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123
Viktor M. Grishkevich
Max Grishkevich
Plastic and
Reconstructive Surgery
of Burns
An Atlas of New Techniques
and Strategies
s

Plastic and Reconstructive Surgery of Burns

Viktor M. Grishkevich • Max Grishkevich
Plastic and Reconstructive
Surgery of Burns
An Atlas of New Techniques and Strategies

Viktor M. Grishkevich, MD
Happy Valley, OR
USA
Max Grishkevich, MD
VIP MediSpa
Clackamas, OR
USA
ISBN 978-3-319-78713-8 ISBN 978-3-319-78714-5 (eBook)

Library of Congress Control Number: 2018941866
© Springer International Publishing AG, part of Springer Nature 2018
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
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Printed on acid-free paper
This Springer imprint is published by the registered company Springer International Publishing AG, part of Springer
Nature.
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

v
For I neither received it from man, nor was I taught it,
but I received it through a revelation of Jesus Christ.
(Galatians 1:12)
In the early 1970s, the first ever 55-bed inpatient Department of Plastic and Reconstructive
Surgery opened in the A. V. Vishnevsky Institute of Surgery at the Russian Academy of Science
in Moscow, Russia. Being a main referral burn center in Russia, we had an opportunity to oper-
ate on thousands of burn patients and we came to the conclusion that more research was needed
to develop more effective surgical techniques, especially for severely burned patients. Over the
years, we studied the anatomical features of patients with burn complications and developed
multiple advanced surgical methods to treat scar deformities of skin and soft tissues, especially
postburn contractures of joints and other body areas.
With divine help and revelations from the Creator, the anatomical structure of scar contrac-
tures was successfully studied, which led to the development of new methods for the surgical
treatment of burns that significantly improved outcomes for the surgical rehabilitation of
burned patients.
Some of the most significant results of this research include:
• A direct anatomical cause of contractures was established: for most patients, it is a scar
surface deficit of a trapezoid shape. This determines the trapezoid shape of the flap neces-
sary to compensate for the surface deficit.
• Research of the anatomy of the contractures led to a new classification of all contractures:
Edge, medial, and total contractures, independent of their location and severity.
• Based on the anatomical research, a more effective trapezoid-flap plasty surgical method
was developed, which yields superior results for edge- and medial-type contractures (85%
of all the contractures seen in clinical settings).
• New methods of surgical treatments of face and neck deformities were developed due to the
identification of axial blood supply to the skin of the neck. Various surgical techniques
using split cervico-thoracic flaps were offered for the reconstruction of burned face tissue
and contractures of the neck with great results.
• Very important work was done in restoring function of the burned hand (syndactyly, finger
contractures, tendinopathies, and arthropathies due to burns). Use of trapezoid-flap plasty
for contractures along with mechanical traction devices and tendon transplantation can
return function to many disabled patients.
• An effective new method for the reconstruction of the shape, position, and skin of the
burned breast was developed.
• We developed a new treatment method for severe adduction contractures of the shoulders
based on the use of axillary island skin or scar tissue in the form of a subcutaneous pedicle
flap in combination with skin transplantation.
• Sural flap with proximal base was developed and helped resolve the problem with ulcers
and skin defects in the Achilles tendon area.
Preface

vi
We invite you to expand your knowledge and learn new approaches to burn treatment based
on a three-dimensional understanding of tissue deficit and excess. Our extensive experience
demonstrated that most contractures can be successfully and completely eliminated without
re-contracture as long as the surface/tissue deficit is fully compensated. The first two chapters
explain the anatomy of contracture surface deficit and classification based on the location of
the scar fold and tissue surplus in relation to joint surfaces. Understanding these principles will
enable surgeons to apply recommended surgical techniques to a variety of burn contractures
regardless of location and severity.
Many of the surgical procedures described in this atlas provide detailed planning, marking,
and step-by-step surgical details, supported by pictures, schemes, and illustrations. We chal-
lenge you to step out of the comfort zone of triangular flaps and try your first Y-shaped radial
incision to see an additional 30% release of the contracture and the appearance of a trapezoid
wound requiring a trapezoid flap. Once you perform your first successful trapezoid-flap plasty,
there will be no going back to triangular flaps for most contractures encountered in your
practice.
The authors wish success to all surgeons using surgical techniques presented in this atlas.
We want to see better outcomes and happy, thankful patients filled with gratitude to God and
to the surgeons who offered them help.
Happy Valley, OR
Viktor M. Grishkevich
Clackamas, OR
Max Grishkevich
Preface

