The radial forearm skin graft-fascial flap

The radial forearm flap has become a versatile flap for upper extremity reconstruction. The use of the forearm flap for hand reconstruction in the patient with previously burned forearms has not been widely appreciated. In those patients whose forearms have been previously split-thickness skin-grafted on fascia, we have employed the reverse radial forearm flap as a skin graft-fascial flap for hand reconstruction and have obtained excellent functional results. Three patients at various intervals postburn are presented to demonstrate use of this flap for wrist contracture release, coverage of arthroplasties, first web space contracture release, and acute salvage of phalanges and tendons. Assessment of the hand's vascular anatomy and careful treatment of the donor area have contributed to no added morbidity and an excellent aesthetic result at the donor site.     

Conchal transposition flap for postburn ear deformities

Severe thermal injuries to the external ear often lead to extensive loss of peripheral structures such as helix and lobule but frequently spare the more central parts of the ear, even though they may be grossly deformed by scar contracture. The use of spared conchal structures as a transposition flap in combination with remodeling of the residual auricle and release of surrounding scar when indicated has been a useful technique in the reconstruction of a frequently occurring type of postburn ear deformity. Twenty-four ears have been reconstructed in 18 patients over the past 5 years using a conchal transposition flap. The residual concha with its overlying skin can be transposed superiorly, based on a very narrow pedicle in the area of the crus helicis. The raw central area remaining is then resurfaced with a split-thickness skin graft. This technique maximally utilizes the unique remaining auricular elements and can provide a satisfactory reconstruction in selected patients without resorting to more complex and extensive procedures. There have been no significant complications in this series, and patient acceptance of the results has been excellent.     

The use of skin grafts in postburn contracture release: a 10-year review

Postburn scarring and contracture affecting function remain the most frustrating late complications of burn injury. Various techniques are used to release contractures; the choice depends on their location and/or the availability of unaffected skin adjacent to the contracture or elsewhere. A retrospective review was carried out of the case notes of patients who had skin grafting for the release of postburn contracture at the Burns Unit, City Hospital, Nottingham between May of 1984 and August of 1994 to evaluate the experience over this period. Information was obtained about the burn injury, contracture site, interval between burn and release of contracture, indication, age at first release, intervals between releases, operative details (donor and graft sites), complications and nonoperative treatment, and follow-up to the end of the study period. A total of 129 patients underwent skin grafting for release of contractures as opposed to any other method of correction. Full-thickness skin grafts were used in 81 patients (63 percent) and split-thickness skin grafts in 26 (20 percent). Twenty-two patients (17 percent) had both types used on different occasions. Flame burns (41 percent) were the most common causes, followed by scalds (38 percent). Two hundred thirty-nine sites of contracture were released, with the axilla (59) and the hand/wrist (59) being the most common sites involved, followed by the head/neck region (42). It was found that for the same site, release with split-thickness skin grafts was associated with more rereleases of the contracture than with full-thickness skin grafts. Also, the interval between the initial release and first rerelease was shorter than with full-thickness skin grafts (p < 0.048). It was also noted that children required more procedures during growth spurts, reflecting the differential effect of the growth of normal skin and contracture tissue. Patients reported more satisfaction with texture and color match with the full-thickness skin grafts. There was comparable donor-site and graft morbidity with both graft types. The use of skin grafts is simple, reliable, and safe. Whenever possible, the authors recommend the use of full-thickness skin grafts in preference to split-thickness skin grafts in postburn contracture release.     

Breast reconstruction with the internal mammary artery pedicled fasciocutaneous island flap: description of a new flap

Postburn skin contracture of the inframammary sulcus is a commonly encountered problem, especially in pubescent girls. Release of these contractures is commonly performed by split-thickness skin grafts, which necessitate further operations as the child grows. If the contracture of the inframammary sulcus is only one-sided, then the inframammary tissues of the contralateral breast can be used for reconstruction with the fasciocutaneous island flap. The donor site can be closed primarily without disrupting the appearance of the healthy breast, and the skin incision is hidden in the inframammary sulcus. The flap described here is a fasciocutaneous island flap based on the internal mammary artery and the perforating branches to the skin and subcutaneous tissues that the artery gives off as it leaves the thoracic cavity through the seventh intercostal space. After being supported by fresh cadaver and angiographic studies, the flap was applied to seven female patients (four of whom were pubescent) with burn contracture of the breast; satisfactory results were obtained. In defects of the mammary region that required volume or for which repair by skin grafting was planned, in sternal defects, or in young patients, this flap seems to be the best choice.     

