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CHAPTER30 Burn contracture surgery
Techniques used indierent
anatomical sites:important note
The following sections deal with dierent anatomical areas in three regions: the upper limb, the head and neck, and the groin/ perineum and
lower limb regions.
For relative brevity, various methods have only been illustrated in one or
two anatomical sites (eg. perforator- based propeller ap is illustrated for
antecubital fossa, but it can readily be applied in many dierent sites such as
axilla, groin, popliteal fossa, and leg/ foot). Square aps and asymmetric Z
plasties can be used in many sites.
Many of the techniques are applicable to many dierent sites. To some
extent the selection of techniques illustrated represents the author’s own
experience and bias, but ultimately the choice of technique is determined
by many factors that include the following:
• The nature of the contracture
• Necessity for surgery on underlying joint (more likely to need ap)
• Availability of local tissue
• Availability of good graft donor sites
• Age of patient (more likely to use graft/ dermal regeneration template
in child)
• Compliance of patient (more likely to use ap or free ap in less well
compliant patient who will not do aftercare)
• Wishes of the patient (eg. are they keen to have an abdominoplasty that
might allow harvest of a big full thickness graft?)
• How long can patient take o work/ childcare/ school/ university etc.?
• Any problem with infections? (less likely to use dermal template or
tissue expansion)
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TECHNIQUES USED INDIFFERENT ANATOMICAL SITES
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CHAPTER30 Burn contracture surgery
The upper limb
The hand
General principles
Generally, aim to release signicant contractures of axilla and antecubital
fossa before operating on the hand. Technically, it is very dicult to operate on the hand with the major proximal joints contracted. Functionally,
the hand is severely impaired if the limb is adducted at shoulder and exed
at elbow.
Release from proximal to distal in the hand itself:release of the proximal
wrist/ palm contracture makes it much easier to operate on the digits.
Operate with tourniquet to produce a bloodless eld. Do not keep tourniquet inated for >2 hours to minimize risk of ischaemia or nerve palsy.
As a general principle, following contracture release, deate tourniquet and
apply compressive gauze dressing, prior to taking graft so that haemostasis
in complete by time graft is applied.
Use bipolar diathermy and magnifying glasses.
Always have regard for the anatomy of the digital nerves and vessels.
Local ap ‘plasties’ inthe hand
Underlying principles
• Local ap plasties are most useful for relatively narrow
contraction bands
• Avoid damage to digital nerves, but raise aps as thick as possible to
protect vascularity of ap
• Eectiveness of release with local ap plasties depends on there being
reasonable soft tissue laxity in a transverse plane
• In children who have a signicant amount of scarring, release with local
aps in the hand may be short- lived (with eect of growth) and full
thickness grafts may be a better option to produce a long- term benet
Five- ap Z plast y
This is made up of two Z plasties and a central Y– V plasty.
This technique is particularly useful for moderate contractures of the rst
web where there is laxity of tissue at 90° to the direction of the contraction
band (Fig. 30.1).
It is also occasionally useful for moderate contractures of the exor surface of the digits.
Z plasty
Multiple Zs are good on the exor surface of the ngers for linear contraction bands (more often after trauma than burns) Angle of Zs is usually 60°.
A single large Z is excellent for deepening the rst web when there is relatively little scarring or a very tight but narrow contraction band.
With moderate or severe diuse scarring, there is a high risk of Zplasty ap necrosis, because of requirement to undermine aps to allow
transposition.
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Fig.30.1 Diagram showing possible design of local ap procedures for linear band
contractures on little, ring nger and rst web. For more severe diuse contractures
shown on the index and middle ngers, the methods of incisional release with
either lateral Z plasties (double trapezoid aps) or shtail darts are shown reaching
midlateral lines. These more severe contractures ideally require full thickness skin
grafts, or possibly thick split thickness grafts.
Y– V plasty
This is an excellent technique for linear contraction bands in moderately
scarred skin. Because the aps of a Y– V plasty do not have to be undermined, there is less risk of skin ap tip necrosis. Conversely, a greater length
of incision is required than with a Z plasty, hence the ‘Z’ is more elegant
where there is less diuse scarring.