vii
1 Postburn Scar Contracture: Formation, Anatomy and Classification�� 1
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis
for Adequate Reconstructive Techniques Development and Choice �� 15
3 Single-Stage Upper Lip and Philtrum Reconstruction in Burned Patients�� 33
4 Postburn Microstomia: Anatomy and Elimination with Trapeze-Flap Plasty�� 41
5 Elimination of Postburn Dorsal Nasal Contracture�� 47
6 Split Ascending Neck Flap in Burned Face Resurfacing�� 51
7 Burned Half-Cheek Resurfacing Techniques�� 65
8 Total Cheek Resurfacing with Split Ascending Neck Flap�� 75
9 Postburn Neck Scar Contracture Classification �� 87
10 Medial Neck and Submandibular Scar Contractures:
Anatomy and Treatment �� 93
11 Unilateral Neck Scar Contracture and Deformity Elimination
with Contralateral Split Neck Flap�� 101
12 Lateral Neck Contractures: Anatomy and Treatment �� 109
13 Total Neck Anterior Scar Contracture: Anatomy and Treatment
with Local Scar-Fascial Trapezoid Flaps�� 117
14 Lateral Truncal Medial Contractures: Anatomy and Treatment
with Local Adipose Scar Trapezoid Flaps�� 127
15 Restoration of the Shape, Location, and Skin of Severely
Burn-Damaged Breast�� 137
16 Shoulder Edge Anterior Adduction Contracture: Anatomy and Treatment
with Axillary Adipose-Cutaneous Trapezoid Flap�� 147
17 Edge Shoulder Adduction Contracture in Pediatric Patients: Anatomy
and Treatment�� 159
18 Shoulder Edge Posterior Adduction Contracture: Anatomy
and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap�� 167
19 Bilateral Shoulder Edge Adduction Scar Contractures: Anatomy
and Treatment�� 179
20 Total Shoulder Adduction Contracture Treatment
with Preserved Skin in Axilla Apex: Anatomy and Treatment�� 189
Contents

viii
21 Shoulder Medial Adduction Contracture: Anatomy and Treatment
with Local Adipose Scar Trapezoid Flaps�� 197
22 Shoulder Total Adduction Contracture After Burns: Anatomy
and Treatment with Quadrangular Local Subcutaneous Pedicle Flap�� 205
23 Elbow Edge Flexion Contracture: Anatomy and Treatment
with Local Trapezoid Flaps�� 213
24 The Postburn Elbow Medial Flexion Scar Contracture Treatment
with Trapeze-Flap Plasty�� 223
25 Total Elbow Flexion Contracture Treatment�� 231
26 Wrist Scar Contracture, Hand Deviation: Anatomy and
Treatment with Trapeze-Flap Plasty�� 235
27 First Web Space Postburn Scar Contractures: Anatomy
and Elimination with Local Trapezoid Flaps�� 243
28 Postburn Dorsal and Palmar Interdigital Scar Contractures:
Anatomy and Treatment �� 259
29 Postburn Flexion Contractures of Fingers: Anatomy and Treatment
with Trapeze-Flap Plasty�� 269
30 Surgical Treatment of Postburn Boutonniere Deformity �� 287
31 Burned Perineum: Anatomy of Medial Contracture and Reconstruction
with Trapezoid Adipose-Scar Flaps�� 297
32 Postburn Perineum Obliteration: Elimination of Perineal,
Inguinal, and Perianal Contractures with the Groin Flap�� 303
33 Knee Edge Scar Flexion Contractures: Anatomy and Treatment�� 307
34 Knee Medial Scar Flexion Contractures After Burns: Anatomy
and Treatment�� 317
35 Total Knee Flexion Contracture After Burns: Anatomy and Treatment�� 325
36 Ankle Edge Dorsiflexion Scar Contractures: Anatomy and Treatment
with Trapeze-Flap Plasty�� 329
37 Medial Ankle Dorsiflexion Contractures and Techniques
for Their Treatment �� 339
38 Total Ankle Contracture: Anatomy and Treatment�� 347
39 Proximally-Based Sural Adipose-Cutaneous/Scar Flap in
Elimination of Ulcerous Scar Soft Tissue Defect Over the Achilles
Tendon and Posterior Heel Region�� 353
40 Inguinal Scar Contractures: Anatomy and Treatment�� 363
Index�� 371
Contents