Optimizing the correction of severe postburn hand deformities by using aggressive contracture releases and fasciocutaneous free-tissue transfers

Severe postburn hand deformities were classified into three major patterns: hyperextension deformity of the metacarpophalangeal joint of the fingers with dorsal contracture of the hand, adduction contracture of the thumb with hyperextension deformity of the interphalangeal joint, and flexion contracture of the palm. Over the past 6 years, 18 cases of severe postburn hand deformities were corrected with extensor tenotomy, joint capsulotomy, and release of volar plate and collateral ligament. The soft-tissue defects were reconstructed with various fasciocutaneous free flaps, including the arterialized venous flap (n = 4), dorsalis pedis flap (n = 3), posterior interosseous flap (n = 3), first web space free flap (n = 3), and radial forearm flap (n = 1). Early active physical therapy was applied. All flaps survived. Functional return of pinch and grip strength was possible in 16 cases. In 11 cases of reconstruction of the dorsum of the hand, the total active range of motion in all joints of the fingers averaged 140 degrees. The mean grip strength was 16.5 kg and key pinch was 3.5 kg. In palm reconstruction, the wider contact area facilitated the grasping of larger objects. In thumb reconstruction, key-pinch increased to 5.5 kg and the angle of the first web space increased to 45 degrees. Jebsen's hand function test was not possible before surgery; postoperatively, it showed more functional recovery in gross motion and in the dominant hand. Aggressive contracture release of the bone,joints, tendons, and soft tissue is required for optimal results in the correction of severe postburn hand deformities. Various fasciocutaneous free flaps used to reconstruct the defect provide early motion, appropriate thinness, and excellent cosmesis of the hand.     

"Malignant" contracture of the eye socket

A new method for reconstruction of "malignant" contracture of the eye socket is described using a simple procedure based on the principle of epithelial inlay. The lining consists of a free skin graft. No cumbersome external appliances for the prevention of contraction of the graft are used; hence the hospitalization is minimized. The results have been satisfactory.     

Adjustable dynamic external splint for control of first web contracture

A method is presented to overcome problems of first web space contracture by means of a dynamic, continuously adjustable, wedge-shaped splint. The device is easily constructed of inexpensive material by physician or hand therapist. The splint is custom-tailored to the individual patient and is lightweight and comfortable, promoting good patient compliance. Its continuously adjustable nature maximizes its effects throughout therapy, and the even distribution of the pressure makes for a high surface area of patient/splint contact for even pressure distribution and eliminates the problems of skin necrosis, even with lengthy applications.     

Region-Oriented and Staged Treatment Strategy in Reconstruction of Severe Cervical Contracture

Introduction

Severe cervical contracture after burns causes obvious impairment of neck movement and the aesthetic silhouette. Although various surgical techniques for treatment have been described, there is not a definitive strategy to guide treatment. Over the past 6 years, we have been utilizing a region-oriented and staged treatment strategy to guide reconstruction of severe cervical contracture. Satisfactory results have been achieved with this strategy.

Methods

The first stage of treatment focuses on the anterior cervical region and submental region. Procedures include cicatrix resection, contracture release, division and elevation of the platysma to form two platysma flaps, and skin grafting. Three to six months later, the second stage treatment is performed, which localize to the mental region. This includes scar resection, correction of the lower lip eversion, and reconstruction with free (para)scapular skin flap. Three subtypes of cervicomental angle that we proposed were measured as quantitative tool for evaluation of the reconstruction.

Results

24 patients who completed the treatment were reviewed. By the 3rd postoperative month, their CM angles changed significantly: the soft tissue CM angle was reduced from 135.0° ± 17.3° to 111.1° ± 11.3°, the osseous CM angle increased from 67.1° ± 9.0° to 90.5° ± 11.6° and the dynamic CM angle increased from 21.9° ± 8.7° to 67.4° ± 13.1°. 22 in 24 (91.7%) of these patients gained notable improvement of cervical motion and aesthetic contour.

Conclusions

Our results suggest that the region-oriented and staged treatment strategy can achieve satisfactory functional and aesthetic results, combining usage of both skin graft and skin flap while minimizing the donor site morbidity.     

