The Unfavorable Result in Plastic Surgery_ Avoidance and Treatment (2018, Thieme)

SECTION VIII THE HAND AND UPPER EXTREMITY
1316
Collagenase Clostridium Histolyticum
Collagenase Clostridium histolyticum is a newer FDA-
approved treatment for Dupuytren’s contracture.16,17 The
two metalloproteinase enzymes work on all types of col­
lagen, while sparing type IV collagen. Type IV collagen
is prevalent in basement membranes of neurovascular
structures, which offers the benefit of preserving arteri­
oles, nerves, and epithelium with collagenase injection.17
Up to two separate cords can be injected simultaneously
with reasonable efficacy. The 0.58-mg dose is diluted per
specifications based on the site of injection and injected
directly into the cord. The patient usually returns within
24 hours for gentle passive extension of the finger to initi­
ate cord rupture. Patients should then be fitted for a night­
time splint to be worn for up to 4 months to maintain finger
extension and instructed to perform finger extension and
flexion exercises during that time.
Avoiding Unfavorable Results and
Complications in Dupuytren’s
Contracture Intervention
Summary Box
Common Complications in Dupuytren’s
Contracture Intervention
•• Neurapraxia and digital nerve injury
•• Skin necrosis and skin tears
•• Joint and scar contractures
•• Recurrence and disease progression
•• Complex regional pain syndrome and flare
reactions
•• Flexor tendon transection and rupture
Patient Expectations
Managing patient expectations before surgery is the first
step in managing complications.1 Patients should be edu­
cated on the cause of Dupuytren’s disease and the possible
recurrence and progression of the disease after correction.
They should have a clear understanding of the expected
outcomes and the limitations of the treatment, especially
in the presence of substantial PIP contracture. The impor­
tance of the recovery period needs to be understood by the
patient, because optimal functional outcome is dependent
on the patient’s rehabilitation effort.
recurrence by excising fascia that may have the potential of
developing into pathologic cords. This method is not com­
monly used and is outdated because of the high morbidity
and no significant reduction in recurrence rates.
Dermofasciectomy involves excision of the diseased fas­
cia and the overlying skin with subsequent skin grafting.1,11
It was believed that the skin graft decreases the chance of
recurrence by serving as a division between diseased and
nondiseased fascia. The utility of this procedure is primarily
in patients with recurrent aggressive disease and associated
skin involvement or shortage.
The open palm technique originally described by Mc­
Cash12 is the excision of involved fascia through a combined
transverse palm and zig zag finger incision with subsequent
closure of the digital incision only. Most hand surgeons
practice a modification of the McCash technique by leaving
partial wounds open to avoid closing incisions tightly and
compromising skin flap vascularity. The open palm tech­
nique remains a treatment option for diffuse palmar disease
and multiple MCP contractures.13 Leaving the transverse
­incision open avoids skin grafting and allows for immediate
active range of motion.
Partial fasciectomy has long been the mainstay of surgi­
cal treatment for more severe contracture.1,10 Only the dis­
eased fascia is removed under skin flaps. It is the treatment
of choice for multiple digit involvement and recurrent Du­
puytren’s contracture.
Segmental fasciectomy is performed through multiple
small transverse incisions, removing only segments of the
cord to release the contracture while leaving behind the in­
tercalary fragments. Its use is less common but it has the
benefit of minimal surgical dissection and scarring.1
Needle Fasciotomy
Needle fasciotomy can be performed in an office setting
or outpatient treatment room without the need for seda­
tion or tourniquet use, and the hand is prepped with an­
tiseptic solution.14,15 Multiple portals should be marked
longitudinally over the cord at a minimum of 5 mm apart.
The procedure sequence is usually from distal to proximal
portals. ­After injecting local anesthetic at the portal sites,
a 25-gauge needle with the bevel oriented perpendicular
to the cord fibers is used to pierce the skin through the der­
mis. A transverse fasciotomy is performed by sweeping the
needle from side to side, advancing deeper with each sweep
until the cord is fully released. The contralateral hand should
be used to palpate the cord and apply gentle traction and
passive extension of the finger. Multiple fasciotomies are
performed at the portal sites until disruption of the cord is
appreciated. Strenuous grip activities are avoided for 1 week.
Postoperative therapy is usually not needed.

1317
Chapter 68 Dupuytren’s Contracture
finger with warm saline-soaked sponges to improve capil­
lary refill, and apply topical lidocaine or papaverine in the
wound to facilitate smooth-muscle relaxation.19 Sufficient
time should be allowed for interventions to work before for­
mal exploration, because early dissection will further aggra­
vate the vasospasm.
Needle Fasciotomy
Nerve injuries associated with needle fasciotomy are mini­
mized with intradermal anesthesia because of preserva­
tion of sensory feedback.14 Patients should be assessed for
fingertip sensitivity before and after local anesthesia and
frequently throughout the procedure.
Assessment of the skin overlying the cord may be help­
ful to prevent digital nerve injury. At the level between the
distal palmar crease and the proximal digital crease, a spi­
ral cord may be present that can cause medial and volar
displacement of the neurovascular bundle.20 Unless the
overlying skin is directly adherent to the cord, which would
minimize the risk of an interposed digital nerve, caution
should be taken at this level during needle fasciotomy. A
Doppler examination should be performed if a spiral cord
is suspected.14 Areas of identified Doppler tones should be
marked to indicate where portal sites should be avoided.
Injury to both digital arteries with needle fasciotomy
is rare and preventable with thorough knowledge of the
anatomy.10
Wound Healing
Fasciectomy
Preoperative assessment of the quantity and quality of the
skin is essential for incisional planning and wound closure.
Skin necrosis is the most feared complication and is usually
related to devascularization of a flap or to wound closure
under tension.21 Rather than risking wound closure under
excessive tension or using questionably viable flaps on ex­
posed tendons, the central palm wound may be left open to
heal by secondary intention.
In the fingers, a midline longitudinal incision with
­z-plasty closure is preferred.21 The midline longitudinal inci­
sion ensures that the pedicle of the flap does not lie within
the watershed area. Multiple z-plasties are advised to dis­
tribute tension and to provide a greater gain in length com­
pared with a single z-plasty. When raising the skin flap, as
much fatty subdermal layer as possible should be preserved
to prevent vascular compromise (Fig. 68.2). However, if there
is deep dermal involvement by Dupuytren’s disease, this may
not be possible. Z-plasty should be avoided at the skin crease
if possible, because this area often has minimal subcutaneous
Avoiding Neurovascular Injury
Fasciectomy
To minimize the risk of neurovascular injury, the surgeon
needs to have a thorough understanding of the anatomy.
Proximal to the distal palmar crease, the digital nerves
remain deep to the transverse fibers of the palmar fascia
and can be dissected with assurance that the nerves do not
wind around it.18 However, beyond the level of the distal
palmar crease, the nerves can sharply turn over the top of
the band and create a potential for injury.
Normal fascial bands in the hand become cords when
they are pathologically thickened and contracted.8 Recogni­
tion of the different types of cords is helpful to the dissec­
tion and prevention of accidental nerve injury10 (Fig. 68.1).
Spiral, lateral, and abductor digiti minimi cords are known
to displace the neurovascular bundle (NVB) superficially and
to the midline. In the presence of a spiral cord, the structure
first encountered at the digital flexion crease is often the
NVB rather than the fascia of the cord.1 Dissection of the NVB
should be started in the palm where the cords coalesce and
followed to the palmar digital junction.1,18 Fasciectomy can
be initiated by transecting the cord at the level of the super­
ficial arch. It is found that release of the cords in the palm
may help to partially correct the contracture and facilitate
the dissection into the digit.
If a digital artery injury is suspected, digital perfusion
through the other digital artery should be evaluated by re­
lease of the tourniquet before skin closure. Vasospasm is the
more common cause of transient digital ischemia.10 It is rec­
ommended to flex the finger to relieve traction, wrap the
Fig. 68.1 A spiral cord (black arrow) is clearly identified during fas­
ciectomy of the middle finger Dupuytren’s contracture. Note the
displacement of the digital neurovascular bundle (red arrow) by the
spiral cord.

SECTION VIII THE HAND AND UPPER EXTREMITY
1318
compromise flap viability. If uncertain about hemostasis, the
surgeon may consider leaving the palmar incision open or
placing a small, flat, soft drain.
Needle Fasciotomy
Skin tears are the most common complication, and it is not
always possible to avoid them.20 Flexion creases are prone
fat18 (Fig. 68.3). When there is skin shortage or potential for
excessive tension under closure, alternative options may be
to leave the wound open, skin graft, use a rotational flap, or
even to use a heterodigital or cross-finger flap.
Before wound closure, the tourniquet should be deflated
to evaluate for flap viability and hemostasis.21 Evaluation
for adequate hemostasis is important, because development
of postoperative hematoma under the thin skin flaps can
a
b
c
Fig. 68.2 (a) Incision design with z-plasty flaps for contractures
to adjacent fingers can only be safely performed if undermining is
avoided and deep blood supply is preserved in critical areas. (b) By
preserving perforating blood supply to this distally based flap and
adjacent z-plasties, viability to skin flaps is ensured. (c) Tension-free
closure is accomplished.

1319
Chapter 68 Dupuytren’s Contracture
Flexion Contracture
Joint Contracture
A clear understanding of the anatomical structures sur­
rounding the interphalangeal (IP) joints is necessary to
minimize persistent flexion contracture or lack of complete
extension after fasciectomy.23 Curtis23 lists several mechan­
ical factors that may limit the extension of the IP joints:
•• Inadequate skin over the volar surface of the finger
•• Fascia contractures within the finger
•• Contracture of the flexor tendon sheath within the
finger
•• Contracted flexor muscles or adherent flexor tendons
•• Contracture of the volar plate
•• Shortening of the oblique retinacular ligament
•• Adherence of the accessory volar ligament to the neck
and condyle of the proximal phalanx
If there is greater than 30-degree residual PIP joint con­
tracture after thorough resection of the involved fascia and
flexor tenolysis, a volar plate release can be performed.23 If
extension still cannot be obtained after volar capsulotomy,
the oblique retinacular ligament can be excised on either
side of the PIP joint. The surgeon may even make a conscious
intraoperative decision not to perform volar release on any
PIP joint contracture of less than 30 degrees, because many
to skin tears and should not be used for portal sites.14 Places
with redundant, mobile skin are the best areas for fasciot­
omy portals. At areas with nodular skin involvement, Ea­
ton22 recommended dispersing the tension by using more
portals, deferring definitive stretching until multiple por­
tals have been released, and pushing on adjacent skin to­
ward the firm area to protect it from the overall stretch. If a
portal is beginning to tear, the surgeon might avoid further
extension if it will propagate to an unmanageable wound.
Collagenase Clostridium Histolyticum
Skin tears are often sustained during a finger extension
procedure. It is most common with MCP contracture
greater than 50 degrees, especially if the skin overlying the
cord is calloused.16 Meals and Hentz16 outlined a sequential
four-step manipulation technique to minimize skin tears:
1. Flex the PIP joint while extending the MCP joint.
2. Flex the MCP joint while extending the PIP joint.
3. Extend both joints together.
4. Press on and disrupt any residual intact cords while
keeping the finger extended under moderate tension.
These steps can be repeated several times if necessary. If
a skin tear is imminent, the surgeon may consider stop­
ping and performing gentle passive progressive extension
(Video 68.1).
Fig. 68.3 The z-plasty should start with a midvolar
longitudinal incision, because this lies in the “safe-
zone” watershed area between the two digital
arteries. Although a z-plasty as drawn by the solid
line does not result in the transverse limbs being in
the digital flexion crease, this may be a safer de­
sign than that created by the dotted lines because
the thinnest part of the flap is then at the flexion
crease directly across the base of the flaps. It is un­
necessary to preferentially have the z-plasty flaps
traverse precisely into the flexion creases.

SECTION VIII THE HAND AND UPPER EXTREMITY
1320
erative night splinting and that it is only indicated with early
recurrent contractures.26 Flexor tendon bowstringing can
also be a cause of flexion deformity because of the greater
force applied by the flexors when important pulleys are ac­
cidentally resected during dissection.27 This reinforces the
importance of finding the precise plane between the deep
fascial dissection and the flexor sheath.
Recurrence
Recurrence of flexion contracture, whether in a previ­
ously operated area or outside the surgical zone, does
will relapse24 (Fig. 68.4). Final extension may then be ac­
complished with postoperative therapy.
Flexion Deformity
Flexion deformity can occur if there is an imbalance of force
between the extensor and flexor tendon. Powerful flexors
readily overcome the chronically stretched and weakened
extensor tendons of Dupuytren’s contracture and draw the
finger into flexion.25 A nighttime extension splint may be re­
quired to correct the flexion deformity. A recent systematic
review concluded that there is no efficacy in routine postop­
a
b
c
d
e
f
Fig. 68.4 (a) This patient with a little finger proximal interphalangeal (PIP) flexion contracture required not only fasciectomy but also volar
joint release. Intraoperatively, the finger was able to gain full extension. (b) Postoperatively, the patient demonstrated full flexion of the fin­
gers, but (c) the PIP joint remained painful and swollen. The PIP flexion contracture relapsed to 30 degrees. (d) In contrast, a patient with
a similar little finger PIP flexion contracture did not require PIP joint release and was able to reach full extension by fasciectomy alone. Full
postoperative flexion (e) and extension (f) was maintained. The morbidity commonly associated with joint release was avoided.

1321
Chapter 68 Dupuytren’s Contracture
simultaneous carpal tunnel release and fasciectomy. Gon­
zalez and Watson34 later reported that there was no signifi­
cant difference in complication rates in the combined group
compared with fasciectomy alone. They recommended
these two procedures be performed concomitantly when
indicated to avoid an extra operation and progression of
symptoms. A recent survey to the members of the Ameri­
can Society for Surgery of the Hand (ASSH) 35 concluded
that controversy remains among hand surgeons regard­
ing this issue. A comparison of reported data on CRPS and
stiffness did not find an increased rate of these two com­
plications. Consequently, they concurred with the recom­
mendations of Gonzalez and Watson.
Tension-Free Splinting and Flare Reactions
Postoperative extension splinting has been traditionally
applied after fasciectomy to prevent recurrent joint con­
tractures during the healing process. Studies have found
that sustained tension to the healing tissues may promote
local reactive changes, leading to excessive scar forma­
tion and flare reaction.36 Patients who exhibit flare reac­
tion initially have a normal postoperative course followed
by symptoms of pain, erythema, and stiffness during the
third to fourth week after surgery. When placed in post­
operative tension-free splints, the incidence of flare reac­
tion was lower. It has been proposed that the mechanical
stress on vessels causes decreased lumen diameter, which
limits the oxygen delivery to tissues and promotes con­
tinued fibroblast formation, scarring, contracture, and
possibly sympathetic flare. It was also found that delay­
ing joint extension in the early wound-healing phases
with tension-free splinting did not result in loss of motion
gained from surgery.36
Flexor Tendon Injury
Needle Fasciotomy
Flexor tendon injury is a rare complication after needle fas­
ciotomy.10 If there is a suspicion that the needle is in the
flexor tendon, a small amount of passive motion at the ­distal
interphalangeal joint is applied to evaluate for movement
of the needle with fingertip motion.14,15 If movement of the
needle is observed or if the patient reports pain or pares­
thesia, the needle should be withdrawn and ­repositioned
(see Chapter 61).
Collagenase Clostridium Histolyticum
Rare flexor tendon ruptures have been reported after col­
lagenase injection to cords at the PIP joint of the little
finger.37 Several modifications are recommended to avoid
tendon ruptures. Before injection, the cord is palpated for
the proximal and distal end to identify the midportion
where the cord is maximally separated from the underly­
ing tendon.16,17 The needle is then inserted in that area and
care is taken to ensure that the needle does not go through
not necessarily indicate inadequate primary excision.28 It
can represent a local progression of the disease or new
disease in fascia outside the original operated area. Re­
currence rates for each procedure vary greatly in the lit­
erature.29 The reason for this inconsistency is related to
a lack of standard definitions of recurrence and a time
point for reporting recurrence. A recent systematic re­
view identified the range of recurrence rates to be 12 to
39% for fasciectomy, 50 to 58% for needle fasciotomy, and
10 to 31% for collagenase.30
Current available treatments are intended to release
contractures rather than treat the underlying pathology;
therefore recurrence is not unexpected and prevention is
often not possible.1 Accurate identification of disease se­
verity and careful preoperative planning is key to reduc­
ing further morbidity. Presenting contracture severity
and number of involved digits are both correlated with
complication rates and subsequent recurrence.30 Under­
standing of the disease prognosis will help to select which
treatment options will be effective and be able to provide
long-term benefit. An elderly patient with a single, palpa­
ble cord causing MCP joint contracture may benefit from a
trial of needle fasciotomy or collagenase injection. Dupuy­
tren’s diathesis may rather benefit from partial fasciectomy,
because there is greater initial correction and lower recur­
rence rates compared with needle fasciotomy and collage­
nase injection.5,30
Complex Regional Pain Syndrome
(CRPS) and Flare Reactions
Complex Regional Pain Syndrome
CRPS is more commonly reported after fasciectomy com­
pared with needle fasciotomy and collagenase injection.
It is also more prevalent in females.30 Diagnosis relies on
clinical assessment, because there are no reliable or specific
tests.31 It should be suspected in patients reporting pain out
of proportion to what would be expected from the inciting
event or that lasts beyond the average healing time for the
injury. Individuals should be referred to a specialty pain
clinic early for initiation of appropriate medications.10,31
Because it is difficult to identify the patients who will
develop CRPS, it is recommended to take precautions in all pa­
tients during the perioperative period.32 Measures such as ele­
vation of the hand to prevent swelling and providing ­adequate
analgesia to minimize pain and anxiety should be applied. For
patients who have severe disease and will require an extensive
operation, it may be helpful to admit patients to the hospital
after surgery for better postoperative pain control.
Concurrent Carpal Tunnel Syndrome
The surgical management of coexisting Dupuytren’s dis­
ease and carpal tunnel syndrome was first studied by
Nissenbaum and Kleinert33 in 1980. They reported an 87%
complication rate in 15 patients who were treated with

