196 patients with a total of 223 axillary cicatricial contracture deformities. The range of shoulder abduction varied between 10 and 120 degrees. Our treatment approach included various methods such as the lateral thoracic flap, transverse scapular artery flap, cervical superficial artery flap, medial upper arm flap, latissimus dorsi flap, Z-shape modification, and the use of local flaps combined with skin grafting. After 2 weeks, the sutures were removed, and patients were instructed to start functional exercises. To categorize the deformities, we divided them into 2 types: axillary-adjacent region cicatricial contracture (type I) and extended area contracture (type II).

RESULTS

For each subtype, a specific treatment method was chosen based on a designed algorithm decision tree. Out of the total cases, 133 patients underwent treatment with various types of local flaps, including Z-plasty, whereas 63 patients received treatment involving skin grafting and different types of local flaps. At the time of discharge, the abduction angle of the shoulder joint ranged from 80 to 120 degrees. Among the 131 patients who were followed up, 108 of them adhered to a regimen of horizontal bar exercises. After a 1-year follow-up period, the abduction angle of the shoulder joint had significantly improved to a range of 110-180 degrees.

CONCLUSIONS

We have proposed a novel classification method for the correction of axillary cicatricial contracture deformity. This approach involves utilizing distinct correction strategies, in conjunction with postoperative functional exercise, to ensure the effectiveness of axillary reconstruction.

The Modification of Five-Flap Z-Plasty for Web Contracture

BACKGROUND

Web contractures are fairly commonly encountered in those who have suffered from burn injury or other trauma. Numerous local flaps have been adopted previously. The five-flap Z-plasty is one that has been used frequently. To release the scar as much as possible, based on the traditional design, we developed a modified technique of the five-flap Z-plasty to reconstruct the axillary and elbow web contractures. Hence, the length of the axis of the cicatrix could be much lengthened.

METHODS

Twenty patients (12 females and 8 males, 7 to 48 years-old) with 27 web contractures were arranged for the operation using the new flap. The contractures were formed on by burn injury in 17 patients, surgery in 2 patients, and traumatic cicatrix in 1 case. All patients were operated on using a modified five-flap Z-plasty to reach the aim of maximum contracture relaxation.

RESULTS

All flaps survived well. No flap tip necrosis occurred. Good function was gained in all patients postoperatively by the one year average follow-up. There was no recurrence. The contracture band was freed satisfactorily.

CONCLUSION

The technique is very easy to execute and can be used both in web and linear contractures. With the virtue of extending the length of the scar axis to a higher degree compared to the traditional method, we suggest this modified five-flap Z-plasty application.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Pedicled anterior lateral thigh flap in managing a bilateral groin contracture

A fifteen-year-old female patient presented with a severe bilateral groin contracture for the last 8 years. She had sustained burns at the age of seven years. Three attempts to release the contracture with split thickness skin grafts had been done without success. A pedicled anterior lateral thigh flap was raised and advanced into the defect after the contracture had been released. Postoperatively the patient healed well without any complications and was able to achieve hip abduction of about 130 degrees.

An extraordinary case of axillary contracture: trapped healthy skin and its adnexes under contracted scar

Although striking improvements have been achieved in overall management of burn injury, postburn contractures are still an ongoing challenge to burn surgeons. Axillary adduction contracture is one of the most common types of these disabling postburn complications that usually result from suboptimal treatment after acute burns. An unusual and complicated case of axillary contracture in which the unburned, healthy axillary dome skin was trapped as a cystic mass under the scarred area was reconstructed by transfer of a big (17×13-cm) thoracodorsal artery perforator flap after contracture release. The result was satisfactory in terms of function and acceptable cosmetically. The underlying reasons for the inadequate treatment the patient received after surviving a severe electrical injury were discussed.

Postburn shoulder medial-adduction contracture: anatomy and treatment with trapeze-flap plasty

BACKGROUND

Shoulder-adduction contractures after burn, most frequent among big joints, cause functional deficiency of the upper limb and, therefore, benefits from surgical correction. Many reconstructive techniques and flaps have been suggested for contracture treatment, but the problem in choosing an adequate reconstructive technique based on the anatomy of the contracture remains. Shoulder-adduction contracture has been given less emphasis in research than any other type and its surgical reconstructive technique remains of concern.

