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

Minimally invasive burn reconstruction with subcutaneous scar contracture release

BACKGROUND

Scar contracture bands after burns are frequent problems that cause discomfort and physical limitation. This study investigates the efficacy of a minimally invasive contracture band release technique (MICBR) inspired by closed platysmotomy.

METHODS

Patients with burn scars treated with MICBR in our center were included retrospectively. Our routine scar and contracture treatments (non-invasive and invasive) were utilized prior to undergoing MICBR. Range of motion (ROM) and Vancouver Scar Scale was measured before and after the procedure when feasible.

RESULTS

Forty-five patients were included, with 97 total contracture sites treated all over the body. An average of 1.6 sites were treated per patient, with a maximum of six. Patients age was 6-68 years; total burn surface area ranged from 0.5% to 85%. 24% were performed under local anesthesia. 84% were in originally skin grafted areas. We found significant improvements in ROM and VSS. 84% of patients surveyed were "satisfied" or "very satisfied". 95% reported improved mobility. No significant adverse events occurred.

CONCLUSION

This MICBR technique is a versatile, safe, and well-tolerated adjunct procedure that can help patients regain mobility after a burn injury.

Flexible application of scar tissue flaps in scar contracture release surgery: A retrospective study

BACKGROUND

Complete release of scar contracture often relies on surgery, but if the surgery injures normal skin tissue triggers new wounds and scarring, which adds insult to injury for the patient.

OBJECTIVE

To explore a method that uses scar tissue to repair the defect after the release of scars and try to avoid damage to normal skin tissue.

MATERIALS AND METHODS

Forty-eight scar contracture patients admitted to our hospital from October 2014 to October 2019 were treated with scar tissue flaps (including Subcutaneous pedicle rhomboid flap, Z-plasty flap, 5-flap, and their combination model) and minor defects in combination with little scattered skin grafts. Medical and demographic data were collected on each patient. Assessed the joint range of motion (ROM) preoperatively and postoperatively, and complication was recorded. The rate of scar contracture recurrence was recorded at a follow-up of 6-24 months.

RESULTS

Twenty-eight cases of scar contracture located in the joint sites, 20 in the trunk. All the surgical outcomes were satisfied, with significant improvement in contracture scarring and joint status. Postoperative joint range of motion (ROM) showed a significant improvement in comparison with preoperative mobility, whereas the difference was statistically significant (p < 0.05). After 24 months of follow-up, five joints showed recontraction, with a recurrence rate of 10.42%.

CONCLUSION

Scar contracture could be efficiently treated by properly designing incisions and making the most of the scar tissue flap, to minimize and avoid damage to the normal skin.

Concepts in soft-tissue reconstruction of the contracted hand and upper extremity after burn injury

Burns and their subsequent contracture result in devastating functional and aesthetic consequences which disproportionally affect the upper extremity. By focusing on reconstruction with analogous tissue and utilizing the reconstructive elevator, function can be restored concomitantly with form and aesthetic appearance. General concepts for soft-tissue reconstruction after burn contracture are presented for different sub-units and joints.

W-plasty in Scar Revision: Geometrical Considerations and Suggestions for Site-specific Design Modifications

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Background:

A large proportion of scars in clinical practice represent good candidates for surgical revision by virtue of their unfavorable characteristics and relative orientation with respect to skin relaxed tension lines. W-plasty is a very popular excisional revision technique, which involves breaking up the scar margins into small triangular components, which are advanced and interdigitated without any rotation or transposition.

Methods:

We performed an extensive literature search using Pubmed MEDLINE, Web of Science, and Embase using the following keywords [W-plasty] AND [scar] AND [revision]. We retrieved 13 articles pertinent to the indications, geometrical design, and technical evolution of the W-plasty scar revision variants. We formulate indications for the use of isosceles/equilateral as opposed to scalene triangle W-plasty and integrate our experience with regards to the choice of geometrical design for different bodily regions.

Conclusions:

W-plasty represents a popular technique in reconstructive plastic surgery practice. We believe that the exact W-plasty design should be guided by the relaxed skin tension line definition and to this effect propose 2 main variants of geometrical design pertinent to the index anatomical site.

Surgical treatment algorithms for post-burn contractures

Burn contractures produce restrictions in motion and unacceptable aesthetic results, frequently with persistent wounds. Proper planning and tissue selection are essential to minimize donor site morbidity optimizing outcomes. The principle of burn reconstructive surgery requires that the defects after release should be replaced with donor tissues which have matching texture and color as well as enough pliability. Autologous skin grafting or flap surgeries meet these criteria to replace scar tissues and resurface the subsequent to post-released scar defects. Despite the benefits, the use of flaps is often limited in burn patients for many reasons. If a surgeon intends to release completely and reconstruct in one-stage operation, a large defect may result in large donor site morbidity, necessitating flap surgery including free flap surgery. A lot of different methods and procedures are available for resurfacing the defects, and these are reviewed. In this article, algorithms for the release of burn contractures and reconstructive methods are presented. These treatment algorithms should aid in achieving significant improvement in both joint motions and aesthetic deformities.

STARplasty for Reconstruction of the Burned Axilla

BACKGROUND

Postburn axillary contractures are common and significantly impact quality of life. Simple release combined with split thickness skin grafting necessitates a donor site, requires immobilization, and may result in poor functional outcome. Common methods of adjacent tissue rearrangement are not well designed to treat broad linear contractures. Flaps from the back, flank, or arm can be used, but may come with significant donor site morbidity. We demonstrate the use of the STARplasty, a novel adjacent tissue rearrangement initially developed to treat neosyndactyly, as a useful reconstructive option for the release of Kurtzman type 1 posterior or anterior axillary contractures.