SECTION VIII THE HAND AND UPPER EXTREMITY
1322
Skin Tears
Skin tears are common after needle fasciotomy and colla­
genase injection, with rates ranging from 9 to 25% and 9
to 15% of cases, respectively.40 Fortunately, most skin tears
heal uneventfully by secondary intention, even when ac­
companied by a small area of exposed flexor tendon. Avoid­
ance of tendon desiccation is achieved by application of
medicated ointment two times a day and wrapping the
wound with an adhesive strip bandage until the skin edges
are approximated by secondary healing.15 Skin tears rarely
need to be closed primarily or require skin grafting. Mi­
nor bleeding is not uncommon, and patients are advised
to apply gentle pressure, change the dressing as needed,
and continue full active finger range of motion during the
wound-healing phase.
Flexion Contracture
Joint Contracture
Joint contracture after fasciectomy has been reported to
occur in 6.7% of cases and predominantly involves the PIP
joint.40 PIP joint contracture may be secondary to extrin­
sic causes such as skin contracture or diseased palmar-
digital fascia.38 The patient in Fig. 68.5 had multiple prior
Dupuytren’s contracture releases to the little finger and
developed a significant scar contracture. He had a large
soft tissue deficit after scar excision that required local
tissue rearrangement with multiple z-plasties and an ar­
terialized heterodigital flap from the left ring finger to the
palm.
PIP joint contracture can also be related to an intrinsic
source, such as adhesions to the flexor sheath, tendons, vo­
lar plate, or collateral ligaments.38 Intrinsic joint release is
an option for a severely contracted PIP joint that is not cor­
rected by fasciectomy alone. As previously mentioned, it is
the cord. For central cords, it is recommended to not inject
more than 4 mm distal to the palmar digital crease and to
insert the needle in a horizontal or coronal plane. For PIP
joint contractures, it is advised to insert the needle close
to the palmar digital crease and no more than 2 to 3 mm in
depth (see Fig. 68.4).
Managing Unfavorable
Results and Complications
in Dupuytren’s Contracture
Intervention
Digital Nerve Injury
Neurapraxia
Many patients complain of numbness after surgery that
is usually caused by digital nerve traction during dissec­
tion. This results in sensory neurapraxia, which is a tran­
sient nerve conduction block that typically improves
within 6 to 12 weeks.38 A systematic review of outcomes
for ­Dupuytren’s contracture reported neurapraxia occur­
ring in 0.4 to 52% of cases with partial fasciectomy and 2 to
3% of cases with needle fasciotomy.30 Patients should have
close follow-up, and if symptoms persist with no clinical
improvement, they may benefit from appropriate diagnos­
tic workup and possibly exploration.10
Digital Nerve Division
The incidence of digital nerve division ranged from 2 to
5% of cases with partial fasciectomy and in 0.4% of cases
with needle fasciotomy.30 Digital nerve laceration should
be repaired to improve sensation and to prevent persis­
tent painful neuroma.32 End-to-end tension-free nerve
coaptation remains the treatment of choice.39 When this
is not feasible, a conduit can be used for gap lengths less
than 10 mm and nerve graft can be used for longer gap
lengths.
Wound-Healing Complications
Skin Necrosis
Skin necrosis was reported to occur in 4.3 and 11.1% of
patients undergoing fasciectomy for primary and recur­
rent Dupuytren’s disease, respectively.40 Small areas of
skin necrosis will likely heal spontaneously and can be left
open if there are no exposed tendons.41 Patients are en­
couraged to maintain active finger range of motion during
the wound-healing phase, even in the presence of an open
wound. A very large area of skin necrosis may result in
slower healing, infection, or scar contracture. The surgeon
may then need to perform an excisional débridement of
the necrotic area and repair the defect with possible skin
graft or flap.
Palmar digital crease
Fig. 68.5 The green zone indicates the safe area to inject a cord af­
fecting the proximal interphalangeal (PIP) joint of the little finger.
The red zone shows the danger area near the digital PIP joint crease
where potential tendon rupture can occur if the needle is inserted.

1323
Chapter 68 Dupuytren’s Contracture
tation. The patient in Fig. 68.6 previously had Dupuytren’s
contracture release to the left little finger and developed
PIP joint contracture. A heterodigital flap was required from
the adjacent ring finger to fill in the very large wound and
acceptable to not perform volar capsulectomy for PIP con­
tractures of less than 30 degrees, because these will likely
relapse.24 Severe, dysfunctional contractures may require
salvage procedures such as PIP joint fusion or even ampu­
a
b
c
d
e
f
g
Fig. 68.6 (a) This 61-year old patient developed a severe scar contracture of the little finger after multiple Dupuytren’s contracture re­
leases. (b) After scar excision and release, a template of the large soft tissue wound in the distal palm was created with a rubber Esmarch
bandage. (c) A heterodigital vascularized island flap from the left ring finger was dissected back to the branch point of the common digital
artery. (d) The flap was transposed to the palm and inset. A groin full-thickness skin graft was used for closure of the donor defect. Early
postoperative demonstration of finger flexion (e) and extension (f,g). The patient will need therapy to achieve full PIP flexion and extension.

SECTION VIII THE HAND AND UPPER EXTREMITY
1324
tissue, making dissection difficult and the potential for
neurovascular injuries more likely. Therefore reopera­
tion for Dupuytren’s contracture should be preceded by a
thorough assessment and planning.1,38 Evaluation of pre­
vious incisions and extent of soft tissue contracture may
help to anticipate the need for skin grafting and possible
flap to achieve wound closure. Identification of previously
injured nerves and vessels is helpful. This is done by thor­
ough sensory assessment and a digital Allen test. Patients
should once again be counseled on realistic outcomes and
the potential for recurrence. They should be warned that
postoperative therapy may be more extensive.
Needle Fasciotomy
When compared with partial fasciectomy, the recurrence
rate of needle fasciotomy was significantly higher based on
a 5-year follow-up from a randomized control trial (84.9
versus 20.9%).42 Patients who developed recurrent disease
after needle fasciotomy were offered a second treatment
with needle fasciotomy or partial fasciectomy. On average,
50% of the patients treated with repeat needle fasciotomy
developed a second recurrence after 4.4 years. Based on
these findings, the authors concluded that needle fasci­
otomy is an effective alternative treatment for recurrent
Dupuytren’s disease as long as patients are willing to ac­
cept the higher recurrence rate for the benefit of shorter
recovery time and less invasiveness.
skin deficit during the revision surgery. Another patient (Fig.
68.7) required little finger PIP joint arthrodesis for severe
recurrent flexion contracture. The large PIP and volar fin­
ger soft tissue deficit was covered with a cross-finger flap.
Bowstringing
Flexor tendon bowstringing is a rare complication. It may be
more common in recurrent Dupuytren’s contracture when
the flexor tendon sheath is not identified within the scar
and is accidentally disrupted.38 Fig. 68.8 shows a patient
who had disruption of the A2 pulley resulting in PIP flex­
ion contracture and bowstringing of the left middle finger.
He had release of PIP flexion contracture and flexor tendon
pulley reconstruction with a tendon graft. Wide-awake
tumescent local anesthesia is useful so that full functional
correction can be assessed by patient activity (Video 68.2).
Recurrence
Fasciectomy
Although the recurrence rate is highly variable, it is well-
established that the overall recurrence rate for partial
fasciectomy is lower compared with needle fasciotomy
and collagenase injection.30 Repeat surgery for Dupuy­
tren’s contracture presents a challenge for hand surgeons.
The anatomy is often distorted because of adherent scar
Fig. 68.7 (a) A 73-year-old patient who previously had Dupuytren’s contracture release of the little finger developed a severe flexion proxi­
mal interphalangeal (PIP) joint contracture into the palm. (b) A soft tissue deficit on the volar aspect of the little finger was left after PIP
arthrodesis. (c) A cross-finger flap from the adjacent left ring finger was used for coverage. (d) The long-term outcome after division of the
cross-finger flap with resolution of PIP flexion contracture.
a
b
c
d

1325
Chapter 68 Dupuytren’s Contracture
Thirty percent of patients with recurrent Dupuytren’s
disease underwent a second collagenase injection. The
recurrence rate from the second treatment group is
pending. Similar to needle fasciotomy, collagenase in­
jection may be an alternative option for recurrent dis­
ease because it offers a faster recovery and has minor
complications.
Collagenase Clostridium Histolyticum
A 5-year follow-up study of the Collagenase Option for
Reduction of Dupuytren Long-term Evaluation of Safety
Study (CORDLESS)43 showed a recurrence rate in 47% of
cases. Recurrence was defined as a change in baseline of
20 degrees or greater with an associated palpable cord.
Fig. 68.8 (a) Magnetic resonance imaging of this patient’s middle finger revealed disruption of the A2 pulley with an associated bowstringing
deformity. (b) Preoperative markings for the incision. This plan may need to be altered based on prior scars. There is a 60-degree proximal
interphalangeal flexion contracture. (c) Adhesions posterior to the flexion tendon sheath were marked for excision. (d) Reconstruction of
the A2 pulley with a tendon graft.
a
b
c
d

SECTION VIII THE HAND AND UPPER EXTREMITY
1326
for unrecognized nerve injury and missed carpal tunnel
syndrome, which could be the underlying cause of postop­
erative pain.
Flexor Tendon Injury
Flexor Tendon Transection
Complete or partial flexor tendon laceration after par­
tial fasciectomy and needle fasciotomy for Dupuytren’s
Complex Regional Pain Syndrome and
Flare Reactions
CRPS is more commonly reported after fasciectomy (2 to
13%) compared with needle fasciotomy (0.4%) and collage­
nase injection (0.3%).40 According to a recent Cochrane sys­
tematic review, 44 the consensus on the optimal treatment
for CRPS cannot be made because high-quality evidence
is lacking. Early diagnosis and referral to a specialty pain
clinic is recommended. Patients should also be evaluated
a
b
c
d
e
f
Fig. 68.9 (a) This 55-year-old patient who had contractures of the first web space, including the finger and thumb, and of the little and ring
fingers. (b) The severe little finger flexion contracture resulted in palm maceration. Planned surgery procedures involved (c) initial release
of the first web space and (d) needle fasciotomy of the little finger to open up the palm for skin care. (e) This was followed by application of
dynamic torque traction (Digit Widget, Hand Biomechanics Lab) for the little finger proximal interphalangeal flexion deformity. (f) Finally,
fasciectomy was performed for the little and ring fingers.

1327
Chapter 68 Dupuytren’s Contracture
and the indications, common complications, and potential
recurrence of each procedure will allow the surgeon to ad­
vise patients on the most suitable treatment plan.
Partial fasciectomy remains the standard for treatment
of more severe Dupuytren’s contracture, although it has the
potential for neurovascular injury, skin necrosis, flexion con­
tracture, and CRPS.40 It allows for PIP joint capsular release
when necessary and also the ability to overcome skin defi­
cits. Needle fasciotomy can be a good option for high-risk
patients with a less severe, palpable cord who cannot toler­
ate general anesthesia and prolonged recovery time.14,22 It is
not suitable for patients with tight scars and has the disad­
vantage of rapid recurrence. Collagenase injection may re­
quire several injections to achieve full extension but can be a
cost-effective option if the success rate is high.17 It is associ­
ated with minor complications such as localized pain, swell­
ing, and bruising but has a potential risk for tendon rupture
with injection near the PIP joint crease of the little finger.
Treatment selection varies with the surgeon’s clinical
judgment and experience. Patient comorbidities, disease
severity, expectations, and commitment to postoperative
therapy should all be taken into account to achieve opti­
mal functional outcome and satisfaction. The case exam­
ple in Fig. 68.9 demonstrates how treatment selection may
guide a complex patient through optimal outcome with few
complications.
contracture is rare, with each occurring at an average rate
of 0.2% of cases.40,45 A tendon defect smaller than 1 cm is
amenable to repair by end-to-end suturing. Larger tendon
gap or neglected injuries may need tendon grafting for ten­
sion-free repair.46
Flexor Tendon Rupture
Rupture of one or both flexor tendons after collagenase
injection is also a rare complication, with an incidence of
0.5%.37 The reported cases of tendon ruptures occurred
with treatment of a little finger PIP contracture. Flexor
tendon rupture caused by collagenase injection will likely
require a staged flexor tendon reconstruction, because pri­
mary repair is not feasible as a result of the loss of tendon
substance.
Conclusion
Avoidance of common complications associated with the
treatment of Dupuytren’s contracture and the ability to
manage the problems effectively is the key to long-term
satisfactory results.10 A full understanding of the pathogen­
esis and natural history of the disease is helpful to perform
risk assessment and select the appropriate time to inter­
vene. Having knowledge of the available treatment options
References
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8. Luck JV. Dupuytren’s contracture; a new concept of the
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10. Cheung K, Walley KC, Rozental TD. Management of
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tracture. Br J Plast Surg 1964;17:271–280
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AF, Kokkalis ZT, Soucacos PN. The McCash technique
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2014;19(1):61–67
14. Eaton C. Percutaneous fasciotomy for Dupuytren’s con­
tracture. J Hand Surg Am 2011;36(5):910–915
15. Morhart M. Pearls and pitfalls of needle aponeu­
rotomy in Dupuytren’s disease. Plast Reconstr Surg
2015;135(3):817–825
16. Meals RA, Hentz VR. Technical tips for collagenase injec­
tion treatment for Dupuytren contracture. J Hand Surg
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17. Hentz VR, Watt AJ, Desai SS, Curtin C. Advances in the
management of Dupuytren disease: collagenase. Hand
Clin 2012;28(4):551–563
18. Varian J. Limited fasciectomy. In: McFarlane RM, Mc­
Grouther DA, Flint MH, eds. Dupuytren’s Disease: Biology
and Treatment, Vol 5, The Hand and Upper Limb Series.
Edinburgh: Churchill Livingstone; 1990:340–344
19. Watt AJ, Leclercq C. Management of Dupuytren’s disease.
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and Upper Extremity. 3rd ed. New York: Elsevier Saun­
ders; 2013:345–62
20. Foucher G, Medina J, Navarro R. Percutaneous needle apo­
neurotomy: complications and results. J Hand Surg [Br]
2003;28(5):427–431
21. Tubiana R, Thomine JM. Surgical treatment of Dupuy­
tren’s contracture: Technique of fasciotomy and fasciec­

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34. Gonzalez F, Watson HK. Simultaneous carpal tunnel re­
lease and Dupuytren’s fasciectomy. J Hand Surg [Br]
1991;16(2):175–178
35. Lilly SI, Stern PJ. Simultaneous carpal tunnel re­
lease and Dupuytren’s fasciectomy. J Hand Surg Am
2010;35(5):754–759
36. Rivlin M, Osterman M, Jacoby SM, Skirven T, Ukomadu
U, Osterman AL. The incidence of postoperative flare
reaction and tissue complications in Dupuytren’s dis­
ease using tension-free immobilization. Hand (NY)
2014;9(4):459–465
37. Zhang AY, Curtin CM, Hentz VR. Flexor tendon rupture af­
ter collagenase injection for Dupuytren contracture: case
report. J Hand Surg Am 2011;36(8):1323–1325
38. Calandruccio JH, Hecos SE. Reoperative Dupuytren con­
tracture. In: Duncan SFM, ed. Reoperative Hand Surgery.
New York: Springer; 2012:7–15
39. Paprottka FJ, Wolf P, Harder Y, et al. Sensory recovery
outcome after digital nerve repair in relation to different
reconstructive techniques: meta-analysis and systematic
review. Plast Surg Int 2013;2013:704589
40. Denkler K. Surgical complications associated with fasci­
ectomy for Dupuytren’s disease: a 20-year review of the
English literature. Eplasty 2010;10:e15
41. Michon J. Operative difficulties and postoperative com­
plications in the surgery of Dupuytren’s contracture. In:
Hueston JT, Tubiana R, eds. Dupuytren’s Disease. London:
Churchill Livingstone; 1974:101–7
42. van Rijssen AL, ter Linden H, Werker PM. Five-year results
of a randomized clinical trial on treatment in Dupuytren’s
disease: percutaneous needle fasciotomy versus limited
fasciectomy. Plast Reconstr Surg 2012;129(2):469–477
43. Peimer CA, Blazar P, Coleman S, Kaplan FT, Smith T,
Lindau T. Dupuytren contracture recurrence following
treatment with collagenase Clostridium histolyticum
(CORDLESS [Collagenase Option for Reduction of Dupuy­
tren Long-Term Evaluation of Safety Study]): 5-year data. J
Hand Surg Am 2015;40(8):1597–1605
44. O’Connell NE, Wand BM, McAuley J, Marston L, Moseley
GL. Interventions for treating pain and disability in adults
with complex regional pain syndrome. Cochrane Data­
base Syst Rev 2013;4(4):CD009416
45. Beaudreuil J, Lellouche H, Orcel P, Bardin T. Needle apo­
neurotomy in Dupuytren’s disease. Joint Bone Spine
2012;79(1):13–16
46. Egeland BM, Sebastin SJ, Chung KC. Acute repair of zone
2 flexor tendon injury. In: Chung KC, ed. Operative Tech­
niques: Hand and Wrist Surgery. 2nd ed. Philadelphia:
Saunders; 2012:64–74
tomy. In: Hueston JT, Tubiana R, eds. Dupuytren’s Disease.
London: Churchill Livingstone; 1974:85–92
22. Eaton C. A technique of needle aponeurotomy for Dupuy­
tren’s contracture. In: Eaton C, Seegenschmiedt MH, Bayat
A, Gabbiani G, Werker PMN, Wach W, eds. Dupuytren’s
Disease and Related Hyperproliferative Disorders. Heidel­
berg: Springer; 2012:267–79
23. Curtis RM. Volar capsulectomy of the proximal interpha­
langeal joint in Dupuytren’s contracture. In: Hueston JT,
Tubiana R, eds. Dupuytren’s Disease. London: Churchill
Livingstone; 1974:135–7
24. Weinzweig N, Culver JE, Fleegler EJ. Severe contractures
of the proximal interphalangeal joint in Dupuytren’s dis­
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release versus fasciectomy alone. Plast Reconstr Surg
1996;97(3):560–566, discussion 567
25. Iselin F. Recurrences in Dupuytren’s contracture. In:
Hueston JT, Tubiana R, eds. Dupuytren’s Disease. London:
Churchill Livingstone; 1974:139
26. Collis J, Collocott S, Hing W, Kelly E. The effect of night ex­
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27. Leeflang S, Coert JH. The role of proximal pulleys in
preventing tendon bowstringing: pulley rupture and
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2014;67(6):822–827
28. Hueston JT. Recurrent Dupuytren’s contracture. Plast Re­
constr Surg 1963;31:66–69
29. Kan HJ, Verrijp FW, Huisstede BM, Hovius SE, van Nieu­
wenhoven CA, Selles RW. The consequences of different
definitions for recurrence of Dupuytren’s disease. J Plast
Reconstr Aesthet Surg 2013;66(1):95–103
30. Chen NC, Srinivasan RC, Shauver MJ, Chung KC. A system­
atic review of outcomes of fasciotomy, aponeurotomy,
and collagenase treatments for Dupuytren’s contracture.
Hand (NY) 2011;6(3):250–255
31. Fukushima FB, Bezerra DM, Villas Boas PJ, Valle
AP, Vidal EI. Complex regional pain syndrome. BMJ
2014;348:g3683
32. McFarlane R, McGrouther DA. Complications and their
management. In: McFarlane RM, McGrouther DA, Flint
MH, eds. Dupuytren’s Disease: Biology and Treatment, Vol
5, The Hand and Upper Limb Series. Edinburgh: Churchill
Livingstone; 1990:377–82
33. Nissenbaum M, Kleinert HE. Treatment considerations in
carpal tunnel syndrome with coexistent Dupuytren’s dis­
ease. J Hand Surg Am 1980;5(6):544–547

