Ten-year experience with one-step correction of constriction rings by complete circular resection and linear circumferential skin closure

Advanced Management of Distal Lower Extremity Congenital Constriction Bands for Foot Salvage

Constriction ring syndrome is a rare congenital condition characterized by the formation of fibrous amniotic bands, which can result in limb or digit deformation, malformation, or autoamputation. Surgical intervention is necessary for patients with progressive or severe forms of constriction banding, but the timing and operative approach vary widely. Here, the authors present a case report detailing the successful removal of multiple congenital constriction bands (CBs), uniquely affecting the distal ankle and foot in an infant meeting Patterson type-2 criteria. This type is characterized by CBs resulting in distal deformation with or without swelling. In this case, urgent intervention was prompted by concerns of vascular compromise, and amputation was considered due to the severity of the banding. However, the authors advocated for a staged approach, with the aim of preserving the patient's limb. A series of three separate procedures tailored to the patient's banding pattern and subsequent tissue complications were required to achieve restoration of ankle and foot functions, as well as satisfactory cosmesis. This case report underscores the importance of a customized surgical approach in addressing complex CBs and emphasizes the need for proactive consideration of salvage interventions by surgeons.

Common Pediatric Hand Anomalies

Upper extremity congenital anomalies in the newborn are second only to congenital heart anomalies. Some of the more commonly encountered upper extremity anomalies are trigger thumb, thumb hypoplasia, polydactyly, syndactyly, and amniotic band syndrome. While some conditions occur in isolation, others are known to commonly occur in association with syndromes. Familiarity with these conditions is important not only to provide adequate evaluation and workup of these patients but also to deliver appropriate surgical intervention and prepare parents with appropriate expectations. In this article, we outline the etiology, classification, surgical management, and outcomes of these five commonly encountered upper extremity congenital anomalies.

Outcomes of Linear Circumferential Skin Closure for Congenital Constriction Ring Syndrome

Background: Congenital constriction ring syndrome (CCRS) is a rare condition diagnosed at birth characterised by deformation due to a constriction ring. The usual treatment for CCRS involves excision of the constriction ring and suture of the skin incorporating a Z-plasty to prevent scar contracture. A Z-plasty often results in an unsightly scar. In order to avoid this, we performed linear circumferential skin closure (LCSC). The aim of this paper is to report the outcomes of LCSC for CCRS. Methods: We retrospectively investigated all patients with CCRS who underwent LCSC between 2002 and 2020. Two linear incisions were placed proximal and distal to the constriction ring in parallel, and the constriction ring was excised carefully so as not to damage nerves or vessels. The deep subcutaneous and dermis layers were sutured. The skin was closed using adhesive tape. Two-stage surgery was performed in two patients with severe CCRS of the lower leg to avoid problems with distal circulation. Patients were followed up for at least 1 year and assessed for complications and quality of scar. Results: We performed LCSC for 31 sites in 19 patients, including one forearm, 14 fingers, 10 lower legs and six toes. The median age at the operation was 16 months (range: 4-175). The median follow-up period after surgery was 5.8 years (range: 1.9-16.0). The linear surgical scar had healed well in all patients and there were no complications. There was no recurrence of the constriction ring and no scar hypertrophy, though we did not perform fat mobilisation in all cases. None of the patients required additional surgery and the aesthetic outcome of the linear circumferential surgical scar was maintained at the final observation. Conclusions: Treatment for CCRS using LCSC resulted in no complications, no recurrence of constriction and an excellent aesthetic outcome. Level of Evidence: Level IV (Therapeutic).

Clinical assessment of the results of one-stage circular incision techniques for limb ring constriction due to amniotic band syndrome

BACKGROUND

Amniotic band syndrome (ABS) is a congenital malformation that results in abnormalities in many parts of the body. Most surgical treatments for ABS used multi-stage Z-plasties. The purpose of this study was to assess the clinical results of one-stage circular incision techniques for limb ring constriction due to amniotic band syndrome.

METHODS

We reviewed 27 patients with limb ring constriction in ABS from 2010 to 2020. The mean ages of the patients were 11.7 months (range, 0-72 months). The complete circular incision release the ABS. All patients' operations were used one-stage circular incision surgical techniques, including patients with multiple bands. All the patients were followed up with a period ranges from 2 years to 10 years. Patient-reported visual analog scale (VAS) scar ranking on a scale of 0 (minimum satisfaction) to 10 (maximum satisfaction) were used to evaluate esthetic outcomes.