METHODS

Anatomic features of scar shoulder-adduction contractures were studied in 346 patients, personally operated upon. This allowed us to classify all contractures into three types: edge, medial and total. New surgical techniques specifically for medial contractures were developed.

RESULTS

Eighty percent of patients had edge contractures in which the axillary fossa was spared. In 20% of patients, axilla, including the hairy dome, was involved. These cases were anatomically classified into two types: medial, making up 30% of the cases, when contracted scars involved only axilla, and total caused by scars, tightly surrounding the shoulder joint. The scars, causing medial contracture, form a crescent-shaped fold along the medial axillary line. The fold's sheets are scars in which there is skin surface surplus in width, which allows the contracture release with local tissues. Surface deficiency in length has a trapezoid form. Medial contracture can be successfully treated with opposite transposition of trapezoid adipose-scar flaps prepared from both sheets of the fold.

CONCLUSION

Medial shoulder-adduction contracture is a newly described type with specific anatomic features. Contracture can be successfully treated with local tissues using trapeze-flap plasty.

Postburn hand border contractures and eliminating them with trapeze-flap plasty

The hand burns can be complicated with the scar contracture of the ulnar or radial hand border. The contracture restricts the mobility of adjacent joints (fifth interphalangeal, wrist joints), causing deviation of the small finger and the whole hand. The contracture and deviation are caused by semilunar fold sheets of which are scars (medial contracture). The fold sheets have the trapeze-shaped surface deficiency in length and surface surplus in width. Thus, the local tissue flaps should have the corresponding form (trapeze-shaped flaps) for surface deficiency compensation. The sheets are transformed into trapezoid flaps along the total length of the semilunar fold with radial incisions until the full tension release is achieved. The incision's ends are split to complete the scar tension release. The distance between radial incisions at the fold's top is approximately 2 to 3 cm, which matches the width of the flap's end. The flaps are mobilized with the full fatty layer and transposed toward each other until the end of one flap reaches the base of the opposite flap. As a result, the skin surface lengthens by two to three times, which allows complete contracture elimination. The contractures were liquidated in all 16 patients without complications. The trapeze-flap plasty is recommended for a wide use in treatment of hand boarder contractures.

Clinical experience and analysis of length gain with the use of seven-flap plasty in burn contractures

BACKGROUND

The seven-flap plasty despite its excellent surgical properties in the release of burn contractures is not widely adopted by surgeons. It is likely that the surgeons may have misgivings about its reliability, its ability to release a contracture and the length gain that can be obtained.

SUBJECT AND METHODS

A sponge model is described to determine the gain in length obtained from the seven-flap plasty. It also helps to understand the physical mechanics. Our clinical series of 55 release procedures with the use of seven-flap plasty is described. The anatomical regions include the neck, axilla, cubital fossa, hand, perineum, popliteal fossa and the foot. Forty-nine procedures were assessed for the immediate gain in length obtained post-release.

RESULTS

The sponge model demonstrated a length gain of 80%. The length of the contractures to be released ranged from 1 to 14 cm. The immediate length gain obtained in the clinical series ranged from 60 to 233% (average=105%).

CONCLUSION

The theoretical length gain in z-plasty is of little clinical significance. A host of factors such as lateral laxity, number of flaps, angle at the tips, the anatomic region, and the cause of the contracture determine the actual clinical length gain obtained following a seven-flap plasty release procedure.

Management of postburn contractures of the upper extremity

Postburn contractures of the upper extremity are better prevented than treated, but many patients still suffer from this disability, especially after suboptimal primary care or major burns. Principles applicable to release of postburn contractures of the upper extremity are discussed, with a joint-specific review of relevant techniques to accomplish the release of the contracture. Pre- and postoperative care is discussed.

The propeller flap for postburn elbow contractures

Flexion contracture of the elbow is a common sequela of burn injury. Numerous methods have been suggested for release, including grafting, Z-plasty, Y-V flaps, local or distant fasciocutaneous flaps, muscle or myocutaneous flaps, free flaps, tissue expanders and non-surgical orthotics. In this article the authors present their experience with the propeller flap method in seven cases of elbow flexion contracture. Sufficient extension and an acceptable aesthetic outcome were obtained. Other benefits include easy design and rapid flap elevation that permits a single stage correction of the deformity without further sacrificing an artery or muscle. We think that the main disadvantage of the propeller flap is using the same skin that has suffered from the burn insult which has a poorer cosmetic result. Other than this and excluding deep burn injuries, we believe that the propeller flap is a useful alternative for elbow contracture release.