1329
Chapter 68 Dupuytren’s Contracture
Discussion by Todd A. Theman and Prosper Benhaim
Dupuytren’s contracture, though common and incur­
able, fortunately has several effective treatment op­
tions. Achieving a good outcome, or avoiding a poor
one, requires patient education and engagement, care­
ful evaluation, and meticulous attention to technique
no matter the procedure chosen.
Patient satisfaction after any intervention is high,1
but there are important caveats. Patients need to be ade­
quately counseled on the treatment modalities, because
they differ significantly regarding patient ­experience,
cost, recurrence rate, posttreatment restrictions, and
complication profile. Comorbidities may also affect
treatment choices. Although some patients will ­select
the intervention with the lowest recurrence, other
­patients prefer different tradeoffs.2
Dupuytren’s disease is common enough that we
quickly screen for it in nearly all patients undergo­
ing hand surgery. We often find early subclinical cord
formation in patients presenting with non-Dupuy­
tren’s hand complaints. This is particularly important
in patients undergoing surgery for another indication,
because we specifically counsel them that this may
“activate” or exacerbate the progression of their Du­
puytren’s disease. Trauma to the hand, both open and
closed, can lead to progression of Dupuytren’s disease.
A surgical incision is no different.
General Considerations
The classic teaching is that patients should not be
treated unless there is at least 20 to 30 degrees of con­
tracture at the metacarpophalangeal (MCP) joint, and
any substantial contracture at the PIP joint. Some pa­
tients are tolerant of greater degrees of contracture,
whereas others are bothered by even 10 to 20 degrees
of contracture. Decisions on the timing of treatment
are also affected by data that suggest that patients
with less severe contracture do better than those with
more severe contracture, and those with primary MCP
joint involvement do better than patients with primary
proximal interphalangeal (PIP) joint involvement.
Treatment is generally less complicated with lesser de­
grees of contracture, and the risk of recurrence is lower
in patients treated at an earlier stage of disease, espe­
cially for PIP joint contractures.3 The recognition that
earlier treatment may lead to a better overall outcome
has implications for how to counsel patients on timing
of intervention.
In patients with a severe starting contracture, a
longer period of immobilization immediately after a
procedure can minimize the risk of rapid rebound con­
tracture. Patients with severe initial contractures, es­
pecially at the PIP joint, will often have attenuation of
the extensor mechanism, leading to weak and inefficient
finger compensatory extension. This can predispose the
patient to rapid recurrent contracture.4 Blocking MCP
joint hyperextension will typically lead to immediate
full active PIP joint extension, similar to taking the MCP
joint out of hyperextension in a claw deformity. An ini­
tial period of immobilization can minimize the risk of
rapid rebound contracture, especially if there is a delay
in getting the patient to the hand therapist for fabrica­
tion of appropriate nighttime and intermittent daytime
splints. We recommend 4 to 5 days of immobilization
before starting range-of-motion exercises in patients
with severe starting contractures who we anticipate
may have a rapid rebound. If there is a significant exten­
sor lag secondary to central slip attenuation, splinting is
similar to treatment for a boutonnière deformity, with
emphasis on distal interphalangeal (DIP) joint flexion
to allow for stretching and gliding of the lateral bands.
Patient education after any Dupuytren’s procedure
stresses the critical importance of range-of-motion exer­
cises to prevent stiffness and recurrent contracture and
to maintain good flexion. This is particularly important
if there is an open skin tear or wound-healing compli­
cation, because there is a natural tendency for patients
to avoid range-of-motion exercises. Remarkably, most
patients do not have much pain and can perform effec­
tive finger range-of-motion exercises. Data suggests that
nighttime splinting can be performed in a progressive
fashion, going from partial extension into full extension
in a stepwise progression.5
In patients with extremely severe contractures, es­
pecially in cases with PIP joint recurrence after prior
Dupuytren’s procedures, there may be a combination
of skin contracture, recurrent Dupuytren’s disease, vo­
lar capsular contracture, collateral ligament contrac­
ture, retrovascular fibrosis, and accessory collateral or
checkrein ligament formation. There may also be global
shortening of all structures on the volar side of the digit,
poor quality skin, and subcutaneous fat atrophy similar
to a burn scar contracture. This represents a particularly
difficult challenge, because none of the conventional
treatment options is optimal. Use of a static progres­
sive device (such as a Digit Widget [Hand Biometrics

SECTION VIII THE HAND AND UPPER EXTREMITY
1330
Lab]) can improve the severity of the PIP contracture in
advance of a more definitive surgical procedure in the
form of formal Dupuytren’s contracture release, PIP cap­
sulotomy, and skin graft or flap. The device is connected
to the digit by placing two percutaneous pins through
the middle phalanx via a dorsal approach, using rubber
bands to apply a gentle extension torque over a period
of 4 to 8 weeks. This minimizes contact with the skin
and is more effective in lengthening the affected con­
tracted tissues than conventional static progressive or
dynamic extension splinting. An intact extensor central
slip is key in helping maintain the gains achieved. Other
salvage procedures can include PIP joint arthrodesis and
amputation of the digit.
Extrapolating from distal radius fracture data, some
surgeons try to minimize the risk of a Dupuytren’s flare
reaction or complex regional pain syndrome with the
use of nonsteroidal anti-inflammatory medications and
vitamin C.6 In addition, the use of steroid injection af­
ter needle aponeurotomy is common to reduce the risk
of recurrence and flare reaction after treatment. In pa­
tients with early disease without measurable flexion
contracture, the risk of treatment generally outweighs
the benefit. The surgeon can consider steroid injections
into painful nodules and cords to help minimize nod­
ule tenderness and possibly the progression of disease.5
Partial fasciectomy may be considered the treat­
ment of choice for multiple digit involvement or recur­
rent Dupuytren’s contracture. This is not necessarily
our experience; we have used needle aponeurotomy
and collagenase in hundreds of patients who have had
multiple digit involvement. We have even used needle
aponeurotomy and collagenase in patients with recur­
rent disease, depending on the pattern of recurrence.
The approval by the U.S. Food and Drug Administration
(FDA) to allow two vials of collagenase to be used in a
single procedure has improved the ability to treat mul­
tiple finger contractures at one time with collagenase.
As with all treatment, this has to be individualized to
the patient.
Fasciectomy
Open surgery is probably at highest risk for patients
taking anticoagulant or antiplatelet medications.
Even in nonmedicated patients, the risk of palmar
hematoma is high enough that this is one of the few
procedures in which we deflate the tourniquet before
closure to ensure adequate hemostasis. In our prac­
tice, clopidogrel or anticoagulation therapy is a relative
contraindication to limited or open fasciectomy, where
a hematoma risks loss of skin flaps (Fig. 68D.1). For a
patient for whom this is the most appropriate option,
we close incisions very loosely to allow for egress of
fluid postoperatively and often use Penrose or closed
suction drains. The open palm technique, as noted in
the chapter, is also an option to minimize risk of he­
matoma. Needle aponeurotomy is potentially safer in
the setting of anticoagulation therapy, because 1% li­
docaine with 1:100,000 epinephrine is used and ma­
terially decreases bleeding complications. Collagenase
may also be an attractive alternative option for patients
taking anticoagulation medication.
a
b
Fig. 68D.1 Partial flap necrosis in patient undergoing open pal­
mar fasciectomy.

1331
Chapter 68 Dupuytren’s Contracture
Avoidance of neurovascular injury with fasciectomy
is one of the primary goals of the surgical procedure.
The presence of a spiral cord is unpredictable and is not
necessarily related to the degree of contracture or the
pattern of disease. Extreme caution must be taken dur­
ing dissection, especially with recurrent disease (Fig.
68D.2). Where dissection is difficult, our approach is
to maximize safety by identifying the neurovascular
bundle both proximally and distally and then dissect­
ing from known to unknown, always keeping the neu­
rovascular bundle in direct view. Appropriate scissors
are crucial. We have found that sharp curved iris scis­
sors are best but do run the risk of injuring the nerve
with the sharp tips. However, we feel that the iris scis­
sors are more facile for dissecting through the cord and
scar tissue than blunt-tipped tenotomy scissors. It is
also important to understand the spiral cord concept,
which is really a misnomer. It is really the nerve that spi­
rals around the cord, not vice versa. The surgeon should
never assume where the nerve is and only divide a cord
with full view of the nerve proximally and distally.
There is a dangerous tendency to focus on the nerve
and to forget about the associated digital artery. Careful
attention must also be paid to preserve it. More proxi­
mally, at the palm level, the safety of dissection can be
increased by understanding the relative anatomy of
Legueu’s and Juvara’s septae and their importance as
signposts for proximity to the neurovascular structures.
Of note, the thumb does not have a spiral cord type of
anatomy, which makes the dissection in the thumb
more straightforward. Despite care taken to avoid in­
jury, the patient must be informed of the significant risk
for neurapraxia after surgery, not only from the dissec­
tion itself, but from potential stretch of the nerve as the
finger goes from contracted to extended, especially in
recurrent disease.
Vascular spasm is common after release, especially
release of severe contractures. The vascular spasm can
be minimized by avoiding placement of the fingers into
full extension after surgery. If therapy is started early
after surgery, the fingers can be progressively extended
into full extension over the next few days. This is also
true after needle aponeurotomy and after collagenase
treatment. Injury to the flexor tendon sheath or pulleys
can also occur if the surgeon is inattentive, predispos­
ing the digit to flexor tendon bowstringing. There is an
identifiable plane between the contracture cord and the
flexor tendon sheath and pulleys; if it is routinely identi­
fied, risk is minimal.
In most patients, radical fasciectomy is no longer
recommended. The additional benefit is minimal, but
the risk of complication is increased significantly. The
generally accepted approach is to proceed with exci­
sion of diseased fascia and associated finger-level cords,
without excision of the entire palmar fascia. A radical
approach predisposes the skin flaps to ischemia, wound-
healing complications, and hematoma.7
With regard to the use of longitudinal incisions at
the finger level with multiple z-plasty closures, our gen­
eral preference is a Bruner incision for mild to moderate
contractures if there is enough skin to allow for primary
closure. If there is a moderate to severe contracture, we
agree fully that a longitudinal incision with z-plasty clo­
sure using multiple z-plasties in sequence is preferred
to reduce the risk of a tight closure and wound-healing
complications.
To minimize the risk of skin flap necrosis and but­
tonhole formation during skin flap elevation, we paint
the skin with a marking pen. During flap elevation, if the
purple color becomes apparent from the undersurface of
the skin, we know that our dissection is too superficial.
This is particularly helpful in cases where the cords are
rather thick and immediately adherent to the dermis
(Fig. 68D.3).
Fig. 68D.2 Open palmar fasciectomy with release of left ring
finger contracture. A spiral cord involving the radial digital nerve
spirals around the central cord at the metacarpophalangeal joint
and proximal phalanx level. The ulnar digital nerve has a non–
spiral cord orientation.

SECTION VIII THE HAND AND UPPER EXTREMITY
1332
The mechanism for residual PIP joint contracture
after a formal Dupuytren’s contracture release was dis­
cussed in the chapter. In many cases, however, the resid­
ual contracture may be related to simple retrovascular
disease, which is often overlooked as part of the dissec­
tion. We agree that a greater than 30-degree contracture
is an indication for PIP joint volar capsulotomy. How­
ever, for less than 30 degrees of contracture, because
Fig. 68D.3 Palmar fasciectomy. (a) A moderate middle finger contracture approached via a Bruner incision and a more severe
ring finger contracture approached via combined Bruner incision in the palm and straight-line incision at the finger level that will
be closed with multiple z-plasties. (b) Initial incision at the immediate subdermal level, demonstrating thin skin flaps. (c) Painting
of the skin with a marker to facilitate dissection and to minimize buttonholing of the skin during flap elevation. (d) Dissection of
thin skin flaps off the underlying pretendinous cords. (e,f) Elevation of the thickened palmar fascia off the underlying superficial
palmar arch and tendons at the distal end of the carpal tunnel.
a
b
c
d
e
f
Continued

1333
Chapter 68 Dupuytren’s Contracture
capsulotomy may lead to additional morbidity, including
prolonged recovery time, additional scar tissue forma­
tion, and decreased functional range of motion, capsu­
lotomy may not be indicated. Many surgeons will accept
a minor degree of residual contracture, because the im­
mediate gain associated with PIP joint capsulotomy may
be offset by the additional morbidity associated with a
formal PIP joint capsulotomy.
One of the greatest frustrations after contracture re­
lease is decreased long-term flexion of the digits. Most
patients present initially with decreased extension of
the fingers, but full flexion both actively and passively.
After surgery, especially extensive surgery, patients will
sometimes develop intrinsic tightness, scar tissue, and
dorsal capsular contracture that limit flexion of the dig­
its. Postoperative hand therapy must focus not only on
maintaining good finger extension, but also on finger
flexion and intrinsic stretching exercises to lessen this
unfavorable outcome.
Needle Aponeurotomy
Needle aponeurotomy is most appropriate for patients
with well-defined palpable cords who desire a faster
return to work and activities and are willing to trade off
a higher recurrence rate. It is also an excellent adjunc­
tive procedure along with collagenase, particularly for
the thumb ray, natatory cords, and first web space com­
missural cords. For some patients, the convenience of
a single office visit can sway the decision-making pro­
cess in favor of needle aponeurotomy. Some patients
may not wish to come back for the second office visit
required for postcollagenase manipulation, especially if
they live remotely. Needle aponeurotomy can be per­
formed in an office setting or surgery center, with the
choice often dictated by patient preference, surgeon
preference, or insurance coverage guidelines. Antico­
agulation medication is temporarily discontinued if it
is medically safe to do so. Anticoagulation, however,
is not an absolute contraindication to needle aponeu­
rotomy.
In our opinion, needle aponeurotomy is not recom­
mended in patients with Dupuytren’s diathesis, because
they have a particularly high risk of recurrence. Patients
who are young also represent a relative contraindication,
also with a higher risk for recurrence.8
The technique is described in the chapter, though
we would emphasize the importance of numbing only
the skin superficially, patient participation to report any
paresthesias, and absolute care in dissection. The sen­
sory end organs in the skin are contained within the
dermis, but the palmar aponeurosis and Dupuytren’s
contracture cords are relatively insensate. The digital
nerves, however, are responsive to pressure and direct
contact.9 The safety of the procedure requires that only
the skin overlying the cords is blocked by the local an­
esthetic, avoiding deeper injection that may create an
anesthetic block of the digital nerves. If the patient re­
ports Tinel’s sign or paresthesia from the digital nerve,
this prompts the surgeon to redirect the needle in a dif­
ferent direction or location to avoid neurovascular in­
jury. This is particularly true in higher-risk locations,
such as spiral cords at the proximal phalanx level of the
digit, where the nerves can be displaced from the nor­
mal anatomical location by the spiral cord.
Our usual technique involves injection with 1% li­
docaine with 1:100,000 epinephrine in a 3 mL syringe
and a 30-gauge needle that facilitates a true intradermal
block only. Bicarbonate is added to the lidocaine to mini­
mize injection pain. To ensure precision, only 0.05–0.1 mL
Fig. 68D.3, cont’d (g) Proximal-to-distal dissection of the pretendinous cords off the underlying common digital neurovascular
bundles and flexor tendon sheath. (h) Final closure of the middle finger–palmar Bruner flaps and z-plasty closure of the ring fin­
ger incision.
g
h

SECTION VIII THE HAND AND UPPER EXTREMITY
1334
of lidocaine is injected locally, with multiple injections
performed to ensure surface anesthesia along the entire
length of the cord (Fig. 68D.4). If the injection is too deep,
there will be loss of light touch sensation, which may re­
quire delay until sensation returns or even rescheduling of
the procedure. To minimize this risk, some surgeons will
utilize a distal-to-proximal approach, sequentially block­
ing the cord in progressive stepwise fashion. With this ap­
proach, the proximal Tinel’s sign is maintained, even if
the distal nerve is unintentionally blocked (Video 68D.1).
Needle aponeurotomy can be performed with hy­
podermic needles of varying sizes. Some surgeons pre­
fer a 25-gauge needle, whereas others prefer a larger
20-gauge or 18-gauge needle. The 25-gauge needle
typically relies more on a perforation technique, sup­
plemented by sweeping maneuvers through the cord,
whereas a larger 20-gauge or 18-gauge needle acts more
like a knife using a back-and-forth method to weaken
the cord. Surgeons who prefer 25-gauge needles cite a
lower risk of neurovascular injury, and surgeons who
prefer larger-gauge needles cite greater efficiency and
better overall release of the cords. In our personal se­
ries of nearly 1,000 needle aponeurotomies using an
18-gauge needle, we have had no major nerve injuries,
indicating that the larger needle approach can still be
used safely. The key, importantly, is strict observation
for possible Tinel’s response as the needle is placed per­
cutaneously into the cords.
Treatment portals are best located in areas of maxi­
mal cord bowstringing, which is maximized with fin­
ger extension. Direct release of nodules is not typically
recommended, unless they are directly contributing to
the contracture and only if needed after the proximal
and distal nonnodular cords are successfully released.
Portals directly over flexion creases are not ideal, be­
cause there is closer proximity to the underlying flexor
tendon sheath, although they are sometimes necessary
to achieve release. Cords are placed under tension and
stabilized by the surgeon’s nondominant hand. Maxi­
mal extension of the digit is discouraged when release is
a
b
c
d
Fig. 68D.4 Needle aponeurotomy. (a) After skin preparation with alcohol, ethyl chloride is used to minimize the pain associated with
injection of local anesthetic. (b) The skin is locally infiltrated at multiple focal sites with 1% lidocaine with 1:100,000 epinephrine,
buffered with bicarbonate, using a 3-mL syringe and a 30-gauge needle. (c) The injection is performed at an extremely superficial
dermal layer to avoid anesthetic block of the digital nerves that would potentially eliminate the protective Tinel’s sign feedback.
(d) The numerous sites of injection and the local vasoconstrictive effect of the epinephrine.