Skin grafting and aps forhand contractures
Palmar surface— exion contractures
Where possible, full thickness grafts should be used on the exor surface of
the hand. Other options include split skin grafts from the instep (no weightbearing) surface of the sole of foot, or thick split skin grafts.
For severe palm contractures, excision of a central portion of the scar
with extensive incisional release usually produces a bed that is graftable.
When grafting, it is important to excise as much of the scar from the bed
as possible, so that a well- vascularized surface is produced. K wiring of the
digits in extension for several weeks is usually essential to optimize the
outcome.
THE UPPER LIMB
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CHAPTER30 Burn contracture surgery
Important technical points
• Surgery should be undertaken under tourniquet
• Release proximal contractures (wrist/ palm) before the ngers
• On the digits, it is important to design the release so that grafts reach
the mid- lateral line on each side of the nger. This prevents the scar at
the margin of the graft from re- contracting
• The margins of the grafts should be zig- zagged or the release. planned
with lateral Zs— the trapezoid ap) (see the index nger in Fig 30.1)
• Great care should be taken to avoid damage to the digital nerves and
arteries. These can easily be mistaken for scar bands. Operating using
magnication is essential
• On extension of the digit in a severe contracture, ischaemia may
result— usually this is transient and relates to tethering of the digital
vessels. Either reducing the degree of extension or (preferred)
extending the release of scarring, will allow the ow to recover (as long
as the digital arteries have not been divided!)
In severe palmar contractures after very deep burns, it is sometimes necessary to use a ap if burn extends through palmar fascia (eg. electrical
injury). One of the simplest options is a radial forearm fascial ap covered
by a skin graft. This avoids excessive bulk. Alternatives are a well- thinned
pedicled groin ap or a Becker ap. The latter has the advantage of being a
single- stage transfer, although both the groin ap and Becker ap are almost
certain to require secondary thinning if used for a palm defect.
A variety of thin free ap options may be used, such as free fascial aps,
radically thinned free muscle aps (covered by graft), or perforator based
free thin skin aps.
After such very deep injuries assessment needs to be made as to whether
reconstruction of digitals nerves or exor tendons is indicated and/ or feasible. Auseful passive range of joint movement and good resting posture of
the hand are essential prior to undertaking such complex reconstructions.
The PIPJ exion deformity
Often, release of the proximal interphalangeal joint (PIPJ) is dicult in established contractures because of contracture of the volar plate and accessory collateral ligaments. In children, it is possible to stretch these by strong
steady pressure, but care should be exercised to avoid overstretching the
digital nerves and arteries. In older patients, with a long history, release of
the volar plate and accessory collaterals may be indicated. Where possible,
this should be carried out through a lateral approach around the side of
the neurovascular bundles so as to avoid exposing exor tendon through
the defect to be skin grafted. The joint should be K wired in extension
postoperatively. If the exor sheath is opened, a skin graft will often ‘bridge’
across a small defect which exposes exor tendon, especially if the nger is
kept extended with a K wire.
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Extensor surface— extension contractures
Skin grafting
These contractures are common and usually respond well to excision of a
small portion of the scar and extensive incisional release with medium thickness split skin graft. Ideally, this should be carried out supercial to the large
veins of the dorsum of the hand, producing an excellent bed for the graft
to take, and allow tendon gliding. However, in deeper burn injuries, release
may have to be undertaken supercial to the extensor paratenon.
Commonly the metacarpophalangeal joints (MCPJs) are contracted in an
extended position and a dorsal MCPJ capsulotomy is required. Usually this
is done through a separate longitudinal incision to avoid exposing the joint
in the release. K wiring or splinting the MCPJs in exion postoperatively for
several weeks is essential to maintaining the correction.
Occasionally, extensive hypertrophic scarring of the dorsum of the hand
may be resurfaced with thick skin graft or dermal substitute. Meticulous
aftercare is required.
Severe dorsal contractures (role ofaps)
Commonly, more severe dorsal contractures involve the extensors tendons, or are associated with severe hyperextension/ subluxation of the
MCPJ and IPJ exion. To achieve a release, the tendons and possibly MCPJ
will have to be exposed without paratenon cover. Aap is commonly required, and the ngers may need to be temporarily syndactylized up to PIPJ.
MCPJ capsulotomy and K wiring of MCPJs in exion in required. PIPJ release
is often necessary with palmar skin grafting and K wiring.