METHODS

A retrospective review was performed to identify patients who underwent STARplasties for treatment of type 1 axillary burn contractures. All reconstructions were performed by a single surgeon at a single ABA burn center (April 2011 to December 2015). A version of the surgical STARplasty technique previously described for treatment of neosyndactyly was modified for use in the axilla. Patient and injury demographics, as well as complications and outcome, were collected.

RESULTS

Twelve patients with upper extremity burns underwent 16 primary STARplasties for treatment of axillary contractures. Three patients underwent simultaneous bilateral procedures. The majority (15/16) of the primary procedures were used to address contractures of the anterior axillary fold. Mean patient age was 51 (R 38-63) and average burn size was 35% (R 18-80). Average time from initial injury to primary reconstruction was 11.1 months (R 3-54). One patient required revision for persistent contracture and another experienced wound dehiscence that ultimately required split-thickness skin grafting. No other significant complications were noted, and all remaining patients had closed wounds and full range of motion by 30 days postprocedure.

CONCLUSIONS

Axillary contractures remain common despite improvements in physical/occupational therapy. While common techniques, such as z-plasty, continue to be helpful for the surgical release of narrow contractures with bilateral laxity, axillary contractures are typically broad based and often contain only unilateral unburned tissue. Based on our experience, the axillary STARplasty represents a safe and efficacious technique to be considered in the case of broad-based contractures involving either the anterior or posterior axillary fold.

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.

Double opposing rectangular advancement flap is an alternative technique in the treatment of wide linear postburn scar contractures

BACKGROUND

Double opposing rectangular advancement is a new and alternative technique in the treatment of postburn scar contractures. The technique consists of opposing two adjacent subcutaneously pedicled rectangular flaps by advancement and lengthening a contracture band. Experimental studies demonstrated that the technique is efficient to elongate a tension line as much as Z-plasty in the rat inguinal skin. In this clinical study we investigated the efficiency and versatility of the technique in the treatment of wide linear postburn scar contractures in various parts of the body.

MATERIALS AND METHOD

We applied 16 double opposing rectangular advancement in 7 patients (aged 4-56). Flaps were applied in the upper extremity (11 flaps), lower extremity (4 flaps) and trunk (1 flap).

RESULTS

Average follow-up was 1-year. All flaps achieved adequate relaxation postoperatively and healed uneventfully. Postoperative measurements indicated that the lengthening provided with the technique ranged from 72 to 100%. The subcutaneous pedicle of the rectangular flaps provided a distinct advantage in terms of vascularity. Recontracture was seen in one patient to whom two double opposing rectangular flaps in series were applied in the axilla.

CONCLUSION

Clinical results indicated that double opposing rectangular advancement is effective in the treatment of wide linear postburn scar contractures. Preoperative planning and application of flaps are simple. One knows preoperatively the exact elongation along the contracture line and narrowing perpendicular to this line which will be provided with the technique. Since the flaps are subcutaneously pedicled, the vascularity of the flaps are reliable. However the technique may not avoid recontracture in the axilla.

Tissue expansion and latissimus dorsi transfer for arm-thorax synechia reconstruction

Inadequate treatment of severe burn injury often results in scar contractures with subsequent functional impairment and cosmetic deformities depending on the body area involved. Arm-thorax synechia is a rare but devastating complication of burns. The authors report a case of a 17-year-old boy with subtotal arm-thorax synechia, secondary to burn contracture. Reconstruction was accomplished, in two stages, with the use of tissue expanders and a latissimus dorsi muscle flap. The postoperative course was uneventful in both stages, with complete survival of both the expanded skin and the muscle flap. Early initiation of intensive rehabilitation resulted in excellent functional outcome, while significant aesthetic improvement was also ensured. In conclusion, the combined use of tissue expansion and latissimus dorsi transfer may prove to be a very good option in the treatment of complex postburn axillary contractures. The main advantages of the suggested method are the best quality of skin provided by tissue expansion and the safe coverage of any vital structures exposed with the use of the muscle flap.

A circumferential incision technique to release wide scar contracture

SUMMARY

Wide scar contracture in patients with large burns is generally treated with a skin graft or flap after release of the contracture. In children, however, the creation of a new scar at the donor site should be avoided because additional operations are sometimes required later in life. Patients with large scars often lack adequate donor sites. We describe a simple technique that effectively reduces wide scar contracture without the use of a skin graft or flap. A spindle-shaped incision line is designed around the contracted scar. The major axis of the spindle should coincide with the direction of strongest contracture. Incision of the skin releases the contracture, and the surrounding skin returns to a normal position. If satisfactory release of the contracture is not obtained by a simple incision, the surrounding skin is slightly undermined. The doughnut-like skin defect resulting from undermining is sutured again, taking care to avoid increased tension in the direction of contracture. We used this technique to treat 28 scar contractures in 21 patients. All sites had good outcomes without any complications, such as congestion or haematoma. Scar contracture markedly resolved, both subjectively as well as objectively. Hard red scars consistently became whiter and softer after the operation. The design is similar to the double opposing V-Y plasty or rhomboid flap but the significant feature of our technique is that the design includes the entire scar in the central area. It makes it possible to release multiple contracture bundles or a largely contracted area at one time. This technique is simple, safe, minimally invasive for patients, and requires no other donor sites. It should be tried before resorting to the use of skin grafts or flaps in patients with large scar contractures.