1335
Chapter 68 Dupuytren’s Contracture
being performed at the MCP joint level, because hyper­
extension in this area places the flexor tendons in very
close proximity to the skin at the distal palm crease, in­
creasing the risk of tendon injury.
Once the needle penetrates the skin, the needle is
oriented to create a tangential plane between the dermis
and the cord. The tip of the needle is then placed per­
pendicular to the longitudinal axis of the cord. A side-
to-side motion is used to scratch through the cord in a
progressive stepwise fashion. If using a 25-gauge nee­
dle, a perforating technique is more commonly used to
weaken the cord initially, followed by a sweeping tech­
nique thereafter. Regardless of needle gauge, a scrap­
ing sensation feedback should be received, indicating
that the needle is still within the cord. When the scrap­
ing sensation is lost, that typically signifies the end of
the cord, and deeper dissection should be avoided. A
“trampoline” sensation when the finger is extended re­
peatedly helps determine whether the cord has been
ruptured successfully or not.
As noted, some surgeons prefer a proximal-to-distal
approach and others a distal-to-proximal approach. Ei­
ther way, effort is taken to maintain a central position on
the cord, avoiding injury to the adjacent neurovascular
bundles. Caution is also taken to avoid deep needle pen­
etration to avoid underlying neurovascular and tendon in­
jury. Testing for finger sensation is performed repeatedly
to confirm intact nerve function. Each needle penetration
or motion should be performed slowly enough to allow
the patient time to respond with a possible Tinel’s reac­
tion, if one is encountered. This gives the surgeon enough
time to react appropriately and to redirect the needle, if
necessary. If there is any concern for needle placement
into a tendon, actively or passively flexing the finger to
determine whether the needle moves will confirm.
Palmar pits should be avoided, if possible, because
transection of a dimple sinus predisposes the patient to
a higher risk of skin tear. The skin at the deepest portion
of the pit is also often not well anesthetized, increasing
patient discomfort.
Spiral cords are located at the distal palm and base
of the finger at the proximal phalanx level. In these ar­
eas, particular caution should be taken during release of
the Dupuytren’s cords, because the neurovascular struc­
tures are displaced centrally and superficially. The pres­
ence of fat between the cord and the dermis is often a
clue that there is a spiral cord beneath. Eaton10 reports
the use of ultrasound or Doppler to minimize the risk
of injury.
Once the needle aponeurotomy has been completed,
sensation is tested and all flexor tendons are confirmed
to be intact on individual testing. Then the postnee­
dle manipulation is performed by infiltration of local
anesthetic to achieve digital blocks in the fingers. Our
preference is to use 0.5% bupivacaine without epineph­
rine. Using local anesthesia, the fingers are manipulated
forcefully to achieve complete rupture of the cords. The
wrist is flexed to minimize tension on the tendons as
the fingers are extended. If necessary, closed capsulot­
omy of the PIP joint can also be performed. A PIP joint
closed capsulotomy is commonly successful in this set­
ting. Many patients will not have a true fixed PIP volar
capsular contracture, but will have thickening or short­
ening of the A3 pulley and flexor tendon sheath instead
that is much more amenable to closed capsulotomy ma­
nipulation than a more rigid fixed volar capsular con­
tracture that may require an open capsulotomy instead
(Fig. 68D.5). However, the surgeon must avoid excessive
hyperextension of a tight PIP joint, which can lead to
joint instability. A forceful manipulation to maximize
complete rupture of the cords is important to minimize
the risk of recurrence, although it may generate a higher
skin tear rate. Some skin tears are large enough that this
approximates a needle-assisted variant of the McCash
open palm technique, with many of the advantages of
that method. In our view, skin tears are acceptable in
the context of an aggressive manipulation after needle
aponeurotomy. This is a bit controversial, because many
surgeons minimize skin tears. In contrast, others are ag­
gressive about manipulation and finger extension, ac­
cepting skin tears that will heal by secondary intention.
We believe that the risk of a skin tear is much less than
the risk of incomplete release of the cord, which predis­
poses to a higher risk of recurrence.
We inject all released cords and nodules with ste­
roid to minimize the risk of posttreatment inflamma­
tion, flare reaction, and even recurrence. We have not
appreciated any delayed wound healing. Our personal
preference is 30 to 50 mg of triamcinolone (10 mg per
mL). Skin tears are treated with topical application of
a generous amount of antibiotic ointment to minimize
desiccation of the underlying tissues, especially if there
is exposed tendon. Local wound care instructions are
reviewed with the patient. Hand therapy is prescribed
for all patients, including use of a nighttime extension
splint for 3 to 4 months after the procedure. The amount
of hand therapy necessary largely depends on the start­
ing severity of the contracture and whether skin tears
are encountered.
Needle aponeurotomy should not be considered for
contractures not attributable to Dupuytren’s disease, in­
cluding burn scar contractures, PIP joint volar capsular
contracture, scleroderma, and posttraumatic scar tissue
formation.11
Hovius et al and others have reported good results
with extensive percutaneous aponeurotomy and lipo­
grafting.5,12,13 This technique makes multiple perfora­
tions along the length of cords, followed by injection of
autologous lipoaspirate and splinting. Early results com­
pare favorably to other techniques, though more data
and longer follow-up are needed to determine the role
of this technique.

SECTION VIII THE HAND AND UPPER EXTREMITY
1336
A recent prospective randomized controlled trial ex­
amined supplemental triamcinolone injection into pal­
pable areas of thickness at 6 weeks and 3 months after
needle aponeurotomy.5,12,13 Although total active motion
was better in the steroid group, those patients started
with more severe contractures and may have had more
potential for correction regardless of technique. Longer-
term follow-up data is needed, but if either lipoaspirate
or steroid meaningfully lengthened remission follow­
ing needle aponeurotomy, these techniques will likely
remain useful.
Collagenase
Collagenase Clostridium histolyticum (Xiaflex) has been
approved by the FDA for use in the United States since
2010. Data show a rapid uptake by surgeons with a cor­
responding decrease in both needle aponeurotomy and,
particularly, limited or open fasciectomy.14 A recent
survey of ASSH members found that collagenase is pre­
ferred 2:1 over either needle aponeurotomy or limited
fasciectomy for primary Dupuytren’s disease involving
only the MCP joint.15 For patients who desire an office-
based intervention with minimal time off work, colla­
genase may offer an attractive alternative, including for
patients with both MCP and PIP joint contractures.
Collagenase is approved for adult patients with
Dupuytren’s contracture and a palpable cord. Its use
is governed by a Risk Evaluation and Mitigation Strat­
egy (REMS) program, so all surgeons must register to
prescribe and administer it. Administration according
to package instructions is likely too restrictive, call­
ing for 0.58 mg to be injected into a single cord, with
slightly different volumes of diluent used for MCP or PIP
contractures. The Multiple Treatment Investigation of
Collagenase Optimizing the Resolution of Dupuytren’s
(MULTICORD) study established that injecting two cords
in the same hand was as safe and effective as single in­
jection, though with a trend toward more skin tears.
Our protocol goes further and represents off-label use,
though we believe it leads to more complete and more
durable correction.
b
a
c
d
Fig. 68D.5 (a) Dupuytren’s contracture of the right hand, with advanced contracture of the small finger and an independent proxi­
mal interphalangeal (PIP) joint volar capsular contracture. Note the involvement of the thumb as well. (b) Immediate appearance
after extensive needle aponeurotomy and aggressive manipulation to achieve complete rupture of the cords. The procedure in­
cluded a closed capsulotomy of the small finger PIP joint. (c,d) Follow-up at 3 years after the treatment, demonstrating a good
longer-term result without recurrence of contracture.

1337
Chapter 68 Dupuytren’s Contracture
Cords vary in length and thickness, so it seems il­
logical not to tailor the injection to the patient’s dis­
ease. We routinely use the entire 0.9 mg vial (off-label
usage) and do not hesitate to inject multiple cords at a
visit, occasionally using two vials per patient. In gen­
eral, one vial can treat two simple MCP cords or three
simple PIP cords (Fig. 68D.6). To do so, the standard 0.39
mL of sterile diluent is used to reconstitute the lyoph­
ilized collagenase powder, subsequently withdrawing
all of the fluid back (typically 0.35 mL, not the 0.25 mL
recommended by the manufacturer). Instead of inject­
ing 0.25 mL of medication in three divided doses, as rec­
ommended by the manufacturer, we inject only 0.05 mL
at each location. The fingers are extended and abducted
maximally to highlight the cords. We cleanse the hand
with alcohol and use ethyl chloride spray for topical an­
esthesia. We isolate the cord between two fingers and
inject 0.05 mL (0.13 mg) per site using a 1 mL syringe
and 30-gauge needle. With a total volume of 0.35 mL,
that allows injection of seven individual locations, which
is often enough to treat at least two to three MCP or
PIP joints. In our experience, 0.05 mL at each location is
a
b
c
d
e
Fig. 68D.6 (a,b) A patient with Dupuytren’s contracture of the middle, ring, and small fingers. This patient was treated with col­
lagenase injection using a single vial of medication, in divided doses, into the pretendinous cords over the third, fourth, and fifth
metacarpals. (c) Typical ecchymosis and edema observed 2 days after collagenase injection. (d,e) Full extension of the middle,
ring, and small fingers achieved with manipulation of the fingers under local anesthesia, complicated by a small skin tear at the
metacarpophalangeal (MCP) flexion crease in the small finger. This demonstrates successful release of three MCP joint contractures
with a single vial of collagenase medication.

SECTION VIII THE HAND AND UPPER EXTREMITY
1338
sufficient, thereby allowing treatment of more than one
joint per session. By using smaller aliquots spaced ap­
proximately 5 to 10 mm apart along a cord, there is less
chance for diffusion from the cord into other tissues, or
more superficially into the skin, leading to blood blisters
(Fig. 68D.7). More complex cords are thicker, with nod­
ule formation and associated natatory cords, and require
more medication.
It helps to imagine the disease as pearls on a string.
Although the pearls, or Dupuytren’s nodules, are more
easily palpable, they do not contribute to contracture.
The string (cord), and not the pearls, are the focus of
injection. We counsel patients that nodules will per­
sist after treatment. The approach is perpendicular in­
jection directly into the cord, although many surgeons
prefer an oblique or lateral approach. This keeps the
needle aimed away from tendons, pulleys, and neuro­
vascular structures. Precise injection technique is criti­
cal. The injector should feel resistance when injecting
into a cord, similar to a steroid injection into a keloid
scar, confirming appropriate placement in the cord. If
the needle is accidentally placed too deeply, past the
cord, the needle should be removed and inserted in a
new adjacent location to minimize the risk of the col­
lagenase following the original deep tract as the path
of least resistance to deeper structures. Natatory cords
are also injected if adduction contracture is present
(Video 68D.2).
The manufacturer, based on FDA guidelines,
­cautions against injection at any point more than 4 mm
distal to the MCP flexion crease, because the tendon rup­
tures that occurred during the FDA trials were related to
injections beyond this point. Our experience has been
that it is acceptable to inject distal to this location, even
as far distal as the middle phalanx and DIP joint level, as
long as there is a definable and palpably discrete cord,
especially if relatively bowstrung off the flexor tendon
sheath. We do, however, recommend an oblique or rela­
tively horizontal injection method to minimize the risk
of deep injection that may affect the underlying tendons.
We apply a large bulky dressing and advise the
patients not to use the hand for 14 to 16 hours while
the enzyme is still active. The dressing is removed the
following morning, and the patient may resume unre­
stricted activities as tolerated.
Manipulation of the fingers to achieve rupture of the
Dupuytren’s cords can be performed 1 to 14 days after
the initial injection but is best performed 1 to 7 days
after injection. A delay of several days allows the initial
inflammatory reaction and edema to subside and facili­
tates supplemental needle aponeurotomy, if needed.
Crucially, the manipulation is only done after thorough
blocks of the sensory nerves in the palm and dorsum
with 1% lidocaine and 0.5% bupivacaine without epi­
nephrine. A relatively large amount of local anesthetic
is used to ensure an excellent block, averaging 20 mL of
1% lidocaine (with bicarbonate) and 10 mL of 0.5% bu­
pivacaine. Pain will restrict the manipulation and lead
to an inferior result (Video 68.3).
After local anesthetic blocks are established (Videos
68D.4–68D.7), the hand is cleansed with chlorhexidine
gluconate or alcohol and allowed to dry. This reduces
contamination in the event of a skin tear. A dry gauze
pad is placed in the palm to catch blood if the skin tears.
Manipulation is not a casual stretching of the fingers but
a deliberate, purposeful hyperextension of all joints of
the hand in sequence. Digits are maximally abducted
from each other to break natatory cords. Joint contrac­
tures can also be addressed, essentially performing a
closed capsulotomy of the joint if necessary. Because
the thumb ray generally cannot be hyperextended, we
are more likely to use direct pressure on a cord with
the thumb maximally extended or supplemental nee­
dle aponeurotomy (Video 68D.8). We routinely use
nighttime extension splints and refer patients for hand
therapy.
Primary contractures of the PIP joint can be difficult
to treat in the setting of Dupuytren’s disease, and debate
exists around the optimal initial strategy. In severe con­
tractures, it is difficult to determine clinically whether
the Dupuytren’s contracture, primary joint contracture,
or even a trigger finger predominates. Fasciectomy can
be difficult, because there is often soft tissue paucity,
necessitating grafting or a flap for closure. As such, nee­
dle fasciotomy and collagenase have been advocated,16
though these sometimes require soft tissue stretching
with dynamic splinting for full effect. Soft tissue dis­
traction with the Digit Widget has shown good results,
particularly for severe contractures.17
Full correction of contracture requires aggressive
manipulation, and skin tears are common in our prac­
tice. The manufacturer recommends a gentle manipu­
lation to minimize the risk of tendon rupture. It is our
Fig. 68D.7 Blood blister after collagenase injection. Risk of
such blood blisters is increased with superficial injection of col­
lagenase that may be inadvertently just volar to the cord be­
ing treated.

1339
Chapter 68 Dupuytren’s Contracture
strong priority to ensure a complete release of the cords
to minimize recurrence, accepting a higher incidence
of skin tears and larger skin tears as a result. We have
never noted a tendon rupture. Fortunately, skin tears
are not overly painful, and they heal favorably in nearly
every case, even in the event of tendon exposure (Fig.
68D.8). We treat tears conservatively with liberal appli­
cation of antibacterial ointment to prevent desiccation,
a short course of oral antibiotics, and supervised hand
therapy. We strongly emphasize to the patient and hand
therapist that range of motion exercises must continue
despite the open skin tears. The tears heal well by sec­
ondary intention, even with aggressive finger range-of-
motion exercises. A skin graft or cross-finger flap is not
necessary.
Neurovascular injury with collagenase is rare. A
forceful manipulation, even in a severely contracted
finger, does not cause significant risk of nerve injury,
although there may be a component of self-limited
stretch neurapraxia. We have never observed a perma­
nent nerve deficit. Vascular spasm has been seen after
manipulation in severe cases, but this can be alleviated
by avoiding placement of the fingers into full extension
when the splint is applied.
a
b
c
d
e
f
Fig. 68D.8 (a) This patient had 90-degree contracture of the small finger proximal interphalangeal joint 2 days after collagenase
injection, just before manipulation of the finger. (b) The immediate appearance of the small finger after its manipulation with the
use of local anesthesia. The finger has achieved full extension, but with a large skin tear at the proximal–middle phalanx level and
an associated exposed flexor tendon. (c) The appearance of the open wound 14 days after manipulation of the finger. The open
wound has been treated with topical application of antibiotic ointment to prevent desiccation of the tendon. Granulation tissue
has formed, and the wound is beginning to contract. (d–f) Appearance of the small finger 1 year later, demonstrating full healing
of the open wound, well-maintained finger active extension, and full active flexion.