1
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Postburn Scar Contracture: Formation,
Anatomy and Classification
Introduction
Despite significant achievements in burns treatment, the
number of scar contractures is high [1]. Among three burn
consequences—scar deformity, contracture, and tissue
defect—contractures most often lead to disability. Therefore,
efficient treatment of scar contractures is of primary impor-
tance in the surgical rehabilitation of burned patients.
Treating burn scar contractures remains a challenging prob-
lem for reconstructive surgeons, and no definitive conclu-
sions have been reached about the effectiveness of different
techniques [2].
“According to the World Health Organization (WHO)
burns are a huge global health problem resulting in death
and devastation to those who survive large burns as they are
faced with significant functional limitations that prevent
purposeful and productive living” [3]. For many years, the
classic approach to contracture treatment used triangular
local-flap techniques and skin transplantation. Existing
anatomical contracture names or classifications (linear,
wide, wide linear, web straight linear, narrow, long, qua-
dratic, cordlike) do not characterize the contracture anat-
omy that is the basis for successful surgical treatment. The
techniques based on skin grafting and triangular flaps have
known disadvantages; therefore, rehabilitation of burned
patients with contractures is far from perfect. Our observa-
tions show that the absence of progress in scar contracture
treatment with local triangular flaps is caused mainly by
insufficient study of contracture formation, contracture
anatomy, scar surface deficit (contracture cause), and the
lack of anatomical classification of scar contractures. Our
classification, based on the anatomy of thousands of clini-
cal observations, divides all scar contractures into three
types: edge, medial, and total [4, 5].
Functional Zones of Joint Surfaces
In the plane of surgical treatment, a joint’s surface is divided
into flexion (F) and extension (E) surfaces; the boundary
among them passes along the joint rotation axis level (“+”
symbol) (Figs. 1.1, 1.2, 1.3, 1.4, 1.5, and 1.6). The flexion sur-
face (F) of large joints (axilla, elbow, knee, ankle, and first
interdigital space) has a curvature of nearly 90°, which divides
it into two parts: flexion lateral (FL) and flexion medial (FM).
The dividing line passes along the edges of joint fossa, ankle
anterior surface, and first web space fossa or between the flex-
ion lateral and medial surfaces. The flexion lateral surface of
the large joints (one or both joint sides) spreads from the edge
of the joint fossa to the joint rotation axis level. The scars,
forming the edge commissural contractures (syndactyly,
microstomia), spread from the fold crest on the dorsal and pal-
mar hand to the metacarpophalangeal joints or from the cheek
to the normal level of the mouth orifice angle location. Medial
flexion surface covers the fossa of large joint, interdigital
fossa, ankle anterior, and neck anterior and lateral surfaces.
All flexion rounded surfaces of the small (interphalan-
geal) joints, neck, trunk, and perineum are considered as one
flexion/adduction surface. Scars located on joint flexion sur-
faces (lateral and medial) cause the corresponding flexion
contracture: edge or medial. Scars located on the joint exten-
sion surface (beyond joint rotation axis level), do not partici-
pate in the flexion contracture formation. The flexion surfaces
of the small (interphalangeal) joints, neck, lateral trunk, and
perineum are considered as one flexion medial surface. Scars
located on joint flexion lateral surfaces cause “edge” con-
tracture. Contracted scars covering flexion medial surfaces
form “medial” contracture. Scars that stretch through flexion
lateral (FL) and flexion medial (FL) surfaces cause “total”
contracture. And scars located on the joint extension(E)
1

2
surface (beyond joint rotation axis level) do not contribute to
flexion contracture formation. Scars covering the joint flex-
ion lateral or medial surface and causing contractures are
strongly connected to undamaged neighboring surfaces—
flexion and extension surfaces.
Fig. 1.1 Functional zones of big joint surface and shoulder edge con-
tracture. E extension surface above the shoulder joint rotation axis
(“+”); F joint flexion surface, which is divided by surface curvature into
flexion lateral (FL) and flexion medial (FM); the flexion lateral surface
is scars, the medial flexion surface (joint fossa) is healthy skin; scars
formed the fold (Fd) along the edge of joint fossa; the crest of the fold
(Cr) is the edge of scars; Y-line—the distance from the fold’s crest to
the joint rotation axis or joint FL surface
a
b
Fig. 1.2 Edge joint flexion contracture formation. (a) Scars on the
joint anterior lateral flexion surface and neighbor zones spread down-
ward (distally), involving healthy skin of flexion medial surface (FM)
and form the fold (Fd) located along anterior joint fossa edge, among
the flexion lateral and flexion medial surface. (b) The flexion medial
surface of the joint is undamaged (FM); therefore, the fold’s sheets have
a different quality: the lateral surface comprises scars and is the cause
of the contracture; the medial sheet and the flexion medial surface are
healthy skin (FM). The scar has a surface deficit in length from the fold
crest to the joint rotation axis (“+”) and is the cause of the contracture,
and both sheets have a surface surplus; the fold sheets are used for scar
surface deficit compensation and contracture elimination
1 Postburn Scar Contracture: Formation, Anatomy and Classification

3
a
b
Fig. 1.3 Joint medial flexion/adduction contracture formation. (a, b)
Shoulder joint medial adduction contracture, anterior and posterior
view; scars covered flexion medial surface (FM), displaced down (dis-
tally) and forming a fold that approached the shoulder to chest wall
(scar surface deficit in length) and caused the joint contracture; flexion
lateral surface (FL) and extended surface (E) does not participate in
contracture formation. The fold crest lies along fossa medial line; there-
fore, both fold sheets are scars, have a surface deficit in length (contrac-
ture cause) and surface surplus in width (from flexion lateral surface
[fossa’s edges] to the fold crest [Cr]), which allows contracture treat-
ment with local flaps
Fig. 1.4 Total shoulder joint flexion/adduction contracture formation.
Contracted scars covered the shoulder joint’s flexion lateral and flexion
medial surfaces and connected the shoulder with the chest wall
Functional Zones of Joint Surfaces

4
a
d
b
c
e
Fig. 1.5 (a) Edge shoulder adduction contracture: joint functional
zones and anatomy. (b) Elbow edge flexion scar contracture. (c) Wrist
and elbow edge scar flexion scar contractures. (d) First web space edge
adduction contracture. (e) Dorsal syndactyly-interdigital edge commis-
sural scar contractures. (f) Inguinal edge contracture. (g) Edge knee
contracture. (h) Edge ankle flexion contracture. (i) Lateral neck edge
contracture. (j) Scar microstomia anatomy
1 Postburn Scar Contracture: Formation, Anatomy and Classification

