Tissue Rearrangements

The Art of Local Tissue Rearrangements in Burn Reconstruction: Z-Plasty and More

In recent decades, advances in surgical anatomy, burn pathophysiology, surgical techniques, and laser therapy have led to a paradigm shift in how we approach burn scars and contractures. Scar excision and replacement with uninjured tissue, which predominated burn scar treatment for much of the 20th century, is no longer appropriate in many patients. A scar's intrinsic ability to remodel can be induced by reducing tension on the scar using various techniques for local tissue rearrangement. Often in combination with laser therapy, local flaps can optimally camouflage a burn scar with adjacent normal tissue and restore a patient more closely to their preinjury condition.

A Case of Traumatic Nasal Valve Stenosis Successfully Treated with Open Rhinoplasty and Z-Plasty

External nasal deformity is common and can be treated surgically. It often occurs in conjunction with the development of the nasal septal cartilage, vomer, and vertical plate of the ethmoid bone but may be caused by trauma. Here, we present a case of external nasal deformity caused by trauma. A woman presented with nasal obstruction due to dysfunction of the nasal valve area and was referred to our department for treatment. No chronic rhinosinusitis or nasal septal deviation that causes nasal obstruction was noted at the initial examination. However, trauma-related scarring was observed in the nasal valve area, and a Cottle test yielded positive results. The patient underwent combined rhino- and Z-plasty surgery and is currently undergoing follow-up at an outpatient clinic.Although otolaryngologists generally use an endonasal approach to treat nasal obstruction, it is important to perform an appropriate evaluation of the external nose and to collaborate with a plastic surgeon, as necessary.

Scar Revisions

Scars pose a complex challenge to the reconstructive surgeon in the variability of their presentation and their effect on cosmesis and function. Numerous surgical and nonsurgical options exist for scar management, each with their respective advantages and disadvantages. Each treatment modality should be tailored to the patient to ensure enhanced outcomes. In this review, we discuss different scar presentations, scar management options, and the benefits and risks with undergoing these various treatment modalities.

The Z-plasty contributes to the coalescence of a chronic non-healing wound

This study aimed to explore the treatment effect of Z‐plasty on a non‐healing wound. A total of 72 patients diagnosed with a chronic non‐healing wound in Peking University Third Hospital from November 2009 to August 2019 were retrospectively analysed. Among them, 27 patients were treated with Z‐plasty, and 45 patients were treated with the general method. Detailed patient information was retrieved from medical records, including age, gender, body mass index (BMI), alcohol, smoking, and comorbidities (diabetes mellitus, hypertension, heart disease). Surgical parameters included operation time and intraoperative blood loss. Wound swelling, epidermal blisters, wound edge colour, and skin temperature at 1 day after surgery were assessed to evaluate the blood supply of the wound. Surgical complications included infection, haematoma, dehiscence, and non‐healing within 2 weeks postoperatively. Student t test (for continuous data) and Chi‐square test (for categorical data) were conducted to determine the statistical difference. We found no significant differences in age, gender, BMI, alcohol, smoking, and comorbidities between the two groups. Z‐plasty did not show any advantages in the surgical time, invasive blood loss, hospital days, and hospitalisation expenses. The incidence of abnormal wound edge colour with Z‐plasty was significantly lower than that with the general treatment (P < .05), and the Z‐plasty enables better healing of the patient's wound (P < .05). Z‐plasty promoted better recovery of chronic non‐healing wounds than direct suturing.

Treatment of Superficial Incision Dehiscence after Abdominal Surgery by Z-Plasty: A Retrospective Case Series

OBJECTIVE

To explore the treatment of superficial incision dehiscence after abdominal surgery by Z-plasty combined with negative-pressure wound therapy.

METHODS

A retrospective study was performed on seven patients with superficial abdominal incision dehiscence from October 2018 to February 2019. All patients were given systemic antibiotics and nutrition support. During the first stage, surgical debridement with negative-pressure wound therapy was performed. Local Z-plasty was performed in the second stage.