SECTION VIII THE HAND AND UPPER EXTREMITY
1340
Adverse reactions to collagenase are mild to moder­
ate and typically resolve within 10 days. These mostly
include swelling, ecchymosis, pain, pruritus, lymphade­
nopathy, and skin tears during manipulation. Collage­
nase does have a bradykinin effect, which contributes
to ecchymosis. A particularly superficial injection will
increase the risk of a blood-filled bulla (blood blister).
Postmarketing studies have documented 26 tendon rup­
tures in 49,078 injections, equivalent to a risk of 0.05%.
Unfortunately, tendon ruptures are attritional and not
amenable to primary repair.18 A tendon reconstruction
approach with a tendon graft or two-stage tendon re­
construction is necessary.
Pulley rupture, ligament injury, and severe allergic
reactions are also possible. Anticlostridial antibodies are
very common (93%) but at 5 years showed no associa­
tion with any adverse event.13,19 Despite our use of rela­
tively high doses per patient, we have not observed any
higher rate of local or systemic adverse reactions and
have not had any tendon or ligament ruptures. Manipu­
lation of the digits, particularly in advanced cases with
PIP volar capsular contracture, will rarely lead to volar
plate instability. If instability is noted, this can usually
be treated with a dorsal blocking splint and restriction
against hyperextension during therapy. The instability
typically resolves within a few weeks.
The risk for complex regional pain syndrome (CRPS)
is much lower than for fasciectomy.20 There is no data
to guide risk reduction, but anecdotally we believe that
limiting the initial inflammatory reaction is important.
We suggest that all patients use over-the-counter non­
steroidal anti-inflammatory drugs for discomfort after
collagenase injection. Although we have used steroid
injections extensively in patients who have a needle
aponeurotomy, we have not done so for collagenase pa­
tients.
A stiff finger after collagenase injection is uncom­
mon and should prompt evaluation for joint contracture,
trigger finger, intrinsic tightness, or CRPS. The stiff finger
can be addressed with manipulation using anesthesia
in the office, intra-articular steroid injection, splinting,
hand therapy, and particular attention to patient edu­
cation before treatment to prevent stiffness in the first
place. Severe cases may have to be addressed with dy­
namic splinting, checkrein, or collateral ligament release
with or without the Digit Widget.
Outcomes
The CORDLESS prospective 5-year follow-up study
found a 47% recurrence rate (with 20-degree or more
worsening) or 32% recurrence rate (30-degree or more
worsening) for MCP and PIP joints combined, with
higher recurrence at PIP joints.19 Anecdotally, we be­
lieve these numbers are high and represent sequelae
of restrictions against using local anesthetic during
the phase 3 FDA trials and a more gentle manipulation
technique. With local anesthetic blockade, the initial
improvements achieved are better, as manifested by
the fact that the average number of injections per af­
fected joint has dropped from 1.7 on average in the FDA
trial to 1.04 in actual postapproval use. More patients
are achieving full extension with local anesthetic than
with the FDA trial patients, in which only 64% of pa­
tients achieved full extension of the involved joint with
one to three cycles of treatment. The manufacturer di­
rects surgeons to reinject cords that fail to rupture at
monthly intervals, though we have not found this to be
necessary. The emphasis should be on more thorough
manipulation, not on repeated injection.
Degreef and De Smet21 identified risk factors for
recurrence after surgery, including age younger than
50 years at onset, bilateral involvement, plantar in­
volvement, thumb ray disease, more than two rays ­being
­affected, ectopic disease (knuckle pads, Ledderhose’s
disease, Peyronie’s disease), family history, and male
sex.21 These patients are challenging, and outcome stud­
ies indicate disappointing results. A trial of high-dose
tamoxifen in these patients largely failed.22 Interposi­
tion of a cellulose implant between the resected ends of
cords demonstrates some early success, though no re­
sults past 1 year are available.23 Roush and Stern24 found
that patients with a recurrence had better total active
motion with fasciectomy and local skin flaps than with
a dermatofasciectomy and skin grafting. This is some of
the best available evidence, because 16 of their 19 patients
had some evidence of diathesis, and results are measured
at a median 4-year follow-up, though many had some de­
gree of nerve dysfunction and 3 had anesthetic digits.
The common perception is that patients with dia­
thesis have higher recurrence rates and poorer surgi­
cal outcomes overall. In our experience, open surgery
can result in an exaggerated scar response that leads
to thick, ropelike scar, preventing extension and ironi­
cally recapitulating the original problem. Worse, they
also commonly develop intrinsic tightness or joint stiff­
ness, limiting finger flexion. Needle aponeurotomy is
less invasive, although recurrence is unacceptably high
to many. Collagenase also obviates surgical dissection
and may have the added benefit of locally changing the
biology of Dupuytren’s cords. In the absence of a fixed
PIP joint contracture, collagenase is currently our pre­
ferred modality. Still, there is little consensus on how
to manage patients with diathesis, and data are lacking.
There are no high-quality data to direct manage­
ment of patients on anticoagulant medications. Ini­
tial collagenase studies excluded patients on warfarin
and clopidogrel, though we do not feel these agents
are an absolute contraindication to fasciectomy, fas­
ciotomy, or collagenase given the ability to effectively
compress bleeding areas and temporarily immobilize
the hand. These patients are clearly at higher risk of

1341
Chapter 68 Dupuytren’s Contracture
bleeding complications, including potentially severe
bruising and blood blister formation. Blood blisters
represent greater local tissue destruction and increase
the size and depth of skin tears during manipulation.
Elderly patients with poor tissue quality and patients
taking anticoagulation medications are at highest risk
and must be counseled appropriately. Meticulous at­
tention to needle placement within a cord will limit
unwanted injection superficial to a cord, which we feel
also increases blood blister risk.
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16. Denkler K. Options for severe proximal interphalan­
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Plast Reconstr Surg 2012;130(1):205e–206e
17. Craft RO, Smith AA, Coakley B, Casey WJ III, Rebecca
AM, Duncan SF. Preliminary soft-tissue distraction
versus checkrein ligament release after fasciectomy
in the treatment of dupuytren proximal inter­
phalangeal joint contractures. Plast Reconstr Surg
2011;128(5):1107–1113
18. Peimer CA, McGoldrick CA, Greg Kaufman G. Nonsur­
gical treatment of Dupuytren’s contracture: 3-year
safety results using collagenase clostridium histo­
lyticum. [abstract] J Hand Surg Am 2013; 38(10,
Supplement):e52
19. Peimer CA, Blazar P, Coleman S, Kaplan FT, Smith T,
Lindau T. Dupuytren Contracture Recurrence Fol­
lowing Treatment With Collagenase Clostridium
histolyticum
(CORDLESS
[Collagenase
Option
for Reduction of Dupuytren Long-Term Evalua­
tion of Safety Study]): 5-Year Data. J Hand Surg Am
2015;40(8):1597–1605
20. Chen NC, Srinivasan RC, Shauver MJ, Chung KC. A sys­
tematic review of outcomes of fasciotomy, aponeu­
rotomy, and collagenase treatments for Dupuytren’s
contracture. Hand (NY) 2011;6(3):250–255
21. Degreef I, De Smet L. Risk factors in Dupuytren’s dia­
thesis: is recurrence after surgery predictable? Acta
Orthop Belg 2011;77(1):27–32
22. Degreef I, Tejpar S, Sciot R, De Smet L. High-dosage
tamoxifen as neoadjuvant treatment in minimally
invasive surgery for Dupuytren disease in patients
with a strong predisposition toward fibrosis: a ran­
domized controlled trial. J Bone Joint Surg Am
2014;96(8):655–662
23. Degreef I, Tejpar S, De Smet L. Improved postopera­
tive outcome of segmental fasciectomy in Dupuytren
disease by insertion of an absorbable cellulose im­
plant. J Plast Surg Hand Surg 2011;45(3):157–164
24. Roush TF, Stern PJ. Results following surgery for
recurrent Dupuytren’s disease. J Hand Surg Am
2000;25(2):291–296

(Trang không có chữ)

Burns
S E C T I O N I X

Surgical instruments and suction cups, NAM 1378.
(®Acropolis Museum Athens, Greece. Photo: Socrates Mavromatis.)

1345
As improvements in the delivery of burn care and preven­
tion resulted in greater survival of thermal injuries, pa­
tients are still left with a diverse range of challenges. These
include physical, emotional, psychological, social, and reli­
gious functional impairments that often do not return to
original levels even years after injury.1 These trends of de­
layed recovery in appearance and emotional health status
are further exacerbated when injuries extend to the face.2
Thus lasting facial reconstructions are an essential focus for
restoring patient quality of life and facilitating otherwise
rare full recoveries to preinjury levels. In general, two main
approaches are taken to burn reconstruction: (1) burn scar
excision and (2) burn scar rehabilitation. Burn scar exci­
sion, especially on the face, can cause significant secondary
deformities and introduce further burn scar tension, which
was the reason for the original suboptimal scar. Until re­
cently, only burn scar excision has been an option because
of the lack of rehabilitative tools. The recent advent, optimi­
zation, and validation of laser treatments have revolution­
ized the way that plastic surgeons are able to rehabilitate
burn scars of the face. Our preference is to rehabilitate scars
by releasing scar tension with local tissue rearrangements
and subsequent scar contour improvement with fractional
carbon dioxide and pulsed-dye lasers (PDLs). We prefer to
take a scar under tension, or an “unhappy scar,” and turn it
into a scar without tension, or a “happy scar.” In some se­
vere cases more invasive procedures are needed; however,
surgeons must be cautious before making more incisions
and creating more tension in the setting of burn scars.
Avoiding Complications during
the Acute Burn Phase of the
Face

Facial Burns
Matthias B. Donelan, Benjamin Levi,
Jonathan S. Friedstat, and Charles D. Hwang
CHAPTER
69
Summary Box
Common Complications in Facial Burn
Treatment
•• Poor graft appearance
•• Alopecia
•• Ectropion
•• Microstomia
•• Neck contracture
•• Graft complications
○
○Graft failure
○
○Contracture
○
○Contour defects
○
○Erythema
○
○Hyperpigmentation
Success with restoration of function and aesthetics from
facial burn injury begins at the time of initial assessment.
Once initial goals in terms of resuscitation are established,
it is then vital to consider early inclusion of other specialties

SECTION IX BURNS
1346
similar to documented protocols for calvarial burn injuries.3
For smaller areas, full-thickness grafts can be selected to
decrease the effect of contracture, and for larger areas split-
thickness grafts of .018 to .025 inches thick in adults and
.008 to .012 inches thick in children can be applied.4 Con­
sideration of facial subunits should also play into autograft
design, but excision of additional tissue to conform to facial
subunits is controversial.
Optimal outcomes are also contingent upon appropriate
selection of donor sites based on matching physical char­
acteristics such as color, contours, and dermal thickness as
well as underlying histology. Whereas local nearby donor
sites are ideal, they are often scarce resources and commonly
cannot support the entirety of a recipient site. Remote graft
donor sites have been already identified as suitable candi­
dates for a number of recipient sites and facial subunits.5
Poor Graft Appearance
Sheet grafts or full-thickness grafts tend to have better aes­
thetic outcomes on the face, and meshed grafts should be
avoided.  Sheet grafts  require close monitoring to ensure
excellent take. The two most common reasons for graft fail­
ure are inadequate débridement and hematoma formation.
To minimize the risk of hematomas resulting in graft loss,
small openings in the skin graft can be created to drain any
blood from beneath the graft; this is commonly done with
a small needle (such as a 21- or 25-gauge) or no. 15 blade.
to optimize recovery. Focusing on facial burns, this includes
ophthalmology if there is concern for corneal or globe in­
jury, and otolaryngology for issues related to tympanic
membrane or temporal bone fractures. The next step is de­
termining whether the burns are superficial and can heal in
less than 21 days or are full-thickness and will require exci­
sion. When large burns are being treated, facial burns are
often among the first areas excised and grafted given their
importance in function and appearance (Fig. 69.1).
Facial areas that will not reepithelialize should be dé­
brided within the first 10 days from the time of injury. They
can be temporized with allograft for either future dermal
substitutes or autografts. By placing a temporary skin sub­
stitute like allograft, the surgeon can learn which areas
were débrided to the proper depth by looking at which ar­
eas have good allograft take. After approximately 5 days,
once the allograft can be assessed for adequate débride­
ment, the wound can be autografted using facial subunits
(Fig. 69.2a,b). Then, at the second operation, regions with
inadequate allograft should be débrided further, and areas
with good take do not require further débridement. Often
surgeons are hesitant to débride the face; however, failure
to do so can lead to severe hypertrophic scarring and func­
tional deficits such as ectropion and microstomia, which
are difficult if not impossible to correct in the future. Deep
burns that extend beyond underlying bone require further
débridement through the cortex of the facial skeleton (Fig.
69.2c,d) to ensure the survival of local skin grafts, a process
a
c
b
d
Fig. 69.1 Avoidance of complications from facial burns is contingent on
proper identification of facial subunits requiring débridement and grafting.
(a–d) This patient’s scalp, forehead, and cheeks were grafted from abdomi­
nal donor sites. (e) These areas recovered well, whereas omitted regions
(chin) developed hypertrophic scarring and contracture.
e

1347
Chapter 69 Facial Burns
Ectropion
Early tarsorrhaphy, both temporary and permanent, is cen­
tral to combatting the burn wound contractures that often
pull on the lower lid. In addition, early débridement and
grafting is central to decreasing the burn scar contracture
force on the lower lid. If burn wound ectropion is present
despite these measures, early tarsorrhaphy, canthoplasty,
and midfacelift will add additional support to the lower lid
(Fig. 69.3). A lateral canthotomy and canthoplasty should
be performed to counteract the inferior pull of the burn
scar. The surgeon should suspend the lateral canthus from
the periosteum at the level of the upper limbus, mak­
ing sure to overcorrect. The midfacelift can be performed
through a lateral canthotomy incision. Dissection should be
carried down below the infraorbital rim, taking care not to
injure the infraorbital nerve by dissecting medial and lat­
eral to this. The medial cheek adipose tissue should be sus­
pended laterally from the periosteum providing support.
After these steps a tarsorrhaphy should be performed.6 If
severe ectropion is present a permanent tarsorrhaphy is
performed. If minor ectropion is present and the goal is to
temporarily offload the tension, a temporary tarsorrhaphy
is placed (see Fig. 69.2a,b). In general, external burns do
Alternatively, very small holes can be made in the graft to
allow egression of fluid, but one concern with “pie crust­
ing” the graft is that they can heal with more prominent
scars in that location. Fluid can be rolled out using cotton-
tipped applicators; one trick is to use plastic ones, such as
those used for culture swabs, because the shaft can be bent
and used to roll along uneven surfaces on the face quite
well. Another option is to fit the patient with a compression
garment for the face to help minimize this risk. Monitoring
these skin grafts on at least a daily basis for the first few
days, until no further blood or fluid accumulates beneath it,
helps ensure superior outcomes. For full-face grafts, some
surgeons have also advocated sedation on the ventilator for
around 5 to 7 days to allow for initial skin graft adherence
to the wound bed.
Alopecia
It is important to avoid full-thickness excisions to avoid
burn wound alopecia. In addition, when using the scalp as
a donor site, it is crucial not to harvest a graft that is too
thick to avoid removing the follicles. Offloading the patient
from putting pressure on one region of the scalp will also
help prevent alopecia.
Fig. 69.2 (a,b) Recipient sites for autograft must respect
facial subunits. After appropriate demarcations, early in­
terventions include débridement of allograft, bilateral
tarsorrhaphies to prevent lid contractures, and sheet
grafts to facial subunits. (c,d) Second operations may
require further débridement of regions with inadequate
take, with additional bone débridement in deep burns.
An Integra dermal regeneration template applied to the
frontal scalp for a healthier wound bed is conducive to
successive graft survival.
a
b
c
d

SECTION IX BURNS
1348
in whom infection and structural complications are con­
trolled, grafts still are prone to contour defects and color
mismatch.7 When grafting to the face, grafts must come
from regions above the clavicles or on the inner arm if
available to decrease hyperpigmentation. The surgeon
should also be mindful of moving skin from hair-bearing
regions to the face, especially in wounds.
These irregular contours and erythema can be signif­
icantly reduced through ablative laser therapy. Further­
more, residual hypertrophic scars from prior untreated fa­
cial subunits and grafts themselves traditionally addressed
by more invasive protocols such as excision are also amena­
ble to more efficient ablative laser therapies.8 Ablative laser
therapies provide the essential complementary strategy in
optimizing facial burn injury management.
Facial Subunits
Forehead and Scalp
Burn wounds of the forehead and eyelid ectropion are ad­
dressed similarly, sourcing grafts from the upper arm or
supraclavicular area. Unique considerations related to the
large surface area of the forehead include the use of a thick
split-thickness graft under significant tension and grafting
into the hairlines to hide borders that may be visible be­
cause of difficulty in matching color and textures.9 Further
complicating scalp reconstruction are the unique layers
contiguous to the skin in this region, particularly the apo­
neurosis galea of the anterior and posterior aspects of the
cranium. Skin grafts in this region are particularly vulner­
able, requiring healthy periosteum underneath for success­
ful graft survival.10 External tissue expansion devices offer
an alternate strategy for primary closure for reconstruction
not require treatment of the internal lamella. The upper lid
can often be treated with débridement and grafting alone
given the decreased vector on the lid.
Microstomia
Like ectropion, microstomia is extremely difficult to correct
once it occurs, and thus prevention is crucial. Occupational
therapy is the most important step to prevent microstomia
early after a burn. In addition, early débridement and full-
thickness grafts that take into account the facial subunits
are key to preventing microstomia.
Neck Contractures
Along with axillary contractures, neck contractures are
one of the most common and challenging contractures en­
countered after burn injury. As in other regions, early dé­
bridement and grafting is important to prevent healing by
secondary contracture and subsequent neck contracture.
Concurrently, aggressive occupational therapy and night­
time splinting with a C-collar can help combat the pull on
the neck. In the subacute setting, release and full-thickness
grafting can be performed with release of the platysma.
The release should be placed in a region that divides the
facial subunits, such as at the junction of the chin and neck
subunits. Postoperative splinting and early range of motion
are crucial to preventing recurrent neck contractures.
Graft Complications
Surgical wound infections and incomplete excision of the
underlying wound bed of the recipient site can lead to skin
graft failures and burn wound contractures.4 For patients
Fig. 69.3 A medial canthoplasty decreasing the burn contracture force on the upper and lower lids.