5
e
f
g
h
Fig. 1.5 (continued)
Functional Zones of Joint Surfaces

6
i
j
Fig. 1.5 (continued)
1 Postburn Scar Contracture: Formation, Anatomy and Classification

7
Edge Contracture Formation
Burns and scars that cover a joint’s flexion lateral surface
(FL) spread on lateral surfaces of anatomical segments,
forming the joint and lateral commissural surface (dorsal and
palmar hand and cheek). During wound healing, scars’ con-
nective tissue contracts and spreads distally, approaching the
neighboring segment (Fig. 1.2). Growing distally, scars
involve the healthy skin of the flexion medial surface. As a
result, the crescent fold is formed along the joint fossa’s edge
or among the joint’s flexion lateral and flexion medial sur-
faces. After burns to the neck’s posterior surface, the fold is
formed along the lateral neck; cheek burns are complicated
by the fold formation in the oral angle. Scar protrusion
increases with time, drawing-in neighboring healthy skin.
The resulting crescent fold consists of two sheets of different
quality: the lateral sheet is scars, and the medial sheet is
healthy skin; scars spread in the direction of the undamaged
joint’s fossa or flexion medial surface and commissural
fossa. Thus, the varied qualities of the fold’s sheets are a
most important anatomical and clinical feature of edge con-
tracture. The crest of the fold is the scar’s edge. Contracted
scars located on the flexion lateral (FL) surface and the scars
of the lateral fold’s sheet (continuation scars of FL surface)
have a surface deficit in length, which causes contracture,
but both sheets are new anatomical structures and have skin
and scar surface surplus, allowing contracture elimination
with local tissues.
Medial Contracture Formation
Burns of the large joints’ fossa or flexion medial surface
(FM), ankle anterior surface, finger flexion surfaces, com-
missural fossa, lateral neck and truncal surfaces, and
perineum are complicated with growth-contracted scars,
which approach the neighboring segment of joints and com-
missure and cause medial contracture (Fig. 1.3). Attempts to
keep the joint extended elevate scars above the flexion medial
surface of the joint and neighboring segments, forming a
fold. Maximal scar protrusion or crest of the fold passes
along the central line of the flexion medial surface of big
joints; the lateral neck surface (Fig. 1.3b); the finger flexion
surface (Fig. 1.5e); and the lateral truncal surface (Fig. 1.5i).
Since scar tension is maximal in the center of the medial
flexion zone, both sheets of the fold are scars and are of
equal quality. Scar sheets have a surface deficit in length,
which causes a contracture, and scar surplus in width, which
allows contracture elimination with local flaps. Flexion lat-
eral surface (FL) of the large joint can be undamaged or cov-
ered with scars that do not participate in the contracture
formation. All flexion surfaces of small joints (Fig. 1.5e) and
the lateral surface of the trunk (Fig. 1.5i) are totally covered
with contracted scars, which are elevated above the finger
flexion surface and lateral trunk. As a result, the fold is
formed, both sheets of which are scars in which there is a
scar surface deficit in length, which causes contracture and a
scar surface surplus in width, which allows contracture
release with local flaps alone or in combination with skin
transplants.
Functional Zones of Joint Surfaces

8
Total Contracture Formation
The scar contracture formation shows that there are only
three ways in which scar contractures can develop (Fig. 1.4).
These ways are defined by the scars’ locations, by the pres-
ence or absence of the fold, by the location of the fold on the
flexion surface, and by the quality of the fold’s sheets. The
scar surface surplus in the fold’s sheets allows contracture
treatment with local tissue. Deep and vast burns injuring the
joint’s flexion (and extension) surfaces result in scar forma-
tion, tightly surrounding the joint without a fold. A severe
scar surface deficit forms a total contracture, excluding any
possibility of a local-flap technique application.
Edge Postburn Scar Contracture Anatomy
and Clinical Signs
Edge contractures (Fig. 1.4) make up 60% of the total num-
ber of contractures (authors’ statistics). They are caused by:
(a) Burns and scars covering the flexion lateral surface (FL)
of the large joints from the fold crest to the joint rotation
axis, commissure, posterior neck, dorsal or palmar hand,
or lateral surface of ankle joint.
(b) Contracted scars form a crescent fold along the joint
fossa’s edge, ankle anterior, and lateral neck surface and
commissural edge.
(c) The fold consists of the two different quality sheets;
scars are lateral sheet (according to joint fossa or joint’s
flexion medial surface), commissure, neck posterior sur-
face, or ankle anterior surface. The medial sheet and
neighboring surface of the joint’s fossa, and the surfaces
of anterior and lateral neck and inner commissure,
remain undamaged.
(d) The crest of the fold is the edge of scars.
These four anatomical features determined the name for
this type: Edge. The medial sheet and adjacent joint fossa,
the ankle and neck anterior surface, the inner commissural
angle and cheek, are healthy skin, and serve as donor sites.
A fold’s length and its protrusion differ from case to case,
depending on the contracture’s location and severity, and
can cause the contracture of neighboring joints. Only the
scar sheet causes contracture and neighboring contracted
scars in which there is a surface deficit in length. In both
sheets, there is a scar surface surplus in width sufficient for
scar surface deficit compensation without skin grafts, pedi-
cle, and free flaps.
1 Postburn Scar Contracture: Formation, Anatomy and Classification