Cross-arm triangular flaps for correction of adduction contracture of the first web space in the hand: case report.

We describe the use of two oppositely-based, triangular, cross-arm flaps for primary coverage of a new first web space, created by releasing an abduction contracture of the thumb.     

Use of paired abdominal flaps for release of adduction contractures of the thumb.

A method for correction of an adduction contracture of the thumb is presented. Paired flaps provide good cover to the palmar and dorsal sides of the web space. This method produces better cosmetic and functional results than the traditional methods.     

Postburn breast reconstruction: tissue expansion prior to contracture release.

Tissue expansion of the scarred chest following burns results in a poor breast mound shape with little projection or inframammary fold, since the expander, like normal developing breast tissue, is kept flat by the scarred skin envelope. We present a case that demonstrates that adequate projection of the breast and formation of an inframammary fold can be achieved by expansion if extensive release and skin grafting of contractures over the breast mound are performed after expansion. Maintained expansion will act as a stent reducing secondary contracture of the grafted-areas.     

Hg2+-induced contracture in mechanically skinned fibers of frog skeletal muscle

In mechanically skinned fibers of the semitendinosus muscle of bullfrogs, we examined the role of membrane sulfhydryl groups on Ca2+ release from the sarcoplasmic reticulum (SR). Hg2+, a sulfhydryl reagent (20-100 microM), induced a repetitive contracture of skinned fibers, and this contracture did not occur in skinned fibers in which the SR had been disrupted by treatment with a detergent (Brij 58). Procaine (10 mM), Mg2+ (5 mM), or dithiothreitol (1 mM) blocked the Hg2+-induced contracture. Ag+ or p-chloromercuribenzenesulfonic acid produced similar contractures to that induced by Hg2+. We conclude that Hg2+ releases Ca2+ from SR of a skinned fiber by modifying sulfhydryl groups on the SR membrane, and suggest that the Ca2+ released by Hg2+ may trigger a greater release of Ca2+ from SR to develop tension.     

Breast reconstruction in the burned adolescent female (an 11-year, 157 patient experience)

The experience accumulated after reconstruction of 157 burned breast patients has led to the development of surgical principles and techniques tailored to this problem. Most important among these principles is that the surgeon recognize and preserve viable breast bud tissue in the debridement phase of the acute burn. Reconstruction should begin when the burned breast envelope is insufficient and restricts normal growth. Best results are obtained if contracture release is complete, if defects are covered by thick split-thickness skin grafts, and if nipple-areola reconstruction is obtained from a normal opposite breast if present. Postoperative management should continue until wounds are mature and should include techniques to prevent contracture recurrence.     

Reconstruction of the hand in Apert syndrome: a simplified approach

Children born with Apert acrocephalosyndactyly pose great challenges to the pediatric hand surgeon. Reconstructive dilemmas consist of shortened, deviated phalanges and extensive skin deficits following syndactyly release. We present a 10-year review of patients with Apert acrocephalosyndactyly who were treated with a simplified surgical approach. Between 1986 and 1996, 10 patients with Apert syndrome underwent reconstructive surgery of their hands. The overall strategy involved early bilateral separation of syndactylous border digits at 1 year of age, followed by sequential unilateral middle syndactyly mass separation with thumb osteotomy and bone grafting as needed. In these 10 patients, a total of 53 web spaces were released, 49 of which involved osteotomies for complex syndactyly. Only local flaps and full-thickness skin grafts from the groin were used in all cases to achieve soft-tissue coverage. To date, seven of the 53 web spaces have needed revision (revision rate, 13 percent). Eleven thumb osteotomies (nine opening wedge and two closing wedge) were performed. Bone grafts from the proximal ulna or from other digits were used in all cases. To date, none of these thumb osteotomies have needed revision. This early, simplified approach to the complex hand anomalies of Apert acrocephalosyndactyly has been successful in achieving low revision rates and excellent functional outcomes as measured by gross grasp and pinch and by patient and parent satisfaction.     

Penile reconstruction for a victim of electrical injury with bilateral below-elbow amputations

We report on a young man who had complete loss of the penis and bilateral below-elbow amputations following severe electrical injury. Reconstruction of the penis was completed by using a deliberately tailored dorsalis pedis flap to solve the problems encountered by a migrated skin tube. Construction of a neourethra with release of the contracture was done simultaneously and brought about successful results.     