1349
Chapter 69 Facial Burns
regions were used for ectropion release to provide the best
color matching for the periorbital tissues (Fig. 69.5c,d). At
the same time, the surgeon must pay attention to support­
ing the lids to prevent corneal abrasions. Concurrent sup­
port procedures at the time of release and full-thickness
grafts include a midfacelift and temporary or permanent
tarsorrhaphy. For reconstruction of the posterior lamellae,
retroauricular grafts and palatal grafts can also be applied
to reconstruct the tarsal plate. Palatal grafts offer the ben­
efit of a strong support. Lateral canthoplasties restore the
physiological upward slant typically seen in an open eye
and help fight the pull of the burn on the lower lid.12 For
smaller defects in periorbital volume, fat autografting in­
jections have recovered contours previously deformed by
soft tissue atrophy or scar adhesions.13
Nose
Early treatment of the nose should focus on minimizing alar
necrosis, which can be exacerbated by feeding tubes or na­
sogastric tubes. Also, if nasal mucosa is burned, early stent­
ing can prevent intranasal contracture. Nasal reconstruc­
tion relies on accurate assessment of the skin, cartilaginous
and bony support, and lining. The inner lining is usually
provided by septal hinge flaps that can be used from the
unilateral or contralateral side. The cartilage graft can be
of this complex region.11 In addition, burring of the outer
cortex and the use of Integra dermal regeneration matrix
can help build up an appropriate wound bed for future
grafting (Fig. 69.4). Additionally, with regards to eyebrows,
the surgeon should avoid débridement of hair-bearing ar­
eas if possible. If this is not possible, future reconstruction
with occipital grafts can be performed. When using these
grafts, the surgeon must make sure to orient the hair in the
proper direction.
Eyelids
Burn wound ectropion leaves the globe vulnerable to cor­
neal damage and potential future ophthalmic complications
(Fig. 69.5a). Evaluation of the defect is based on whether
it involves the anterior and posterior lamellae. Most flame
burns affect the anterior lamella, whereas splash chemi­
cal burns may damage the anterior and posterior lamella.
Anterior lamella structures including skin and the orbicu­
laris oculi muscle along with the tarsal plates of the pos­
terior lamella must be both addressed and structurally
suspended. Anterior lamellar reconstruction relies on skin
grafts, and the best match for eyelid defects usually comes
from upper eyelid skin and is removed with traditional
blepharoplasty techniques. For larger areas, full-thickness
grafts from the inner arm (Fig. 69.5b) and supraclavicular
Fig. 69.4 (a) Severe deep burns may require cortical débridement and Integra placement to maximize successful graft survival. (b) Post­
operative result.
a
b
Fig. 69.5 (a) Burn wound ectropion leave the globe vulnerable to corneal damage. The anterior and posterior lamellae must be evaluated
and addressed individually. (b) Full-thickness grafts from the inner arm destined for periorbital tissues. (c) Full-thickness grafts from the
inner arm provide the best color matching for periorbital grafts. (d) The postoperative result.
a
b
c
d

SECTION IX BURNS
1350
Lips
Contractions of the lips produce eversion and exposure of
the vermilion borders, which can manifest functional defi­
cits and exposure of teeth. Early occupational or physical
therapy to minimize contracture is crucial. The degree of
lip eversion is often influenced by contractures of neigh­
boring facial subunits, particularly the nose and chin. Fur­
ther restrictions in oral function found contractures are
commonly excised or lengthened with z-plasty.9 Contrac­
tures causing exposure of the wet vermilion are resolved
through release grafts in the affected subunits (Fig. 69.6),
such as the chin or nasolabial folds. Intraoral flaps such
as tongue flaps are helpful for contracture of the commis­
sure.15 The facial artery myomucosal (FAMM) flap is also an
option for commissure or vermilion reconstruction. Issues
harvested from the septum or concha of the ear. The outer
lining can be covered with a nasolabial, bilobe, or forehead
flap, as are used in Mohs’ reconstruction. Often, however,
these donor sites have been grafted, making their use more
challenging. If using a previously grafted local flap, delay of
the flap may decrease flap necrosis. Other distant alterna­
tives include free tissue transfer. Composite grafts from the
ear including the helical root and preauricular area have
been histologically demonstrated to most closely resemble
nasal dermal thickness and density of pilosebaceous units.5
When the ear is not available as a donor site, a three-unit
construction sourcing inner and outer linings from the na­
sal septa and nasolabial folds with cartilage from the ear
can be used to reconstruct the asymmetrical ala. Alterna­
tives when no donor sites are available include the nasal
turndown flap.14
Fig. 69.6 (a,b) Contractures causing microstomia and exposures of wet vermilion are resolved through release grafts. (c) An upper lip de­
fect after release of the upper lip scar.
a
b
e
Fig. 69.7 (a) The anal verge. (b) An area is marked out for full-thickness skin graft harvest in the region of the transitional epithelium.
(c) The 2-year postoperative image demonstrates improved symmetry but noticeable hyperpigmentation. (d–f) Time-lapse series of phenol
peel treatment on hyperpigmentation secondary to anal verge skin graft.
a
b
e
d
e
f

1351
Chapter 69 Facial Burns
Tissue Expansion
Burn patients often suffer from alopecia. Tissue expansion
and subsequent reconstruction can help alleviate it. Lo­
cal, neighboring tissue exhibits the most similarities with
autograft sites and logically is the ideal donor for burn re­
constructions. However, this strategy is particularly con­
strained in cases involving the face because of the lack of
surface area of healthy skin available for rearrangements,
as described previously. If enough residual healthy tissue
remains, tissue expansion can produce a source of donor
tissue that preserves sensation and adnexal structures9 and
avoids donor site defects encountered with free flaps and
skin autografts. In suitable graft sites such as the scalp and
forehead, external tissue expanders can bypass the disad­
vantages of traditional implant-based expansion, including
delays and the extensive preplanning necessary to preserve
essential local anatomical substructures.11 Tissue expan­
sion is probably the most useful in scalp reconstruction be­
cause it allows movement of hair-bearing tissues into areas
of non–hair-bearing tissues. Measurements, however, are
necessary before excising the scar, because the scalp lacks
elasticity, often limiting the rotation of the expanded tis­
sue. Galeal scoring can improve the elasticity and stretch;
however, caution must be taken to avoid scoring too su­
perficial. Unfavorable results are often related to abbrevi­
ated expansion from infection or extrusion. Additionally,
placing the expander too close to the burn or expanding
the burn tissue can lead to inadequate scar excision. Clo­
sure with excess tension can also cause flap ischemia or
re-­create the tension that caused the scar in the first place
(also see Chapter 46).
Fat Autograft
Healing from burns along with postsurgical trauma often
engender aberrations in natural contours, particularly re­
lated to muscular atrophy and scarring. Fat autografts offer
an ideal source of nonimmunogenic filler that serves as a
complementary refinement of larger reconstructive pro­
cedures. Furthermore, when applied to scars secondary to
burn injury, these autografts have been demonstrated to
produce improvements in function and physiological pa­
rameters of the overlying skin.25 Fat autografts purposed
for improvement in skin quality should be directed im­
mediately below the dermal layer and be transplanted in
thin sheets to avoid central necrosis.9 In more mobile areas
of the face where fat graft survival is the most vulnerable,
direct injection into underlying muscle can facilitate long-
term results.26 Fat grafts are particularly helpful in areas
with contour irregularities. Surgeons, however, must take
caution not to inject too much adipose tissue, because this
can create a distorted appearance. Additionally, in burn
patients, it is often more difficult to find multiple planes
with patient compliance pose challenges for use of this flap
in pediatric patients, and less-invasive options are usually
effective. When treating lip contractures acutely, it is im­
portant to take the subunits into account. In addition, it is
crucial to avoid using skin to replace the lip vermilion, be­
cause this will cause a distorted appearance. The vermilion
can be replaced with the other lip if it is not burned with
an Abbé flap. Alternatively, the anal verge serves as a dis­
tant site to harvest transitional epithelium for a graft (Fig.
69.7a–c). Subsequent phenol peel of the anal verge skin
graft can help refine pigmentation mismatch (Fig. 69.7d–f).
Managing Unfavorable Results
and Complications in Facial Burn
Reconstruction
With greater numbers of patients surviving their injuries,
the morbidity of their hypertrophic scars present several
challenges to patients. Although they are more common
in deeper burns,16 they can result in decreased range of
motion, intense pruritus, and detriments to activities of
daily living.17,18 Although hypertrophic scars can undergo
some spontaneous resolution, because of extracellular
matrix remodeling,19 time alone is usually not enough to
improve symptoms. Nonsurgical approaches to treating
hypertrophic scars include compression garments, sili­
cone gels, intralesional corticosteroid injections, and cryo­
therapy. These therapies harbor mixed reviews regarding
efficacy,20,21 some of which are further confounded by low
patient compliance.22–24 When these treatments are inad­
equate, more invasive treatments can become necessary.
Tissue Rearrangement
One of the most common techniques for reconstructing hy­
pertrophic burn scars has been adjacent tissue rearrange­
ments. The z-plasty works best when the central axis is ori­
ented along a linear band of hypertrophic scarring. For this
technique to be effective, it is important to take the compo­
nents with some subcutaneous fat on the flaps to maximize
blood supply. Another technique to optimize flap survival is
to taper the tips of the z-plasty, keeping the triangular ends
broader and rounded. Additionally, the most successful z-
plasty rotates unburned skin across the contracture band.
Sometimes this is not possible, and in those situations the
thicker flaps described previously become even more im­
portant. Unfavorable results can occur if the z-plasty flaps
are not thick enough, leading to flap tip necrosis. Addition­
ally, if the z-plasty flaps are not measured and planned ap­
propriately, it can be difficult to close the defect, causing
excessive tension on the wound, which may lead to recur­
rent scar contracture.

SECTION IX BURNS
1352
(Er:YAG) lasers are the primary type used for hypertrophic
scars, ablating tissues nonspecifically via energy absorp­
tions by water. Er:YAG lasers are more effective in targeting
raised scar edges, whereas the carbon dioxide lasers cleave
disorganized collagen, allowing for microscopic tension re­
lease and organized tissue regrowth promoted by the unaf­
fected surrounding tissues.30 These targeted zones of laser
therapy have been shown to express upregulation of im­
portant antifibrotic agents such as matrix metalloproteinase
1 to increase important mechanical properties such as pli­
ability to more normal physiological levels.29 As such, their
primary indications are for thicker scars and those associ­
ated with wound contraction.19,31 To ensure a strong sub­
strate for carbon dioxide laser remodeling, candidate scars
for this treatment modality are generally allowed to mature
for longer before initiating laser sessions. In similar practice
to PDL therapy, settings for each patient must be adjusted
accordingly. Current configurations use a laser handpiece
such as the Deep FX (Lumenis), the energy levels of which
are dictated by an objective scar response. Energy levels are
increased until greater than 50% of columns exhibit dermal
bleeding, indicating complete penetration through the entire
depth of the scar, generally around 150 mJ for 4 mm of cu­
taneous penetration with densities below 5% and 10 to 30%
overlap. For added effect on superficial layers, the Active FX
handpiece (Lumenis) is used after the Deep FX treatment
with settings between 70 and 100 mJ and a frequency of 80
to 200 Hz. These treatments are reported to reduce com­
plaints of pain, tightness, and pruritus, particularly through
improvements in scar thickness and pliability.
Scars often express mixed properties of both erythema
and collagenous aberration. Thus combination treatments
leveraging anti-inflammatory and hyperemia-controlling
characteristics of PDL therapies as a pretreatment for deeper
structural remodeling of scar tissue with a carbon dioxide
laser have also demonstrated convincing lasting outcomes.29
Characteristic protocols for the combination treatment use
cryogenic cooling with spray and delay settings of 30 and 20
milliseconds respectively, with pulse durations of 1.5 milli­
seconds at 30% overlap for the PDL laser. To control for possi­
ble dermal injury, energy transfer for pulse are restricted to
fluencies of 5.0 to 8.0 J/cm2. Once the improvements plateau,
the PDL laser is reserved for possible hyperemia induced by
subsequent deep carbon dioxide ablation with parameters
of 15% density, frequency at 600 Hz, and 12.5 to 17.5 mJ
of energy per pulse. Patients were also supplemented with
superficial carbon dioxide laser ablations using settings of
150 Hz and 70 to 90 mJ per micropulse. These configurations
have been demonstrated to accelerate scar healing safely re­
gardless of scar types, scar age, initial type of injury, and pa­
tient demographics.32
Timing is the primary preoperative criterion for success­
ful outcomes. Less mature scars with unstable epidermal
coverages can lead to marginal outcomes. Although surgi­
cal interventions are generally recommended after at least 1
year of healing, laser treatments may be warranted as soon
as 6 months postinjury, with 1 to 3 months of elapsed time
to inject the fat. Unfavorable outcomes result if too much
fat is placed or if excess fat atrophy occurs postoperatively.
This is usually caused by inadequate tunneling decreasing
contact between the fat grafts and well-vascularized donor
tissues.
Laser Treatment
One of the more recent additions to reconstruct hyper­
trophic burn scars has been the addition of laser therapy.
It has received considerable attention for its ability to re­
model burn scars without the complications of surgical ap­
proaches and the scarring linked to any incision. Although
surgical methods certainly have their role in treatment,
laser therapies permit a low-morbidity, low-complication
procedure for treating hypertrophic burn scars, even in pa­
tients with medical comorbidities that can preclude sur­
gery, such as obesity, peripheral vascular disease, and im­
munosuppressant states.27 The two most commonly used
lasers have been the PDL and the fractional ablative carbon
dioxide laser.
Short pulse durations from flashlamp PDLs emit light at
585/595 nm wavelengths that target oxyhemoglobin (ab­
sorption peak of 542 nm) to damage vascular endothelium
and produce hemostasis through thrombi or intravascu­
lar coagulation. PDL has also been demonstrated to induce
changes in the ECM milieu, decreasing proliferation of fibro­
blasts and loosening collagen fiber arrangements from in­
creases in collagenase-3 activity and reduction of collagen
deposition.28 Through these mechanisms, PDL therapy is par­
ticularly effective in the treatment of immature scars that
are undergoing active recruitment of inflammatory factors.29
PDL therapy is the indicated laser configuration best for
erythematous scars with minimal thickness to mitigate ery­
thema, pruritus, and pain, particularly around regions of the
face. Furthermore, PDL therapy has also been shown to be
as effective as prophylactic measures for hypertrophic scars
when used as early as 4 weeks after the burn.28 Settings for
PDL therapy can fluctuate along predetermined ranges and
should be adjusted based on each individual patient’s burn
characteristics. A flashlamp-pumped PDL handpiece delivers
laser pulses of 7 mm or 10 mm spots with 1.5 ms duration,
with varying degrees of overlap. Fluences, or degree of en­
ergy delivery, are started conservatively from 5.0 to 8.0 J/cm2
for 7 mm spots and 4.0 to 5.0 J/cm2 for 10 mm spots based
on scar thickness, pigmentation, and scar location. Pale,
thinner scars in sensitive or thin-skinned areas like the neck
should be treated initially with conservative fluencies. Se­
quential treatments should be dosed according to responses
to previous sessions and continue until improvement pla­
teau, generally around the end of four treatments, although
some cases may exceed double this amount.28 Methods of
minimizing risks of complications with PDL include starting
at low energy settings and, in sensitive areas, considering a
test area before committing to a complete treatment.
Fractional carbon dioxide ablative fractional lasers
(10,600 nm) and erbium-doped: yttrium aluminum garnet