RESULTS

The incision healed well in all patients, and no infection or necrosis occurred in the flaps. During the follow-up of 7.3 months (range, 5-10 months), no incision rupture or redehiscence occurred.

CONCLUSIONS

Surgical debridement, negative-pressure wound therapy, and Z-plasty can be used to treat superficial abdominal incision dehiscence and achieve good therapeutic effect and prognosis. Z-plasty can be used as an alternative to direct suture of incisions because of its simplicity and excellent results.

[How to treat palmar burn sequelae in children, about 49 cases]

INTRODUCTION

Even if they represent only 2.5 % of the total body surface area, the hands are burnt in 50 % of hospitalized patients. The risk of sequelae is significant, especially in children, human being in full growth, and a source of aesthetic and functional handicap. The aim of this study is to research the predictive factors of sequelae, to study their treatment of and their evolution.

MATERIAL AND METHODS

We included children under six years of age with deep palmar burns of the hand between 1998 and 2008. Demographics, characteristics of the initial burn and its treatment were noted. Then, we studied the types of hand burn sequelae and their treatment. Finally, we observed their evolution over time with an aesthetic and functional evaluation and their impact on quality of life.

RESULTS

Forty-nine children, representing 70 hands, were included in the study. The mean age at the time of the initial burn was 16.2 months (6; 60). The initial treatment was directed healing in 39 % of cases and thin skin excision-grafting in 61 % of cases. The type of sequelae most represented was bridle in 73 % of cases. Treatment consisted of rehabilitation measures (13 %) or surgery (69 %). The mean age at the time of surgery was 10.1 years (4; 19). These were plasties (62 %), total skin grafts (15 %) or a combination of both (23 %). The current follow-up is 16.2 years. The aesthetic result is considered good in 52 % of cases, the functional result is good in 78 % of cases. The impact on the quality of life is low and the parents are satisfied with the initial care.

CONCLUSION

The treatment of the sequelae of burnt hands gives good results but involves well-conducted rehabilitation and regular monitoring. The treatment period must be adapted and the surgery simple, effective and specific to the type of sequelae.

Outcomes of Coccygectomy Using the "Z" Plasty Technique of Wound Closure

STUDY DESIGN

Technical note.

OBJECTIVES

Coccygectomy for chronic coccydynia has a high rate of successful clinical outcome. However, the procedure is associated with increased incidence of wound dehiscence and surgical site infection. The main objective was to evaluate the clinical outcomes of coccygectomy using the Z plasty technique of wound closure.

METHODS

Patients with chronic coccydynia refractory to conservative treatment underwent coccygectomy followed by Z plasty technique of wound closure between January 2013 and February 2018. Primary outcome measure was evaluation of the wound healing in the postoperative period and at follow-up; secondary outcome measure included visual analogue scale (VAS) score for coccygeal pain.

RESULTS

Ten patients (male:female 6:4) fulfilled the inclusion criteria. The mean age of patients was 40.78 years (range 19-55 years). The mean follow-up was 1.75 years (range 6 months to 5 years). All wounds healed well with no incidence of wound dehiscence or surgical site infections. The mean VAS improved from 7.33 ± 0.5 to 2.11 ± 1.2 (P < .05). Nine patients reported excellent outcomes and 1 patient reported poor outcome with regards to relief from coccydynia.

CONCLUSION

Z plasty technique of wound closure is recommended as procedure of choice to avoid wound healing problems and surgical site infections associated with coccygectomy. Coccygectomy remains a successful treatment modality for chronic coccydynia.