9
Similar Anatomy of Edge Scar Contractures
of the Joints, Commissures, Neck,
and Inguinal
For common signs of functional zones and anatomy of edge
contractures, see Fig. 1.5. Definition of symbol and
abbreviations:
E—Joint extension surface
“+”—Joint rotation axis
FL—Flexion lateral surface and lateral sheet of the fold
(FD, Fd, Fold) are scars and edge contracture causes
FM—Flexion medial surface (fossa) and medial fold
sheet (Fd) are healthy skin
FD, Fd—Fold is surface surplus, the lateral sheet is scars,
part of flexion lateral surface; medial sheet of the fold and
fossa are healthy skin (donor site)
Cr—Crest of the fold, the edge of the scar.
Anatomical Features and Clinical Signs
of Medial Scar Contractures of the Joints,
Commissures, Neck, Trunk, and Perineum
Medial contracture makes up 25% of the total number of
contractures (Fig. 1.6). Medial contractures, independent of
their location and severity, have specific anatomical features
and clinical signs:
(a) Contractures are caused by burns and contracted scars,
covering the joint fossa or flexion medial surface (FM) of
large joints, or joint flexion surface of the interphalangeal
joints, anterior ankle, perineum, inner surfaces of commis-
sure, anterior and lateral neck, and lateral truncal
surfaces.
(b) Contracted scars form the crescent fold located along
the medial line of the joint’s fossa or medial line of the
joint flexion surface, ankle anterior surface, perineum,
lateral truncal and neck surfaces, nose anterior surface,
and inner commissural surface.
(c) Both sheets of the fold are scars and spread from the
fold’s crest to the joint fossa’s edges (large joints), the
joint rotation axis level of small joints, and commissural
edges. These three anatomical features determine the
name for this type: Medial.
The fold is a new anatomical structure, and scar surface
surplus is useful for contracture elimination with local flaps.
Both scar sheets of the fold have a surface deficiency in
length, which causes contracture, and surface surplus in
width, which allows contracture treatment with local flaps per
se or in combination with skin transplants. The fold can be
small and short or may spread on the neighboring areas and
joints.
Medial Contracture Formation

10
a
b
c
d
e
Fig. 1.6 Anatomy of medial scar flexion/adduction contractures are
characterized by: (1) Scars cover the joint FM-flexion medial surface.
(2) The crescent fold, which is located along the medial line of the
joint’s fossa, or medial line of joint flexion surface, the medial line of
the ankle anterior surface, perineum, and inner commissural surface.
(3) Both sheets of the fold are scarred and spread from the fold’s crest
to the edges of the large joint fossa, the joint rotation axis level of small
joints, or where the scar’s contraction disappears. Scars and sheets of
the fold cover neck anterior and lateral surfaces, trunk, and perineum.
(a) Shoulder medial adduction scar contracture. (b) Elbow medial scar
flexion contracture (two cases). (c) First web space medial adduction
scar contracture. (d) Wrist medial scar deviation/flexion contracture. (e)
Fingers medial flexion contractures. (f) Knee medial scar flexion con-
tracture. (g) Ankle medial scar flexion contracture. (h) Neck lateral
medial scar contracture. (i) Lateral truncal medial scar contracture. (j)
Perineum medial scar adduction contracture
1 Postburn Scar Contracture: Formation, Anatomy and Classification

11
f
g
i
h
j
Fig. 1.6 (continued)
Anatomical Features and Clinical Signs of Medial Scar Contractures of the Joints, Commissures, Neck, Trunk, and Perineum

12
b
a
c
d
f
e
Fig. 1.7 (a–c) Total shoulder, elbow, and wrist scar contractures. (d) First web space total scar adduction contracture. (e) Total interdigital scar
contractures. (f) Knee total scar contracture. (g) Ankle total scar contracture. (h) Total perineum scar contracture (obliteration)
Similar Total Contracture Anatomy
of Different Location
After deep extensive burns, scars tightly surround the joint, or
obliterate commissures and perineum, creating a severe scar
surface deficit without a fold, which does not allow contrac-
ture treatment with local tissue (Fig. 1.7). These anatomical
criteria characterized contracture as total (15% of total num-
ber). Because of severe tension and traumatization during
joint extension, scars are converted to pathologic (solid,
rough, thick), and are prone to necrosis and ulceration. Along
with the scar contracture, deep burns could injure the articular
structures, making the contracture more severe and treatment
more complex. Severe scar surface deficit excludes the use of
local-flap techniques; it can be compensated for and contrac-
ture treated with skin grafts, scar quadrangular subcutaneous
pedicle flap (see Chap. 22), or regional pedicle or free flaps.
1 Postburn Scar Contracture: Formation, Anatomy and Classification