1353
Chapter 69 Facial Burns
Unfavorable outcomes from laser therapy can occur if
nonfractionated carbon dioxide lasers are used, because
these cause hypopigmentation and prolonged wound heal­
ing. In addition, using too high a density or too high power
on the carbon dioxide laser can cause a new thermal injury
to the patient.
Outcomes
Patient 1
A young woman suffered burns on her hands and face, with
the forehead injury reaching the periosteum. Débridement
of her frontal bone through the cortex was covered with
Integra wound matrix and subsequently grafted across the
entire subunit. Her lower lid was retracted down to her
infraorbital rim and upper lid was retracted up to her su­
praorbital rim. To address her ectropion, a release just be­
low the lash line was performed for the outer lamella and
grafted with full-thickness grafts from her inner arm and
supraclavicular region. In addition, lateral canthoplasties
and tarsorrhaphies were performed to restore lid function
and structure. Contracture of the left ala pulled up the up­
per lip, and contractures of the chin pulled down the lower
lip. Full-thickness grafts covered the rest of her facial sub­
units. Reconstruction of the ala was performed with a flap
from the helical root and superficial temporal artery. The
upper lip was later released and laser therapy was used to
reduce erythema and irregular contours.
Patient 2
At the time of another patient’s injury 1 year earlier, she had
facial subunit grafts on the cheeks. The chin was allowed to
heal secondarily and resulted in eversion of the lower lip. Z-
plasties to lengthen and release the contracture along with
ablative laser therapy were used to rehabilitate the scar.
She had typical bilateral ectropion and full-thickness grafts
that addressed the anterior lamella. Her lower lids retracted
with more than 6 mm of lower lid distraction. She had a
delayed lower lid snap-back test and epiphora (Video 69.1).
Conclusion
The management of facial burn wounds relies on two cru­
cial, parallel processes in the surgical approach: Surgical
interventions focus on producing viable coverage through
débridement, grafts, plasties, and respect of facial subunits
control for wound contractures and structural aberra­
tions. Complementary laser therapy promotes subsequent
contour and color matching, while also mitigating any
remaining or resulting scars from surgical intervention.
Concurrent use of these treatments along with additional
complementary refinement techniques provide a powerful
tool in delivering positive outcomes to burn injury patients
who historically have struggled with the path to recovery
to preinjury levels.
between subsequent treatments reflecting current clinical
practice. Patients with a history of herpes simplex are in
need of special care and should receive antiviral prophy­
laxis.19 Other important criteria include treatment areas if
local anesthetic is necessary, variations in absorption among
individuals, and heterogeneity of traumatic injuries.31 Over­
aggressive treatments do carry the risk of worsening scars,
and the spacing between treatments should be observed.
Postoperatively, laser treatments can be cared for with
topical antibiotic ointments for several days and have short
recovery periods of 1 to 3 days. Patients who encountered
pain during recovery responded well to nonsteroidal anti-
inflammatory drugs, with the more extreme cases treated
with short-acting narcotics. Complications in a recent study
were minimal, occurring in less than 4% of treatments, and
included, in decreasing order, hypopigmentation, moderate
to severe blistering, postinflammatory hyperpigmentation,
and infection.29,32 Patients are allowed to resume normal
daily activities within 1 to 3 days after the procedure.
Case reports of successful treatments of scars with frac­
tional ablative lasers have begun accumulating in the pe­
diatric scar contracture population, and in a recent, large
prospective study, episodic laser therapies (at an average
of approximately three sessions per year) have been shown
to dramatically improve the unfavorable results associated
with wound healing both through objective scar scales (Van­
couver Scar Scale and University of North Carolina “4P” Scar
Scale) and subjective measures including patient willing­
ness-to-pay assessments.29,33,34
The most common unfavorable results include hyperpig­
mentation or hypopigmentation after treatment; however,
this is much less common since the advent of fractionated
laser delivery. In addition, multiple treatments are often
needed and at times results may not be dramatic.
Perioperative Considerations for
Laser Therapy
Most adverse outcomes are relatively minor, especially in re­
gards to the surgical interventions, and occur in about 10% of
patients.29 Side effects to PDL are cutaneous, including mild
to moderate blistering, postoperative purpura lasting up to
10 days, and hypopigmentation and hyperpigmentation,
usually in darker-skinned patients related to treatments with
higher fluences needed to mitigate absorption competition
with melanin.21,28 Disadvantages of the pulsed carbon diox­
ide laser include pain, prolonged downtime, postoperative
persistent erythema (up to 3 months), milia, transient and
permanent hyperpigmentation, and increased risk for viral
and bacterial infections.21 Pinpoint bleeding can also occur,
although it is minimized by coagulation from carbon diox­
ide lasers, and mild serous discharges may also be seen.31
Er:YAG lasers cause milder and fewer adverse effects such as
postoperative erythema, temporary postinflammatory hy­
perpigmentation, and infections.21 Poor intraoperative he­
mostasis associated with Er:YAG lasers can be corrected by
the addition of coagulative pulses in the dual-mode laser.21

SECTION IX BURNS
1354
20. Gauglitz GG, Korting HC, Pavicic T, Ruzicka T, Jeschke MG.
Hypertrophic scarring and keloids: pathomechanisms and
current and emerging treatment strategies. Mol Med 2011;
17(1-2):113–125
21. Berman B, Viera MH, Amini S, Huo R, Jones IS. Prevention
and management of hypertrophic scars and keloids after
burns in children. J Craniofac Surg 2008;19(4):989–1006
22. Nedelec B, Carter A, Forbes L, et al. Practice guidelines
for the application of nonsilicone or silicone gels and gel
sheets after burn injury. J Burn Care Res 2015;36(3):345–
374
23. Engrav LH, Heimbach DM, Rivara FP, et al. 12-Year within-
wound study of the effectiveness of custom pressure gar­
ment therapy. Burns 2010;36(7):975–983
24. Anzarut A, Olson J, Singh P, Rowe BH, Tredget EE. The ef­
fectiveness of pressure garment therapy for the preven­
tion of abnormal scarring after burn injury: a meta-anal­
ysis. J Plast Reconstr Aesthet Surg 2009;62(1):77–84
25. Klinger M, Marazzi M, Vigo D, Torre M. Fat injection for
cases of severe burn outcomes: a new perspective of scar
remodeling and reduction. Aesthetic Plast Surg 2008;
32(3):465–469
26. Butterwick KJ, Lack EA. Facial volume restoration with
the fat autograft muscle injection technique. Dermatol
Surg 2003;29(10):1019–1026
27. Reddy S, El-Haddawi F, Fancourt M, et al. The incidence
and risk factors for lower limb skin graft failure. Dermatol
Res Pract 2014;2014:582080
28. Parrett BM, Donelan MB. Pulsed dye laser in burn scars:
current concepts and future directions. Burns 2010;36(4):
443–449
29. Hultman CS, Friedstat JS, Edkins RE, Cairns BA, Meyer AA.
Laser resurfacing and remodeling of hypertrophic burn
scars: the results of a large, prospective, before-after co­
hort study, with long-term follow-up. Ann Surg 2014;
260(3):519–529, discussion 529–532
30. Lee KK, Mehrany K, Swanson NA. Surgical revision. Der­
matol Clin 2005;23(1):141–150, vii.
31. Anderson RR, Donelan MB, Hivnor C, et al. Laser treat­
ment of traumatic scars with an emphasis on ablative
fractional laser resurfacing: consensus report. JAMA Der­
matol 2014;150(2):187–193
32. Clayton JL, Edkins R, Cairns BA, Hultman CS. Incidence
and management of adverse events after the use of laser
therapies for the treatment of hypertrophic burn scars.
Ann Plast Surg 2013;70(5):500–505
33. Krakowski AC, Goldenberg A, Eichenfield LF, Murray JP,
Shumaker PR. Ablative fractional laser resurfacing helps
treat restrictive pediatric scar contractures. Pediatrics
2014;134(6):e1700–e1705
34. Ghahary A, Shen YJ, Nedelec B, Wang R, Scott PG, Tredget
EE. Collagenase production is lower in post-burn hyper­
trophic scar fibroblasts than in normal fibroblasts and is
reduced by insulin-like growth factor-1. J Invest Dermatol
1996;106(3):476–481
References
1. Ryan CM, Lee A, Kazis LE, et al; Multicenter Burn Outcome
Group. Recovery trajectories after burn injury in young
adults: does burn size matter? J Burn Care Res 2015;36(1):
118–129
2. Warner P, Stubbs TK, Kagan RJ, et al; Multi-Center Bench­
marking Study Working Group. The effects of facial burns
on health outcomes in children aged 5 to 18 years. J Trau­
ma Acute Care Surg 2012; 73(3, Suppl 2):S189–S196
3. Gallagher JJ. Avoiding calvarial defects in a Harrison’s
class IV thermally injured skull. Burns 2011;37(3):480–
483
4. Cole JK, Engrav LH, Heimbach DM, et al. Early excision and
grafting of face and neck burns in patients over 20 years.
Plast Reconstr Surg 2002;109(4):1266–1273
5. Rahman M, Jefferson N, Stewart DA, Oliver R, Walsh WR,
Gianoutsos MP. The histology of facial aesthetic subunits:
implications for common nasal reconstructive proce­
dures. J Plast Reconstr Aesthet Surg 2010;63(5):753–756
6. Klein MB, Ahmadi AJ, Sires BS, Engrav LH. Reversible mar­
ginal tarsorrhaphy: a salvage procedure for periocular
burns. Plast Reconstr Surg 2008;121(5):1627–1630
7. Lindsay KJ, Morton JD. Flap or graft: The best of both in
nasal ala reconstruction. J Plast Reconstr Aesthet Surg
2015;68(10):1352–1357
8. El-Zawahry BM, Sobhi RM, Bassiouny DA, Tabak SA. Ab­
lative CO2 fractional resurfacing in treatment of thermal
burn scars: an open-label controlled clinical and histo­
pathological study. J Cosmet Dermatol 2015;14(4):324–
331
9. Spence RJ. Plastic Surgery. 3rd ed. In: Neligan PC, ed. Phil­
adelphia: Elsevier; 2013
10. Dedhia R, Luu Q. Scalp reconstruction. Curr Opin Otolar­
yngol Head Neck Surg 2015;23(5):407–414
11. O’Reilly AG, Schmitt WR, Roenigk RK, Moore EJ, Price DL.
Closure of scalp and forehead defects using external tis­
sue expander. Arch Facial Plast Surg 2012;14(6):419–422
12. Berli JU, Merbs SL, Grant MP. Reconstruction of periorbital
soft tissue defects. Facial Plast Surg 2014;30(5):561–569
13. Wetterau M, Szpalski C, Hazen A, Warren SM. Autologous
fat grafting and facial reconstruction. J Craniofac Surg 2012;
23(1):315–318
14. Taylor HO, Carty M, Driscoll D, Lewis M, Donelan MB. Na­
sal reconstruction after severe facial burns using a local
turndown flap. Ann Plast Surg 2009;62(2):175–179
15. Donelan MB. Reconstruction of electrical burns of the oral
commissure with a ventral tongue flap. Plast Reconstr
Surg 1995;95(7):1155–1164
16. Heimbach D, Engrav L, Grube B, Marvin J. Burn depth: a
review. World J Surg 1992;16(1):10–15
17. Helm P, Herndon DN, Delateur B. Restoration of function. J
Burn Care Res 2007;28(4):611–614
18. Engrav LH, Covey MH, Dutcher KD, Heimbach DM,
Walkinshaw MD, Marvin JA. Impairment, time out of
school, and time off from work after burns. Plast Reconstr
Surg 1987;79(6):927–934
19. Tredget EE, Levi B, Donelan MB. Biology and principles
of scar management and burn reconstruction. Surg Clin
North Am 2014;94(4):793–815

1355
Chapter 69 Facial Burns
Discussion by William B. Norbury and David N. Herndon
Successful treatment of facial burns starts at the mo­
ment of injury and continues for weeks in all cases,
months in some, and years in, thankfully, few. The
process involves not just a surgeon in isolation but a
team approach comprising support for emotional and
psychological needs as well as physical infirmity. The
end result of which, hopefully, is an individual who is
better able to reintegrate into society and maintain a
fully functional, independent life.
It is preferable to rehabilitate a scar rather than ex­
cise it, although in some cases of delayed presentation
excision and grafting remains in the armamentarium of
choices (Fig. 69D.1).
The restoration of function and aesthetics com­
mences at the time of initial assessment and should in­
volve all interested parties such as ophthalmology and
otolaryngology specialists as well as the burns surgeon.
Most common partial-thickness burns will heal with­
out grafting, but they do require specialist intervention.
In particular, for those with darker skin types (Fitzpat­
rick types IV–VI), the use of amnion membrane in the
treatment of partial-thickness burns appears to reduce
the amount of hypopigmentation or hyperpigmentation
(Fig. 69D.2).
Regarding the early débridement and staged recon­
struction using allograft initially and then autografts
once the level of resection has been determined, we
recommend a delayed approach to facial resection and
often leave the facial wound to demarcate over a period
of not more than 10 days. During this time the facial
wound is usually excised using a tangential approach
with Goulian/Weck knives together with a Versajet
Fig. 69D.1 (a) Facial hypertrophic burn scars. (b) Postoperative result after limited excision of hypertrophic burn scars.
a
b
Fig. 69D.2 (a) Initial presentation of a facial burn in a patient with Fitzpatrick type VI skin. (b) Day 45 after the use of amnion as
facial dressing. (c) At 12 months follow-up, normal pigmentation is restored.
a
b
c

SECTION IX BURNS
1356
(Smith & Nephew) for areas that are difficult to reach
because of the contours of the face. Regarding the ap­
propriate grafts, we recommend adhering to Gilles and
Millard’s adage1 that the “next nearest skin is the best
skin,” and as such tend to plumb for the scalp as a pri­
mary donor site for grafting of the face.
If the scalp is unavailable for a face graft, we usu­
ally take the upper back as sheet grafts rather than the
abdomen. We find that large, wide grafts can be ob­
tained with little difficulty other than needing to turn
the patient for the harvest. The abdomen can be a more
difficult area to harvest large grafts from, especially in
children.
In securing the grafts to the face, we often use a fi­
brin sealant. We have extensive experience with Tis­
seel fibrin sealant (Baxter) as an adjunct to both graft
adherence and hematoma prevention. 2-cyano-butyl­
acrylate (Histoacryl [TissueSeal]) is also used to secure
the edges of the grafts to the face. We have also begun
to use a dressing that can be applied to the face under
tension and secured in the hairline—Mepitel Ag (Möln­
lycke Health Care). This is a silicone-based product that
can be placed on the face with holes cut out for the eyes,
nostrils, and mouth, then secured under slight tension
to reduce the likelihood of hematomas and other fluid
collections beneath the sheet grafts while allowing the
patient to see, breath, and speak. Other problems dis­
cussed include “pie crusting” of the grafts to the face,
which can leave unsightly scars. We choose to place the
grafts onto the face as sheets and then, if needed, pass
a small needle attached to a 1-mL syringe to aspirate
any hematomas that collect. Rolling of the grafts needs
to be done by an experienced hand, because it requires
the individual to prevent additional sheering forces to
the graft suspended by the hematoma.
The need to avoid full-thickness excisions, exces­
sively thick graft harvest from the scalp, and off-loading
of the scalp (especially the occiput) to reduce alopecia
is important. We would normally attend to any burn
wound alopecia during the reconstructive phase with
tissue expansion, serial excision, rotation scalp flaps, or
hair transplants depending on the distribution (type I–
IV) as set out by McCauley et al.2
One of the most important areas of facial burn man­
agement is that of eye preservation, which can be threat­
ened by ectropion, most commonly of the lower eyelid.
The chapter emphasizes the need for early tarsorrha­
phy and possible lateral canthopexy suspended from the
periosteum at the level of the upper limbus. We would
reinforce this and also suggest the use of full-thickness
grafts to the released lower eyelid wherever there is a
case of early ectropion. The upper eyelid may be resur­
faced with a thick split-thickness graft (0.012 inches
thick) in such cases. Medial and occasionally lateral can­
thoplasty is also sometimes required—most often using
a jumping-man–style flap release of the webbing in such
cases—although this is usually required at a later stage
than the first few weeks.
The unfortunately common problem of microsto­
mia after burns involving the face is always a concern.
The use of mouth spreaders supplied by an occupa­
tional therapist has attenuated the need for early sur­
gery. However, we often find that a commissuroplasty
using a Y-V flap rearrangement is required, taking care
not to disrupt the modiolus but also ensuring a three-
layer separation of tissues (skin, muscle, and mucosa)
to allow the mucosal surface to move into the wound
bed (Fig. 69D.3).
Neck contractures, along with axillary contractures,
are one of the most common and demanding deformi­
ties after burn injury. We agree that the use of post­
operative splinting, physical therapy, and three-quarter
mattresses to allow full neck extension all play into the
prevention of neck contractures. However, for contrac­
tures that are resistant to these measures, early release
and grafting certainly aids in the rehabilitation of the
lower face and aids in airway management. A release
can be done at the junction of the chin and neck sub­
units; however, we have found that a release at the level
of the hyoid bone allows the more cranial side of the
wound to edge up toward the cervicomental angle. If a
release is centered over the lower mandible, then once
released this can rise up onto the face, leading to a del­
eterious scar on the lower face. A simple incisional re­
lease through scar tissue and platysma covered with a
split skin graft may be all that is required. In those with
severe contractures spanning the entire anterior (and
occasionally lateral) neck, an alternative approach us­
ing a bilaminate dressing (Integra dermal regeneration
template) subsequently covered with a thin split-thick­
ness skin graft helps to prevent recontracture. In these
patients we often use negative-pressure wound therapy
to assist in splinting the Integra to the neck beneath a
hard collar (Fig. 69D.4).
Regarding the facial subunits, in particular the fore­
head and eyelids, the use of grafts from the upper arm
and supraclavicular area, respectively, are encouraged,
especially if a full-thickness graft is to be harvested for
lower eyelid ectropion. For scalp defects we also use ex­
ternal tissue expansion devices for small areas of de­
nuded skull and would also advocate the use of grafts
onto healthy periosteum. When large areas are involved,
burring of the outer table is carried out to reveal the dip­
loe onto which a split skin graft is placed or Integra is
used to improve overall cosmesis in this area. Tissue ex­
pansion always remains in the realm of the reconstruc­

1357
Chapter 69 Facial Burns
Fig. 69D.4 (a) A hypertrophic burn scar of the neck causing significant flexion contracture. (b) After excision of the scar tissue and
resurfacing with Integra Thin dermal regeneration matrix and a split skin graft.
a
b
Fig. 69D.3 (a) Initial markings for oral commissuroplasty. (b) Three-layer release indicating scar tissue. (c) Three-layer release in­
dicating the orbicularis oris muscle. (d) Three-layer release indicating the underside of the oral mucosa. (e) Final position of the
mucosa, advanced without tension.
a
b
c
d
e