Etiology, Evaluation, and Management Options for the Stiff Digit

The stiff digit may be a consequence of trauma or surgery to the hand and fingers and can markedly affect a patient's level of function and quality of life. Stiffness and contractures may be caused by one or a combination of factors including joint, intrinsic, extensor, and flexor tendon pathology, and the patient's individual biology. A thorough understanding of the anatomy, function, and relationship of these structures on finger joint range of motion is crucial for interpreting physical examination findings and preoperative planning. For most cases, nonsurgical management is the initial step and consists of hand therapy, static and dynamic splinting, and/or serial casting, whereas surgical management is considered for those with more extensive contractures or for those that fail to improve with conservative management. Assuming no bony block to motion, surgery consists of open joint release, tenolysis of flexor and/or extensor tendons, and external fixation devices. Outcomes after treatment vary depending on the joint involved along with the severity of contracture and the patient's compliance with formal hand therapy and a home exercise program.

Non-union: Indications for external fixation

External fixation is currently used as the definitive mode of fracture stabilisation in the management of ˜50% of long-bone non-unions. Distinction between non-union and delayed union is a diagnostic dilemma especially in fractures healing by primary bone repair. This distinction is important, as non-unions are not necessarily part of the same spectrum as delayed unions. The aetiology of a fracture non-union is usually multifactorial and the factors can be broadly categorized into mechanical factors, biological (local and systemic) factors, and infection. Infection is present in ˜40% of fracture non-unions, often after open fractures or impaired wound healing, but in 5% of all non-unions infection is present without any clinical or serological suspicion. General indications for external fixation include clinical scenarios where; 1) percutaneous correction of alignment, or mechanical stimulation of the non-union site is required; 2) fixation of juxta-articular or 'emmental' bone fragments is necessary; and 3) staged bone or soft tissue reconstruction is anticipated. Specific anatomical indications include infected non-unions of the tibia, humerus, and juxta-articular bone. External fixation is an essential tool in the management of fracture non-unions. However, with greater understanding of the outcomes associated with both external and internal fixation the relative indications are now being refined.

Z-plasty as an alternative choice for the treatment of recurrent local sternal wound infections

OBJECTIVE

Sternal wound infections after sternotomy are associated with high morbidity, high mortality, and prolonged hospital stay. The recurrence rate of sternal wound infections after single-stage closure is greater than expected. The aim of the study is to present our results of a consecutive series of Z-plasty for the treatment of recurrent sternal wound infections.

METHODS

Between March 2015 and March 2017, a total of 9 patients were referred to our clinic with a recurrent sternal wound infection due to sternotomy with or without osteomyelitis. All patients previously underwent one or more surgical procedures for sternal infection. Negative pressure wound therapy and several debridement methods were performed before reconstruction. Two triangular double-transposition fasciocutaneous flap techniques as Z-plasty under local anesthesia was performed for all of the patients.

RESULTS

The flaps survived completely without any tissue loss. There were no major postoperative complications. One patient had recurrent infection after the flap procedure and was treated with antibiotic therapy. At 6 months of follow-up, all of the patients were able to return to normal activities of daily living with a high patient satisfaction rate.

CONCLUSIONS

Local sternal wound reconstruction is an effective, rapid, and simple with Z-plasty associated with low recurrence risk. We believe that Z-plasty can be used for recurrent local sternal wound infections as an alternative treatment option for selected patients without mechanical dehiscence.

Cosmetic camouflage improves quality of life among patients with skin disfigurement: A systematic review

This study systematically reviewed the impact of cosmetic camouflage use on different psychosocial outcomes in patients with disfiguring skin disorders. Electronic databases and reference lists were searched in February 2018 for studies reporting the impact of cosmetic camouflage on different quality of life (QoL) outcomes. Eighteen studies met the inclusion criteria: six randomized controlled trials, two quasi-experimental studies, nine single group 'before and after' interventions, and one comparative study with single post-intervention measurement. Quality appraisal of included studies was undertaken using the Joanna Briggs critical appraisal tools. While the studies varied in design, those included in this review indicated significant improvement in QoL after the use of cosmetic camouflage. The mean reduction in Dermatological Life Quality Index scores ranged from 1.4 to 6.4 signifying improvement in QoL of participants after treatment with cosmetic camouflage. Cosmetic camouflage can be an effective therapy in improving QoL among patients with skin disfigurement.