13
g
h
Fig. 1.7 (continued)
Anatomical Features and Clinical Signs of Medial Scar Contractures of the Joints, Commissures, Neck, Trunk, and Perineum

14
Conclusion
The flexion surface of large joints is divided into flexion
lateral (FL) and flexion medial (FM); the flexion surface
of the small joints, perineum, and trunk are all classified
as medial. In all cases, contracted scars covering the
flexion lateral surface form an anatomically specific
contracture type: Edge. Contracted scars covering the
flexion medial surface form medial contracture. Scars
located on the joint extension surface (beyond joint rota-
tion axis level) do not participate in the flexion contrac-
ture formation. The tissue of flexion lateral (FL) and
joint extension (E) surfaces, and both joint’s flexion sur-
faces (FL and FM) are tightly connected between
themselves.
Our three-type classification system includes all spe-
cific anatomical features and clinical signs.
Scars that are located on all joint flexion surfaces, or
circularly, create a total contracture. Every contracture
type has specific anatomical features and clinical signs,
regardless of location and severity, and these are the basis
for diagnosis, operation planning, and choice of
technique.
The fold’s presence and surface surplus in the fold’s
sheets allows the edge and medial contractures to release
with local flaps that compensate for scar sheet surface
deficits in length (contracture cause).
Inadequate anatomical studies and the absence of an ana-
tomical classification have impeded the development of
anatomical-based surgical techniques for treating postburn
scar contractures. Therefore, Z-plasty and Y-V plasty, based
on the use of triangular pointed flaps, are considered to be
basic local-flap techniques, and are used despite their short-
comings and disadvantages. Multiple existing modifications
and combinations have been proposed that confirm that the
anatomy of scar contractures is as still inadequately studied.
The understanding of postburn scar contracture anat-
omy, including the scar surface deficit, is the first and
main step toward successful surgical rehabilitation.
The rationale behind the choice of surgical technique
and estimation of its efficacy in treatment is based on the
use of a commonly accepted anatomical classification.
References
1. Schneider JC, Holavanahalli R, Helm P, Goldstein R, Kowalske
K. Contractures in burn injury: defining the problem. J Burn Care
Res. 2006;27:508–14.
2. Stekelenburg CM, Marck RE, Tuinebreijer WE, de Vet HC, Ogawa
R, van Zuijlen PP. A systematic review on burn scar contracture treat-
ment: searching for evidence. J Burn Care Res. 2015;36:e153–61.
3. Serghiou MA, Niszczak J, Parry I, Li-Tsang CWP, Van den
Kerckhove E, Smailes S, et al. One world one burn rehabilitation
standard. Burns. 2016;42:1047–58.
4. Grishkevich VM. The basic types of scar contractures after burns
and methods of elimination them with trapezeplasty flaps. Plast
Reconstr Surg. 1991;88:1044–54.
5. Grishkevich VM, Grishkevich M. Postburn scar contractures: forma-
tion, anatomy and classification. Adv Plast Reconstr Surg. 2016;1(1).

01-000105.pdf. Accessed 29 Dec 2017.
1 Postburn Scar Contracture: Formation, Anatomy and Classification

15
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Deficit of Postburn Scar Surface is
Contracture Cause and Basis for
Adequate Reconstructive Techniques
Development and Choice
Introduction
Of the three outcomes of burns—scar deformity, contrac-
ture, and tissue defect—contractures most often lead to dis-
ability. Therefore, the efficacious treatment of scar
contractures is of the greatest importance in the surgical
rehabilitation of burned patients. Complete contracture
removal significantly improves the appearance of the con-
tracted region. Over many years, scar contracture treatment
has conformed with classic methods, especially concerning
local-flap techniques. Triangular-flap techniques—Z-plasty
and Y-V plasty and their modifications and combinations—
continue to serve as the basis for scar contracture treatment.
The techniques based on triangular flaps have known disad-
vantages, and results of rehabilitation of burned patients
with contractures are far from perfect. The development of
new techniques is needed (see Chap. 1). Therefore, complex
regional flaps are used in adults and children. According to
our research [1], the main cause of the slow progress in scar
contracture treatment with local tissues is insufficient study
of (a) contracture anatomy, (b) contracture cause (scar sur-
face deficit), and (c) anatomical classification of scar
contractures.
Postburn Scar Contracture Anatomy
In the plane of surgical treatment, the joint’s surface should
be divided on flexion (F) and extension (E); the boundary
between flexion and extension passes along the joint rotation
axis level (Fig. 4.1). The flexion surface of large joints
(axilla, elbow, and knee), ankle, and first web space is divided
into two areas: flexion lateral (FL) and flexion medial (FM).
The lateral surfaces of the large joints are spread from the
edge of the joint fossa to the joint rotation axis level; the
flexion medial surface includes the joint’s fossa and ankle
anterior surface; and the scars, forming the commissural
contractures, spread from the fold crest on the dorsal and
palmar hand or cheek. All flexion surfaces of the small (inter-
phalangeal) joints, neck, lateral trunk, and perineum are con-
sidered as one flexion medial surface. Scars located on the
joint flexion lateral surface cause edge contracture (Fig. 2.1),
contracted scars covering the flexion medial surface form
medial contracture (Fig. 2.1), and scars located on the joint
extension surface (beyond the joint rotation axis level) do not
participate in the flexion contracture formation. Scars cover-
ing the joint flexion or the flexion and extension surfaces are
tightly connected and form total contracture.
2