Useful aps in this situation are a reverse radial forearm ap (although
it cannot readily reach distal to mid- proximal phalanx level if covering the
whole width of the dorsum) or a free ap (thin tissue should be used if
possible).
A pedicled groin ap is a very safe alternative, but is associated with signicant stiness and oedema and almost always requires secondary thinning. If the hand is very scarred the groin ap has to be left attached for
longer than usual as vascularization through scarred skin is poor (3 weeks
rather than 2).
For smaller, more proximal defects on the dorsum of the hand, a Becker
ap may be used.
Interdigital web contractures
Mild dorsal or palmar web contractures can readily be released by 5- ap Z
plasty or by the square ap technique (Fig. 30.2)
If scarring is more severe, incision and full thickness grafting is required.
Often the defect to be grafted is quite concave, and a tie- over dressing is
required. Arectangular dorsal ap as in congenital syndactyly can help to
create a web in severe contractures, with the defects on the sides of the
ngers, repaired with full thickness grafts.
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CHAPTER30 Burn contracture surgery
Fig.30.2 Square ap technique that can be used for linear band contractures of
moderate thickness and provides optimal geometric lengthening. The square ap
in healthy skin advances into aps of same side length in the contracture band with
angles of 45° and 90°. This technique is unlikely to work at all well if the skin is
heavily scarred around the square ap.
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THE UPPER LIMB
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CHAPTER30 Burn contracture surgery
The axilla
Adduction contracture of the axilla is very common after burn injury. Avariety of options are available.
Procedures forlinear band contractures
The type of discrete linear band contracture shown could readily be released with multiple Y– V plasties or multiple Z plasties. Our preferred option is Y– V because of minimal risk of skin ap tip necrosis (the aps do not
have to be undermined).
The Y– Vs should be continued for the length of the contraction band to
provide a good release. All subcutaneous scar should be incised. The stems
of the Ys should be as long as reasonable tension permits to allow optimum
advancement of the aps. The interdigitating aps break up and lengthen
the contracture (see Fig. 30.3).
Perforator- based aps foraxilla
A wealth of perforator- based aps are available around the axilla They may
be raised on known vessels, or as ‘ad hoc’ perforator aps based on vessels
near the defect using a ‘propeller’ design. Figs 30.3 and 30.4 show two aps
which we have found to be consistently reliable. We nd it helpful to use
magnifying glasses so as to visualise the perforating vessels in the ap base.
Medial Arm Flap forThick anterior axilla/ shoulder band
The medial arm ap is centred approximately over the line of the medial
intermuscular septum of the arm. It is based on perforators which emerge
from the axilla, and on the medial cutaneous nerve of the arm (it is not to
Fig.30.3 Multiple Y– V for axillary band.
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be confused with the classical medial arm free ap, whose pedicle emerges
more distally) (Fig. 30.4).
Posterior arm ap
This is a similar ap to the medial arm fasciocutaneous ap. This ap is based
on a perforating artery, which arises from the axilla at the base of the posterior axillary fold. The ap is widely used for repair of axillary hair bearing
skin after excision for infection (hidradenitis suppurativa). It is occasionally
useful for burn contractures where the posterior fold area is spared and the
posterior arm relatively scar- free (see Fig. 30.5).
Procedures fordiuse axillary contractures
Flaps
For a broadband axillary contracture, a variety of aps are available. Note
that application of any of these aps depends on whether sucient healthy
skin is available to allow design of a ap, which can be transposed to cover
the axilla. This is commonly not the case.
Flaps require less splintage and aftercare than grafts, although they not
uncommonly require secondary thinning.
The simplest aps are fasciocutaneous and perforator- based aps that
are based on the axilla or adjacent area, and involve harvest of a ap of skin
from the arm (see above, medial arm, posterior arm) or from the chest
wall below the axilla. Propeller aps and the islanded perforator- based
THE AXILLA
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Fig.30.4 This medial arm ap is a fasciocutaneous ap based in the axilla and
harvested from the medial aspect of the arm. It is designed at a width that allows
primary closure of the donor defect. The medial cutaneous nerve of the arm is
included in the ap. The ap is transposed 90° and is inset into defect after release of
a broadband anterior axillary fold contracture.
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