RESULTS

After our surgery, all the limbs, toes, and fingers were rescued, and the lymphedema reduced remarkably. The VAS scores (mean ± SD) for patient satisfaction were 7.55 ± 1.89. The surgical treatment of amniotic band syndrome in a one-stage circular incision is safe and effective.

CONCLUSION

The one-stage circular incision surgical techniques have many advantages, including reduced surgical invasiveness, scar formation, and the cost of treatment.

LEVEL OF EVIDENCE

Level IV-retrospective case series.

Congenital Constriction Band With Lymphedema in a Neonate: A 17-Year Follow-Up After Single Stage Excision and Z-Plasty

Congenital constriction band syndrome is a rare condition that presents with constriction bands affecting different types of extremities. Timely surgical intervention for moderate and severe stages of this condition can be performed either in a single stage or multiple stages. We report the case of a neonate who presented with a congenital constriction band and had excision of the constriction band and z-plasty reconstruction. The surgery was done in a single stage. This case highlights the outcome and safety of this single-stage surgery with Z-plasty reconstruction. At 17 years of age, he has a functional lower limb and excels in archery.

One-stage circumferential limb ring constriction release and direct circular skin closure in amniotic band syndrome: a 14-case series

The aim of the present study was to report results of direct circular suture after 1-stage circumferential resection of limb ring constriction in amniotic band syndrome. A multicentre retrospective study included 14 patients with amniotic band syndrome (mean age, 13.3 months) operated on between 2004 and 2019 by circumferential release of ≥1 ring constriction. Assessment was based on limb function and clinical scar aspect on the POSAS and Vancouver scales. Mean follow-up was 3.9 years. There were no scar-related, vascular or neurologic complications, postoperatively or at last follow-up. POSAS and Vancouver scores were satisfactory. One-stage circumferential release with direct closure is a simple technique that provides satisfactory functional and esthetic results.

Serial Z-plasty for Correction of Cicatricial Conjunctival Constriction Rings

BACKGROUND

Cicatricial conjunctival constriction rings caused by trauma seriously influences visual function and causes blepharon deformities. The treatment of cicatricial conjunctival constriction rings is intractable.

METHODS

A 45-year-old male presented severe cicatricial conjunctival constriction ring due to traffic accident injury. This 5-mm diameter constriction ring resulted in the patient's eyelid deformities, including eyelid ptosis, ectropion, and visual obstruction. The patient underwent primary surgery of serial conjunctival Z-plasty for correction of the constriction ring. Conjunctival constriction ring was corrected immediately after Z-plasy. Fornix deepening suturing was adopted to promote formation of fornix and correct eyelid ectropion. A secondary surgery of frontalis flap suspension was adopted to correct ptosis 6 months after Z-plasty.

RESULTS

The patient achieved a satisfactory and symmetrical appearance with no recurrence of cicatricial conjunctival constriction and no other complications during the 6-month follow-up period.

CONCLUSION

In this patient, the authors claimed that serial Z-plasty surgery can effectively be used for correction of cicatricial conjunctival constriction rings. No further material implantation was applied during the operation.

Treatment of Constriction Bands of Limbs by Fat Injection: An Additional Modality

BACKGROUND

Constriction bands in the majority of cases presents as a contour deformity. The gold standard of treatment is a single-stage constriction ring excision and serial Z-plasty. The expense is unsightly scarring. We present case reports of deformity correction by serial fat injections.

METHODS AND PARTICIPANTS

Three case studies of children in whom this modality was used in limbs to correct the deformity are presented.

RESULTS

Two participants showed a good correction of the deformity and in a single-case treatment failed requiring excision and serial Z-plasty for correction.

CONCLUSION

Fat injection in combination with Khouri's technique of aponeurotomies is an attractive modality of managing superficial constriction bands of limbs.

Single-Stage Resection of Type II Constriction Rings in Limbs on the Basis of Histologic and Magnetic Resonance Imaging Observations: A Retrospective Study of 21 Consecutive Patients

BACKGROUND

The purpose of this study was to determine the feasibility of single-stage resection for type II congenital constriction rings by means of histologic examination of resected specimens and imaging examination of affected extremities, and to evaluate the appearance and function of the extremities after single-stage surgery.