Reconstruction of axillary contractures with thoracodorsal perforator island flap

The axilla is one of the most frequently sites affected by contractures after severe burns. These contractures often cause cosmetic problems and functional deficiency. A variety of therapeutic methods such as skin grafting, Z-plasties, local flaps, island flaps, and free flaps, have been reported for treatment of the contractures. Each has its own advantages and drawbacks. In this clinical study we report 15 cases of post burn axillary contractures treated with thoracodorsal perforator-based cutaneous flaps. The flaps were harvested in range of sizes up to as large as 27 cmx15 cm. All flaps survived completely without even marginal necrosis. The donor sites were closed primarily except in one case who needed a small skin graft. Satisfactory improvement in shoulder abduction was obtained. The range of abduction was on average 46.6+/-19.3 degrees before the operations and 159+/-12.4 degrees after the operations. Cosmetic results were satisfactory from the patient's point of view. The thoracodorsal perforator flap can be safely raised to meet any size required even in the most severe contractures. The donor site scar may be considered as acceptable considering the advantages of the flap. We strongly recommend this flap as the treatment of choice in releasing challenging axillary contractures.

Figure-of-8 sling for prevention of recurrent axillary contracture after release and skin grafting

The axilla is a frequent site of adduction contracture after deep thermal injury, especially in burns in developing countries where the timely treatment of burns and the prevention of contracture are not possible for lack of appropriate services. Chronic contractures are difficult to treat, as large areas of wounds need to be covered with skin grafts or flaps. However, the most daunting aspect of adduction contracture is the maintenance of release after correction; this is often dealt with using long-term abduction splints, most of which are very uncomfortable. Our purpose here is to analyse our results with a simple figure-of-8 sling. A descriptive study was made covering a period of 10 years, comprising 40 cases of chronic extensive axillary contracture. All the cases were treated with simple release and skin grafting followed by a figure-of-8 sling. Preoperative limb abduction ranged from 0 degrees to 80 degrees; whereas, the postoperative range, at 1 year of follow-up, was from 140 degrees to 180 degrees. Hence, we conclude that the application of a figure-of-8 sling for axillary post-burn contractures is a safe, comfortable, easy and more compliant way of splintage with at least as reliable results as with other abduction splints.

Treatment of axillary burn scar contracture using opposite running Y-V-plasty

Burn scar contractures are frequently observed following full-thickness burns of the axillary area. Such contractures are traditionally reconstructed sometime within the first year after injury with therapeutic methods including skin grafting, Z-plasty, local/regional flap, island flap, perforator flap, free flap or combination thereof. Flap methods have many advantages over split skin grafting, including less likelihood of recurrence of contracture as well as making prolonged splinting unnecessary. However these flaps are cumbersome, unattractive, and apparently distort the axillary hair. Moreover, they have a risk of flap necrosis or marginal vascular compromise. A new opposite running Y-V-plasty presented here is designed to overcome those dilemmas. This procedure was performed in eight cases with good functional recovery and cosmetic appearance. It is also a simple, adaptable, and reliable method. The range of motion of shoulder joint was also satisfactorily achieved since axillary contracture scars were almost completely released. Most of all the procedure can be repeated if the release is not enough. In short, the opposite running Y-V-plasty is a good alternative method when we consider the reconstruction of axillary burn contracture.

Experience with the seven flap-plasty for the release of burns contractures

Eighteen patients with burns contracture to the knee 7 (34%), elbow 5 (28%), perineum 4 (22%), and axilla 2 (11%), were treated at our unit between February 1998 to October 2001 using the seven flap-plasty. We chose this method because of its suitability for such contractures, which take the form of a web rather than a straight or linear pattern. Because it involves no donor area, that is no donor site morbidity and therefore less chance for longer hospital stay. The majority of these patients were children 11 (61%). Ten were females (56%) and 8 (44%) were males. Age of patients ranged between 2 and 35 years. The results of the procedure were satisfactory in all patients with good functional recovery of the affected sites.