Scar deformation, contractures and tissue defects

Among three main forms of burn consequences (scar deformation, contractures and tissue defects), most often the are formed, causing disability. These contractures should be treated surgically.

More than 80% of scar contractures can be treated with local new (trapezoid) flaps.

Existing local-flap methods are based on classic triangular local or other forms of the flaps (Z-, V-Y plasty and multiple modifications and combinations). These methods, however, are not anatomically substantiated and ineffective due to insufficient research of contractures anatomy, contracture cause, and no existent anatomical classification

Vast personal experience showed that the results of these methods yield results that are far from perfect as contractures are released incompletely, and often re-contracture appears and re-operation is needed.

Anatomical studies determined main principles and characteristics of post burn scar contractures on which the diagnoses must be constructed and the choice and development of new reconstructive techniques should be based:

Big joint surfaces are divided into extensionand flexion; the flexion surface is divided into two joint flexion lateral surfaces, and medial or joint fossa. Depending on scars location, three types of scars contractures are formed: edge, medial, and total.
Scars covering flexion lateral one or both surface, neck posterior, scars of dorsal hand cause edgecontracture; scars located on flexion medial surface (big joint fossa), anterior neck, contractures of fingers, trunk and perineum cause medial contractures; scars involving entire flexion surface cause total contractures.
Every contracture type has specific anatomic features and clinical signs regardless of location and severity and can be easily diagnosed.
Scars causing contractures grow distally and form a fold the sheets of which are a new anatomic structure that has a surplus of scars and healthy skin, allowing edge and medial contractures’ elimination with local flaps.Scars’ contraction causes scar’s surface deficit which causes the contracture. Scar surface deficit is located on joint flexion surface, lateral or medial, causing edge or medial contracture, corresponding.
Contracted scars have a specific form of scar surface deficit. After contracted scars’ dissection the appeared wound accepts, as a rule, a trapezoid form regardless of contracture location (joints, commissures, other region of body).
For adequate contracture release, the wound or scar surface deficit should be covered with a trapeze-shaped flap. Consequently, all existing local flaps of other than trapeze form are not anatomically substantiated.
Donor sites for trapezoid flaps (edge and medial contractures) are local tissues having surface surplus.
Vast personal experience showed, that the use of trapeze-flap plasty solved the problem of elimination of edge and medial contractures (more than 80% of the total number) fully and definitively.
Besides contractures’ exploration and elimination, new flaps and methods were developed:

– split ascending neck flap which is axial and its basement developed techniques for face and neck resurfacing of different form and location;

– scar-fascial neck trapezoid flap for total cervical contracture elimination;

– method of restoration of the form, location and skin of breast damaged by burns;

– method of tendons plasty for restoration function of fingers in case of boutonniere deformity after burns;

– proximally based sural adipose-cutaneous flap and method of treatment of ulcerous tissue defects in zone of Achilles tendon and posterior heel regions;

– new method or principle of severe adduction joint and commissural contractures treatment with combined (suspending flap and skin transplant) technique.

All presented flaps and surgical techniques are original, effective, and their use significantly improved the level of rehabilitation of burned patients

Posted by: Hanna Grishkevich, Vishnevsky Institute of Surgery, Russia

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