METHODS

The features of the skin on the constriction rings and the subcutaneous tissues were identified through continuous sectioning, hematoxylin and eosin staining, and immunohistologic staining of specimens of type II constriction rings obtained by means of surgery. The relationship between the constriction rings and the deep main blood vessels was evaluated using magnetic resonance imaging. Single-stage resection of the constriction band, reduction of the fascial flap, and triangular flap-plasty were performed for 21 patients. The appearance, lymphedema, and movement of the extremities were compared before and after the operation.

RESULTS

Type II constriction rings in the extremities had normal full-layer skin structures. Collagen was found deposited densely at the base of the grooves, but the normal subcutaneous tissue space remained, and the vital nerves and blood vessels were unaffected. Complete resection of the constriction rings was achieved in all 21 patients, and lymphedema subsided 2 months after the operation. No episode of recurrence was found, and limb function was not affected at 26-month follow-up.

CONCLUSIONS

Type II congenital constriction rings in limbs possess normal subcutaneous tissue spaces. A single-stage operation, which includes complete resection of the rings, fascial flap reduction, and triangular flap-plasty, could achieve a satisfactory appearance and good function.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Lipoinjection and Multiple Internal Cuts for Congenital Constriction Bands: A New Treatment Approach

BACKGROUND

Traditional treatment for a congenital constriction band of the limb involves multiple Z-plasties and W-plasties. We propose an alternative surgical procedure for the treatment of congenital constriction bands that obviates the need for Z-plasties and eliminates the constriction band.

METHODS

We present the case of a 36-year-old woman with a congenital constriction band of the leg. Using a minimally invasive approach, the skin segment that included the band was dissected from the deep tissues. Afterwards, multiple slices were performed on the internal surface of the fibrous ring. This and lipoinjection were used to reverse the depression that characterizes the "hourglass sign" and homogenize the skin surface.

RESULTS

Results have remained stable in a follow-up period of 18 months.

CONCLUSIONS

This surgical alternative can be considered as an option for the treatment of congenital constriction bands. It is a safe, reproducible procedure that does not cause additional scars and has good functional and aesthetic results.

LEVEL OF EVIDENCE V

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 .

Surgical Treatment of Active Amniotic Band Syndrome (ABS) by Z-plasty and Radical Excision of the Overgrown Tissue: A Report of 2 Cases With Progressive Lymphedema Causing Vascular Insufficiency

The study describes 2 children at risk of limb amputation due to lower extremity active amniotic band syndrome, in which the constriction bands were released surgically using the extensive approach. Both patients presented almost the same clinical appearance: a deep constriction band localized in one third of the distal part of the leg and a pseudoconstriction at the ankle joint level resulting from the tightening of the retinaculum of extensors. In both the cases, after birth amniotic band syndrome caused progressive enlargement of the distal part of the foot, which was associated with edema and vascular insufficiency. Case 1, at the age of 3 months, underwent a primary excision and Z-plasty of the proximal constriction band, and after 6 weeks a secondary excision was performed covering the soft tissue bulk from the dorsal part of the foot formed due to vascular insufficiency progression. In contrast, case 2 underwent a more radical 1-staged surgery at the age of 4 weeks, that is, an excision and Z-plasty of the proximal constriction and the same radical excision of the soft tissue bulk. In addition, in both patients decompression fasciotomy was performed. A follow-up after surgery, respectively, at the age of 20 and 5 years, revealed a fully functional foot and restoration of blood supply. Thus, the 1-staged radical excision of constrictions combined with removal of the overgrown skin and pathologic soft tissue can be recommended for similar cases.

LEVELS OF EVIDENCE

Level IV-case series.

Novel techniques for the surgical management of abdominopelvic constriction rings in amniotic band syndrome

Constriction rings are associated with amniotic band syndrome and most often present in the extremities. Constriction bands of the trunk are rare, and a standard of surgical care remains elusive. Traditional methods of constriction ring excision rely on soft-tissue rearrangement with multiple Z-plasties, but renewed interest in linear closure and limited Z-plasty has emerged. The authors review contemporary literature and report two cases of abdominopelvic constriction ring reconstruction with long-term follow-up. Novel techniques including anterior sheath Y-V plasty, pteruges release of the Scarpa fascia, and limited Z-plasty closure may minimize the need for serrated scar patterns.