Dupuytren's Contracture of the Fingers—A Simplified Approach to Surgical Treatment

Hematoma formation, delay in healing, pain, stiffened finger joints are complications that sometimes follow classical surgical approaches to Dupuytren''s contracture. A new surgical approach to the disease that can correct the contractures without the attendant morbidity is urgently needed. By treating Dupuytren''s as any other scar contracture (division of the contracting soft tissue at its point of maximal tension and interposing normal free full-thickness skin) postoperative morbidity can be greatly decreased. Full return of function was achieved within 21 days following operation in 85 percent of the cases in which finger contractures were present before operation. Contracture release of 100 joints was done by this means, with loss of only one graft and without recurrence of the disease. This technique offers simple surgical control of progressive and recurrent Dupuytren''s contracture of the fingers with minimal postoperative morbidity.     

Secondary correction of the burned eyelid deformity.

We describe our experience in late reconstructions of 35 burned eyelids. On this basis we advocate wide, aggressive release of all scar contractures, including the distal part of the levator when necessary. To cover the resultant defects we use generous full-thickness skin grafts, if available, for both the upper and lower lids. Rarely has a tarsorrhaphy been required, and properly constructed dressings provide satisfactory lid immobilization and permit conjunctival hygiene. During the postoperative period the vision need not be obstructed by a tarsorrhaphy, Frost sutures, or the dressings.     

Caerulein secretion by dermal glands in xenopus laevis

Since gastrin and its related peptides are secreted by a minority population of widely dispersed cells in mamamalian tissues it has, in the past, been difficult to study the subcellular aspects of their secretion. From published reports (1, 2) it seemed possible that a satisfactory system for such studies might be provided by the skin of certain amphibians such as Xenopus laevis since in these tissues high concentrations of peptides such as caerulein exist, and there is some indication (3) that this, or a similar gastrin-like peptide, may be a dermal gland secretory product. We have therefore explored this possibility by studying the structure, secretory process, and secretory product of the most prominent non mucous type of gland in the skin of X. laevis. These studies clearly demonstrate that most, if not all, of the caerulein in which the skin is contained in secretion granules within the dermal glands and that its release can be specifically evoked by adrenergic stimulation. The release process by a holocrine mechanism expels all of the stored secretion onto the skin surface and thus for biosynthetic studies it should now be possible to synchronize the processes which lead to the replenishment of the peptide.     

Free radicals and Dupuytren's contracture.

The concentration of substrate expressed as hypoxanthine capable of reacting with xanthine oxidase to release superoxide free radicals (O2-) was measured in control and Dupuytren''s contracture palmar fascia. In Dupuytren''s contracture palmar fascia the concentration of hypoxanthine was six times that of control and was greatest in "nodular" areas. Xanthine oxidase activity was also detected in Dupuytren''s contracture palmar fascia. These results suggest a greater potential for hypoxanthine-xanthine oxidase generated oxygen free radical formation in Dupuytren''s contracture than in control palmar fascia. Production of free radicals may be an important factor in the pathogenesis of Dupuytren''s contracture. The benefit of allopurinol in the management of Dupuytren''s contracture and other fibrotic conditions may thus be explained, as allopurinol binds to xanthine oxidase and prevents release of free radicals.     

The basic types of scar contractures after burns and methods of eliminating them with trapezeplasty flaps

The study of postburn scar contractures in various locations has revealed four contracture variables: edge, medial, strip, and total. Following the surgical treatment of more than 2000 patients with such contractures, a trapezeplasty flap method has been worked out and applied since 1979. This method allows one to make up for deficient scar tissue of the same shape. Flaps are cut out of sheets of a fold with the maximum use of undamaged skin in adjacent sections. They move toward each other and merge with adjacent sides into a state of tension. This surgery is based on use of the reserve on the width of the surface of a fold and the high tension of skin with pressure on underlying tissue. The extended skin grows quickly, the tension disappears, and the scars dissolve. For each contracture type, there are trapeze-flap variables either in pure form or in combination with the transposition of split-thickness skin with a flap to create a flexible joint zone. The trapezeplasty flap method can be used to treat all edge, medial, strip, and total contractures of joints whose natural position is adduction, the shoulder joint, and contractures between fingers. Skin-fat or skin-fascia trapeze flaps prevent the relapse of contracture and make the weakened scars softer, which, as a rule, ensures a good functional and aesthetic result.