The use of subcutaneous pedicle flaps in the treatment of postburn scar contractures

Subcutaneous pedicle flaps, which were usually applied to repair small skin defects in the face or the fingertip, have been used with success in the treatment of 17 postburn scar contractures, with the exception of one partial flap necrosis. The results indicate the reliability and usefulness of this technique in the treatment of scar contractures, even in the extremities or the trunk. Subcutaneous pedicle flaps are effective for relatively wide contractures or quadratic contractures. When the skin tension across the contracture line is too great to use any local flap, such as a Z-plasty or V-Y plasty, the subcutaneous pedicle flap is particularly useful, because it can be freely designed in an area where the tension is small. When the flap contains some superficial scarring, the subcutaneous pedicle flap is preferred over other local flaps because of the superior vascularity and mobility.     

Latissimus dorsi myocutaneous flap reconstruction of neck and axillary burn contractures

Neck and axillary burn contractures are both a devastating functional and cosmetic deformity for patients and a challenging problem for reconstructive surgeons. Severe contractures are more commonly seen in the developing world, a result of both the widespread use of open fires and the inadequacy of primary and secondary burn care in these vicinities. When deep burns are allowed to heal spontaneously, patients develop hypertrophic scarring of the neck and axillary areas. The back is typically spared, however, remaining a suitable donor site. We have used nine latissimus dorsi myocutaneous flaps in a total of six patients, finding the flaps effective in resurfacing both the neck and the axillary regions after wide release of burn contractures. Before flap mobilization, surgical neck release is often necessary to ensure safe, effective control of the airway in patients with significant neck contractures. Flap bulkiness in the anterior neck region can eventually be reduced by dividing the thoracodorsal nerve. Anchoring the skin paddle to its recipient site through the placement of tacking sutures will also help achieve a more normal anterior neck contour.     

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.     

Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn anterior cervical contractures

Free thin anterolateral thigh flaps combined with cervicoplasty were used in a series of seven patients undergoing reconstruction for previous burn injury from September of 2000 to May of 2001 at Chang Gung Memorial Hospital. This method uses a suprafascial dissection technique to provide a thin flap to improve cervical contour. Neck contractures had resulted from flame burns in six patients and from a chemical burn in one patient. The mean age was 32.7 years (range, 22 to 45 years). The size of excised scar ranged from 10 x 2 cm to 26 x 5 cm (mean, 19.7 x 3.3 cm). The size of flaps ranged from 11 x 5 cm to 26 x 8 cm (mean, 21.3 x 6.5 cm). Average operative time was 6 hours. Average hospital stay was 10 days. All flaps survived, with one flap sustaining partial marginal loss. The donor site was closed primarily in five cases and by using a split-thickness skin graft in two cases. At a mean follow-up time of 5 months, the functional improvement was measured as follows: a mean increase in extension of 30 degrees (preoperatively, 95 degrees; postoperatively, 125 degrees), a mean increase in rotation of 18 degrees (preoperatively, 59 degrees; postoperatively, 77 degrees), and a mean increase in lateral flexion of 12.5 degrees (preoperatively, 26.5 degrees; postoperatively, 39 degrees). The average cervicomandibular angle was improved by 25 degrees (preoperatively, 145 degrees; postoperatively, 120 degrees). This series demonstrates that the use of free thin anterolateral thigh flaps combined with cervicoplasty provides a one-stage reconstruction with a thin, pliable flap that achieves good cervical contour with low donor-site morbidity.     

Anterior neck reconstruction with pre-expanded free groin and scapular flaps

To improve aesthetic and functional outcomes in the reconstruction of severe anterior neck burn deformities and to reduce donor-site morbidity, pre-expansion of free-flap donor sites was performed in eight patients. In the first stage of reconstruction, the tissue expander was placed and gradually inflated over a period of 6 weeks. In the second stage, the anterior neck scar was resected up to the limits of the aesthetic unit of the neck, radical release of neck contracture was achieved by transection of contracted platysma muscle, and immediate coverage with a pre-expanded groin or scapular free flap was performed. The early postoperative course was uneventful. Physical therapy was started 1 week after the reconstruction. Long-term follow-up (mean, 4 years) of patients who underwent reconstruction of extensive neck burn deformities demonstrated good aesthetic and functional results. The advantages and drawbacks of using pre-expanded free flaps in the treatment of neck burn contractures are discussed.     

Latissimus dorsi myocutaneous flaps in head and neck reconstruction.

We have found the latissimus dorsi myocutaneous flap, when used as a "pedicled island flap," to be an adaptable and dependable alternative flap for repairs after major resections in the head and neck. The long vascular pedicle, containing large vessels, provides a means to transfer a large bulk of tissue into the head and neck for the repair of major through-and-through defects.     

Uses of the trapezius and sternomastoid myocutaneous flaps in head and neck reconstruction.

Both of these myocutaneous flaps can supplant forehead and deltopectoral flaps, in certain indications. They are additional arterialized flaps for the armamentarium of the reconstructive surgeon, and can be useful in many repairs in the head and neck region.     

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.