SECTION IX BURNS
1358
tive phase rather than the acute phase. Occipital grafts
for eyebrow reconstruction can be either strip grafts or
microfollicular hair transplant techniques.
For nasal reconstruction related to burn scarring, an
often overlooked option is a Tagliacozzi flap from the up­
per arm. If unburned, this flap can make for a very pleas­
ing reconstruction without the need for microsurgery.
For lip reconstruction, we recommend releasing and
grafting where wet mucosa is exposed and emphasize
the use of full-thickness grafts to stabilize these areas
and prevent further contracture. In our institute, the use
of the facial artery myomucosal (FAMM) flap is reserved
for electrical injuries that have caused severe damage
to the commissure—thankfully a rare event. We have
extensive experience of commissuroplasty using an ap­
proach that releases all three layers to allow the mucosa
to advance into the recipient bed of the Y-V flap. The use
of transitional epithelium from the anal verge as a graft
is novel, but we have no experience of this. However, it
likely is no less invasive than a FAMM flap. Managing the
hyperpigmentation of the graft with phenol peels also
seems quite invasive in the pediatric population. If mu­
cosa is missing from the lower lip we simply carry out a
V-Y advancement of the wet mucosa.
There are many methods to increase the likelihood
of successful transposition of a local flap, whether by a
z-plasty (two double-opposing local transposition flaps)
or a scar release and single local transposition flap. We
would emphasize the need to take thicker flaps, with
underlying fascia if larger flaps are required. The leading
edge of the flap can be secured to its underlying fascia
before transfer to increase the blood supply. The chapter
discusses both external tissue expansion and the more
traditional subgaleal tissue expander techniques. We
would add that in some cases more than one expander
can be used, and they may need to be used more than
once in each place, thereby expanding each donor site
more than once with a gap of between 6 months and 1
year between episodes of expansion.
One of the most exciting changes in recent years in
the treatment of burn scars is the advent of laser ther­
apy. We have extensive experience in the use of a frac­
tional carbon dioxide laser, collimated carbon dioxide
laser, pulsed-dye laser (PDL), and most recently on the
new M22 platform the use of filtered intense pulsed
light (IPL) and neodymium-doped: yttrium aluminum
garnet (Nd:YAG) lasers. We had been using PDL therapy
primarily for its ability to reduce burn scar pruritus, a
difficult problem to treat in children. The results have
been encouraging, with the reduction in mast cell num­
bers as primary evidence for a link between therapy and
the results we see. We have recently transitioned to the
use of the M22 laser by Lumenis; the reasons for this
are myriad but can be boiled down to two simple ad­
ditional benefits: We can now target telangiectasia us­
ing the Nd:YAG handpiece, which can further starve the
scar of the vascular network, and the handpiece for the
M22 covers a much larger area, allowing delivery (with
the cooled handpiece) of fluencies of 15 to 17 J/cm2 for
a handpiece that is 15 by 35 mm (covering an area in
a shorter time than the traditional 10-mm handpiece
of the PDL). We can also change the filter to further at­
tenuate depth of penetration. We have seen significant
improvements with this new technology over and above
that achievable with the PDL alone.
When using the fractional carbon dioxide laser, we
would normally use SCAAR FX (Lumenis) at these lev­
els of settings without overlap at a frequency of 250 Hz
(60 to 100 mJ, size 10, 3% density). If there is no need
for ActiveFX (Lumenis) for attenuation of any hyperpig­
mentation then we can increase the energy density to
5% without any wound complications. The DeepFX (Lu­
menis) is only used up to 20 mJ with a density of 10%
and a frequency of 600 Hz. The amount of energy ap­
plied varies as the laser passes over thicker and thinner
areas of scarring. This allows the patient to gain a flat­
ter, more homogenous scar sooner rather than changing
the whole scar to the same degree. We follow a rather
strict postoperative protocol in which the patient uses
chlorhexidine wash twice per day and applies an emol­
lient (such as Hydrophor) five times per day for 2 weeks.
The patient then needs to apply sunscreen with a sun
protectant factor of at least 50 SPF twice per day for a
year to reduce postinflammatory hyperpigmentation
(PIH). If PIH occurs despite use of adequate amounts of
sunscreen, then after the subsequent laser treatment we
prescribe azelaic acid gel 15% to be applied morning and
evening for 3 months. This relies on the action of a tyro­
sine kinase inhibitor in the gel that reduces the produc­
tion of melanin. We do not use any postoperative topical
antibiotic ointments.
For patients undergoing PDL or M22 laser therapy,
aloe vera is prescribed to be applied every 20 minutes
for a day or two. Because of the possibility of making
some scars worse with overaggressive laser treatment,
I would like to point out one area in particular that is
tricky to treat—bridging scars between the breasts.
These need to be treated very carefully, because it is
very easy to make the situation worse by being overag­
gressive with the carbon dioxide laser. Alternating treat­
ments with PDL or M22 and the carbon dioxide laser can
help to attenuate these particular scars that are prone
to difficulty.
The perioperative consideration for laser therapy
needs to be made known to each patient. The presence
of purpura after PDL should not be viewed as a compli­

1359
Chapter 69 Facial Burns
cation; neither should serosanguinous drainage from a
scar treated with fractional carbon dioxide; rather these
are end points that need to be seen initially to ensure
that the patient will achieve benefit from the therapy.
We also use the True Spot collimated handpiece (El­
lex Medical) for troublesome seams between sheets of
skin graft. The ablative action allows the surgeon to burr
down these areas to reveal a smoother final outcome.
Conclusion
In general, a patient does not really care how the sur­
geon achieves the best result. Surgeons should be
aware of the different available modalities, whether
traditional (forehead flap) or novel (laser therapy), and
be able to apply them in a manner fitting for the indi­
vidual patient’s situation.
References
1. Gillies HD, Millard DR. The Principles and Art of Plastic
Surgery. Oxford: Butterworth; 1958
2. McCauley RL, Oliphant JR, Robson MC. Tissue expansion
in the correction of burn alopecia: classification and
methods of correction. Ann Plast Surg 1990;25(2):103–
115

1360
CHAPTER
70
Unfavorable scar maturation is an anticipated and chal­
lenging outcome after acute burn management. The goal
of acute burn care is to minimize the need for secondary
reconstruction. However, secondary burn reconstruction
is often necessary to return a patient to a state of optimal
function while maximizing the aesthetic appearance. The
goal of this chapter is to discuss the most common deformi­
ties that result from acute management of burn injury and
their treatment (Fig. 70.1).
Avoiding Unfavorable Results
and Complications in Burn
Management
Summary Box
Common Postburn Deformities
•• Scar contracture
•• Hypertrophic and keloid scars
•• Scar hypopigmentation and hyperpigmentation
•• Unfavorable scar contour
•• Scar-associated pruritus and pain
•• Heterotopic ossification
•• Alopecia
Patient Selection and Timing
of Postburn Scar Reconstruction
Reconstruction of burn scars should be delayed beyond 12
to 24 months after acute injury unless they interfere with
activities of daily living (ADLs). This time will allow for full
maturation of the scar tissue and optimization of nonsurgi­
cal treatments. Hyperemic, indurated, and immature scars
during the inflammatory phase of healing are technically
challenging to manipulate because of their immobility and

Burns of the Body and Extremities
Shannon L. Wong, Alyson A. Melin, and Debra A. Reilly
Fig. 70.1 After a scalding injury this 7-year-old had severe keloid
formation in areas of split-thickness skin grafts, healed burn, and
donor sites. Her brother was also injured in the same bathtub scald
and experienced severe keloid formation.

1361
Chapter 70 Burns of the Body and Extremities
Fat Grafting
We have used autologous fat injection after scar maturation
with great success to decrease the symptoms of pruritus
and scar-associated pain (Fig. 70.2). Fat grafting under a
mature thermal burn scar has not been associated with any
necrosis of the overlying skin in our patients, and pain and
pruritus resolved in all treated patients who had a follow-
up visit in the early postoperative period.
Laser Therapy
Laser therapy has been shown to be successful in the re­
duction of hyperemia and edema and to accelerate the
maturation of burn scars, thereby reportedly decreasing
pain and the thickness of the scar. A pulsed-dye laser with
a wavelength of 595 nm reduces hyperemia and edema of
the scar, whereas a fractional CO2 laser with a wavelength
of 10,600nm is used to correct the stiffness and texture
abnormalities of thicker scars. Laser treatment of scar de­
formities should be delayed beyond 6 months after injury,
and several treatments spaced 4 to 6 weeks apart are nec­
essary.1 Laser therapy is especially useful for small areas of
scar and in the management of older scars.
Management of Complications
Related to Burns of the Body
and Extremities
Management of Burn Scar
Contractures
Scar contractures are common postburn deformities char­
acterized by a thickened and shortened scar that can in­
volve the skin alone or the underlying muscle and joint
space. Contractures can lead to debilitating and perma­
lack of tensile strength. Furthermore, operating on a scar
during this immature phase of healing can lead to a height­
ened and recurrent inflammatory state and overall worsen­
ing of the scar.
Although it is ideal to allow the scar to mature before
reconstruction, there are certain instances in which more
prompt intervention is required. This includes deformities
resulting in severe functional limitations required for daily
living, unstable scars leading to open wounds, exposure of
vital structures, and growth and development disturbances.
It is imperative to perform a detailed examination and
take a complete inventory of the patient’s injuries to priori­
tize treatment options by first maximizing function and sec­
ond improving aesthetic outcome. It is also paramount that
the patient’s goals for reconstruction align with that of the
surgeon and that the patient be committed to the postop­
erative rehabilitation process to optimize the reconstructive
results. Offering a patient an aesthetic reconstruction in con­
junction with a needed functional revision may help ame­
liorate the patient’s postoperative state of stress and help
the patient to better cope with issues such as chronic pain.
General Reconstructive Principles for
Management of Postburn Deformities
Scar Excision
Primary excision, rather than serial excision, and primary
closure is the optimal treatment of scar deformities that do
not cause great functional impairment. Scar excision and
primary closure are reserved for areas of greater skin laxity
and tissue excess, and incisions should be placed parallel to
relaxed skin tension lines. Scar excision can also be com­
bined with local tissue rearrangement and skin grafting
when primary closure is not feasible. Where larger surface
areas are planned for resection, staged tissue expansion
and scar excision may be the best option.
a
b
Fig. 70.2 (a) This 14-year-old female pediatric patient had a 40% flame burn 10 years prior that was treated with Integra bilateral dermal
regeneration template and a split-thickness skin graft. Fat grafting using the thigh as a donor site was used to improve the pruritic scar, and
a split-thickness skin graft was used to reconstruct ulcerations that formed from picking. (b) Follow-up of the healed graft with resolved
pruritus.

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1362
Skin Grafting
Skin grafting is the most common approach to reconstruc­
tion of a contracture release. It has the advantage of pro­
viding skin from uninjured areas of the body, rather than
­compromising fragile tissue immediately adjacent to the
burn. The choice between split-thickness and full-thickness
skin grafts depends on numerous factors. Full-thickness
skin grafts increase the success of contracture release, be­
cause they contain more dermis and undergo less second­
ary contraction compared with split-thickness skin grafts.
They are more pliable and durable and may also result in
improved appearance by providing better texture and color
match to the adjacent tissue. However, full-thickness skin
grafts have decreased graft take and survival compared
with split-thickness skin grafts and are limited in size by
the availability of donor skin. Full-thickness skin grafts are
usually reserved for reconstruction of scars of the face and
hands and over joint surfaces.2,3
Skin grafts can also be used to reconstruct areas of hy­
popigmentation, replacing sheet grafts containing melano­
cytes over areas of hypopigmented scar.
Split-thickness skin grafts are generally harvested over
a thickness of 0.012 to 0.020 inch. Not only is graft sur­
vival increased with the use of thinner split-thickness skin
grafts, the donor site can be harvested several times once
reepithelialized. This is useful for a larger percentage to­
tal body surface area burn, but the quality of subsequent
harvests and the intensity of repigmentation will be de­
creased. First-pass donor site harvest should be saved for
aesthetic and cosmetic areas such as the hands and face.
In contrast to full-thickness skin grafts, split-thickness
skin grafts result in a greater recurrence of contractures
requiring reoperation.3 In addition, harvesting a thicker
split-thickness graft has the disadvantage of potential hy­
pertrophic scarring of the donor site, which should be dis­
cussed in advance with the patient.
After skin grafting, a pressure dressing or bolster must
be applied to optimize the take of the graft. We prefer a fi­
brin sealant to adhere the skin graft to the recipient site and
nent deformities that affect the quality of life of a burn
patient from both a functional and aesthetic standpoint.
During acute burn wound management, the thickness of
the skin graft should be tailored to the areas most prone
to contracture, such as the hand and antecubital fossa. Ju­
dicious use of thicker skin grafts and postoperative splint­
ing will minimize contraction. In addition, grafts can be
inset in z-plasty fashion (e.g., web space grafts) to prevent
straight-line graft margins that tend to contract with mat­
uration.
Scar Contracture Release
The first goal of burn contracture reconstruction is to re­
lease the contracture. This is performed by several z-plasty
variations, or by making a linear incision perpendicular to
the contracture band in question at the point of maximal
tension. For z-plasty techniques, normal skin becomes in­
terpolated with scarred skin to break up the scar band and
facilitate stretch. For incisional releases the entire thickness
of the scar is incised and sometimes excised. If the contrac­
ture is over a joint surface, stepwise release of the skin fol­
lowed by the underlying fascia and musculature and finally
the joint space may be necessary. The addition of fish tails
at the end of the linear incision will change the shape of the
resultant defect from an ellipse (Fig. 70.3a) to a rectangle
(Fig. 70.3b), increasing the area of release and thereby leav­
ing a larger defect for reconstruction. Multiple incisions
along the scar contracture may be necessary depending on
the anatomic location of the scar and the amount of release
required. The intervening bipedicled flap that results from
making adjacent lineal incisions should not be elevated to
optimize the blood supply. The ultimate size of the result­
ing defect is difficult to predict, and this should be taken
into consideration during preoperative planning because
reconstructive options become limited as the size of the
defect increases. Full-thickness grafts or layered grafts of
dermal construct with split-thickness skin graft overlay are
preferred (see Fig. 70.3).
a
b
Fig. 70.3 (a) Linear contracture release. (b) Contracture release with addition of fish tails.

1363
Chapter 70 Burns of the Body and Extremities
with markedly less pain and pruritus have been reported. In
addition, in the case of exposed bone after acute débride­
ment, these staged procedures can preempt the need for a
flap reconstruction.
For a mature burn scar, these same products can be
used to mimic a full-thickness skin graft using commercially
available dermal templates and thinner autografts. The re­
sulting suppleness of the scars is especially gratifying, be­
cause the donor site morbidity is often less than in the acute
phase of grafting (because of the thinness [0.004 to 0.008
inches] of the harvest).
Local, Regional, and Free Flaps
Flaps provide specific advantages and options when used
in postburn deformity reconstruction, particularly when
compared with grafting. Flaps maintain their blood supply,
provide more uniformity of matched skin quality, and can
replace significant tissue deficits. Using healthy tissue al­
lows the potential for growth and expansion of the healthy
flap tissue to counter the opposing tension of the scar, thus
reducing the risk of recurrent contracture.
Even in locally scarred skin where blood flow to the der­
mis is affected, local flaps may still be used if healthy, per­
fused underlying subcutaneous tissue is incorporated. Linear
contractures are often addressed by z-plasty. This transposi­
tion flap lengthens a scar along the common limb. Derivations
using larger angles will afford greater acquisition of length.
These local flaps can also be used to reapproximate displaced
structures and advance scars to more conspicuous locations.
use a negative pressure dressing for 5 to 7 days postopera­
tively when applicable (Video 70.1).
Dermal Regeneration Template
Dermal regeneration templates such as those made by In­
tegra are versatile tools in the reconstruction of scar con­
tractures. Integra is a bilaminar structure. The first layer
is made of cross-linked bovine collagen and chondroitin-
6-sulfate, followed by an outer silicone layer. This can be
advantageous in contracture reconstruction because it
provides immediate coverage of large wounds without
contributing to any donor site morbidity (Fig. 70.4). Once
the defect is created, the silicone outer layer of Integra
is left in place for several weeks to allow for dermal re­
generation. This time also allows for regeneration of skin
graft donor sites. After removal of the silicone layer, a thin
epidermal autograft is secured to the wound. The use of
this product promotes rapid dermal regeneration and
can provide a cosmetic outcome and scar quality simi­
lar to that of a full-thickness skin graft (Fig. 70.5). This
has been shown to provide a durable reconstruction with
minimal contracture recurrence.4,5 Similar dermal con­
structs donated from both humans and animals are now
available for similar staged reconstructive procedures.
These can be especially useful when an unstable scar or
a scar release exposes underlying nonvascular structures
(Fig. 70.6).
The use of staged dermal regeneration templates is also
useful in the acute burn setting. Reports of more elastic scars
a
b
Fig. 70.4 (a) Staged closure with Integra dermal regeneration templates of full-thickness flame burns to the back of 4-year-old boy.
(b) After 4 years, he has no limitations to growth or flexibility.

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1364
V-Y advancement flaps use lateral tissue to lengthen the
scar. One must be cautious using these in burn reconstruc­
tion, because there can be significant tension once the ver­
tical limb of the Y is closed.
Regional flaps have a robust, dependable blood supply
that does not abide by the length-to-width ratios dictated
for the random flaps previously discussed. Fasciocutaneous
Often we use successive, smaller z-plasties to achieve ade­
quate lengthening of a scar without causing transverse short­
ening. Variations of the traditional z-plasty can be useful if
working in a concave defect (four-flap z-plasty), or lengths
of limbs can be adjusted, particularly if some surrounding
tissue is mobile but some is involved in dense scar (three-
quarter z-plasty).
a
b
Fig. 70.6 (a) A 5-year-old girl with full-thickness scald burns to both thighs. Integra dermal regeneration templates were applied to the
left thigh, and bovine dermis (PriMatrix [Integra]) was used for the right thigh. (b) Similar healing times and scar characteristics result from
both dermal templates after split-thickness skin grafting.
a
b
Fig. 70.5 (a) Fourth-degree flame burns of the scalp of the same child as in Fig. 70.4. (b) Result after use of Integra bilayer dermal regen­
eration templates and repeat split-thickness skin grafts to the central scalp over an exposed outer table of the skull.