16
Edge Scar Contracture Anatomy (Figs. 2.1, 2.2,
2.3, 2.4, 2.5, 2.6, 2.7, 2.8, and 2.9)
Burns and scars that are located on the lateral joint’s FL and
lateral commissural surface form the fold that the contrac-
ture causes. The fold is located along the edge of the large
joint, commissural fossa, and ankle anterior surface; the
crest of the fold (Cr) is the scar’s edge. In the fold, only the
lateral sheet is a scar, and a continuation of scars covers the
FL surface. The scars covering the joint FL surface and the
lateral scar sheet of the fold have a surface deficit in length
that causes contracture. Both sheets have surface surplus of
scar and skin. The medial sheet is a continuation of healthy
skin of the FM surface or the joint fossa and are excellent
donor sites, allowing contracture elimination with local tis-
sue. Thus, four signs characterize an edge contracture:
(a) Contracture is caused by scars covering the joint FL
surface.
(b) Scars growing distally form the fold located along the
edge of the joint fossa.
(c) The lateral sheet in the fold is scar tissue; the medial
sheet is healthy skin.
(d) The crest of the fold is the edge of the scar.
Fig. 2.1 Anatomic features and functional zones of joints of edge con-
tractures (shoulder and elbow). Functional zones: E extension surface;
“+” joint rotation axis; FL flexion lateral surface is scar; Fd fold is con-
tinuation of scars of FL surface; therefore, lateral sheet of the fold is
scar; FM the flexion medial surface is fossa; the medial fold sheet is
part of the fossa and healthy skin; fold sheets are surface surplus of
scars and healthy skin; Cr the crest of the fold is the edge of scar.
Clinical signs of shoulder and elbow edge flexion contractures; (a) scars
cover a FL flexion lateral surface and form a fold (Fd); (b) the fold is
located along the joint fossa’s edge; (c) different fold sheets’ quality:
the lateral sheet is scar and part of the flexion lateral surface; the medial
fold’s sheet and joint fossa (FM) are healthy skin and the donor site; (d)
Cr the crest of the fold is the edge of scar. Sheets of the fold in conjunc-
tion with the fossa’s tissue are sufficient for contracture elimination
Fig. 2.2 Anatomy and joint surfaces of medial contractures (right shoul-
der) and clinical signs. Scars cover a FM joint’s flexion medial surface or
joint’s shoulder fossa; scars form the fold that covers all fossa, has sur-
face surplus in width and surface deficit in length, which causes the con-
tracture. Clinical signs: scars cover the joint flexion medial surface
(FM); Cr the crest of the fold passes along the middle axillary line; FL
the flexion lateral surfaces are healthy skin and does not participate in
contracture formation; E extension surface; “+” joint rotation axis
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice

17
a
b
Fig. 2.3 Anatomy of total
scar contracture: (a, b)
Anterior and posterior view.
Scars tightly surround the
joint on three sides, covering
and obliterating the axillary
fossa; the shoulder fused with
the chest wall and formed the
total contracture; no fold, no
scar surface surplus;
therefore, severe scar surface
deficit forms total scar
adduction contracture and
excludes reconstruction with
local tissues
a
b
Fig. 2.4 Edge shoulder anterior adduction contracture caused by
trapeze-shaped scar surface deficit. (a) Shoulder edge contracture anat-
omy: E joint extension surface; “+” joint rotation axis; FL flexion lateral
surface; Fd fold (lateral sheet) is continuation of FL surface; Cr crest of
the fold; FM flexion medial surface, or axillary fossa, is healthy skin; (b)
scar surface deficit determination: contracted scars (the flexion lateral
surface [FL] and the scar fold sheet [Fd] are dissected from the fold crest
[Cr] to the joint rotation axis [+] with a Y-shaped incision); wound (Dt
scar surface deficit) accepted trapezoid form (upper of strip); length of
wound end along joint rotation axis level is nearly 6 cm; mobilized axil-
lary adipose-cutaneous trapezoid flap (Fp), donor wound (DW) in axil-
lary fossa. Operation details can be found in Chap. 16
Edge Scar Contracture Anatomy

18
a
b
Fig. 2.5 Edge elbow flexion contracture caused by scar surface deficit
of scars covering the joint flexion lateral surface (FL) and scars of the
fold. (a) Contracture anatomy: FM surface (fossa and fold); FL flexion
lateral surface from fold crest to the joint rotation axis (“+”); E joint
extension surface; lines of the trapezoid flap in fossa and Y-line for scar
dissection; (b) after scar dissection and flap mobilization: Dt trapezoid
scar surface deficit of scars on FL surface, end equals 6 cm (contracture
cause); Fp the trapezoid flap is mobilized from cubital fossa; DW donor
wound (see Chap. 23)
a
b
Fig. 2.6 Edge first web space adduction contracture caused by trapeze-
shaped scar surface deficit (Dt). (a) Pre-operative view; FL the fold’s
lateral scar sheet; Cr crest of the fold; Y-line for scar dissection; (b)
contracted scar sheet of the fold dissected with a Y-incision; a trapezoid
wound (Dt-M-trapezoid scar surface deficit) appeared (above strip), end
of M-wound (surface deficit) equals 2.5 cm; trapezoid flap (Fp) ele-
vated from fossa. Operation details can be found in Chap. 27
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice

19
a
b
Fig. 2.7 Dorsal interdigital adduction contractures caused by scars of
the dorsal hand having surface deficit. (a) Scars of the hand dorsum,
growing distally, form the fold between proximal phalanges. The dorsal
fold’s sheet is scar and participates in syndactyly formation, Y-line for
contracture release and cause definition; (b) after scar dissection with a
Y-incision and contracture elimination, a trapezoid wound appeared or
Dt trapezoid scar surface deficit from the fold’s crest to the metacarpal
bone heads, DW donor wound; adequate flap (Fp) elevated in interdigi-
tal fossa (see Chap. 28)
a
b
Fig. 2.8 Scar surface
deficit—cause of knee edge
flexion contracture. (a)
Contracture anatomy: FL
scars on the joint flexion
lateral surface and the lateral
sheet of the fold caused
contracture; FM the flexion
medial surface or popliteal
fossa is healthy skin; Cr crest
of the lateral fold sheet; E
joint extension surface; “+”
joint rotation axis; borders of
the flap in popliteal fossa or
FM surface; Y-line for
contracted scar dissection
from the fold crest to the joint
rotation axis; (b) contracture
released: Dt large wound or
trapezoid scar surface deficit
or contracture cause; FP
popliteal trapezoid flap
mobilized; DW donor wound.
Operation details can be
found in Chap. 33
Edge Scar Contracture Anatomy

20
b
c
a
Fig. 2.9 Ankle edge contracture caused by scars of the joint FL surface
and the lateral scar sheet of the fold. (a, b) Anatomy: FL scars of the
ankle lateral surface forming the fold and causing the contracture; FM
healthy ankle anterior surface and donor site; Cr the crest of the fold is
the edge of scar; planning: Y-line for scar incision and two lines, trape-
zoid flap borders; (c) the wound appeared (right from the strip), which
is scar surface deficit (Dt), real contracture cause, the wound has a trap-
ezoid form, and the matching flap is mobilized (FP flap, DW donor
wound) for scar surface deficit compensation and contracture elimina-
tion. Operation details can be found in Chap. 36
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice

21
Anatomy of Medial Scar Contracture (Figs. 2.2
and 2.6)
Scars covering the FM surface (fossa of large joints), ankle
anterior surface, finger flexion surface, commissural fossa,
first web space, perineum, neck anterior and lateral surface,
nose, and lateral trunk, form the fold. Scars of the FM sur-
face and both sheets of the fold have surface deficit in length
causing the medial contracture. The fold passes along the
medial line of the joint’s flexion medial surface, commis-
sural, and first web space fossa, perineum, lateral trunk, dor-
sum nose, and anterior and lateral surfaces of the neck. Both
sheets of the fold are scars, and have a length surface deficit
and scar surface surplus, the surface of which is enough for
contracture elimination with local flaps. The lateral flexion
surface of the large joint can be undamaged or covered with
scars that do not participate in contracture formation. The
scars located on the flexion medial surface of large joints,
commissural fossa, perineum, nose, neck anterior and lateral
surfaces, and lateral trunk, which form the fold in which both
fold sheets are scars, create the medial contracture type.
Three signs characterize the medial contracture:
(a) Contracture is caused by scars covering the joint flexion
medial (FM) surface and first web space fossa, fingers’
flexion surface, perineum, lateral trunk, dorsum nose,
and anterior and lateral surfaces of the neck
(b) Scars form the fold that passes along the middle line of
the zone covered by scars
(c) Both sheets of the fold are scars
Total Contracture Anatomy (Fig. 2.3)
Deep and vast burns that injure the joint’s flexion and exten-
sion surfaces result in scar formation. The scars tightly sur-
round the joints, without a fold. There is severe scar surface
deficit, which excludes any possibility of using a local-flap
technique; large wounds are covered with skin grafts,
regional pedicle, and free flaps.
Scar Surface Deficit as the Real Cause
of Contracture
The diagnosis of “scar contracture”—including knowing the
contracture type, the contracture severity, and the scar’s loca-
tion and its spreading—does not explain the surgical anat-
omy and cause of the contracture. As the cause is scar surface
deficit, the main focus of reconstruction (planning and tech-
nique choice) is knowing the form and size of the scar sur-
face deficit and its location in relation to the contracted joint.
Exploration of Scar Surface Deficit in Relation
to Contracture Cause and Local Flaps
and Anatomical Local-Flap Technique
Substantiation Allowing Complete Scar
Contracture Elimination (Fig. 2.4)
Reconstruction with classic local techniques for scar con-
tracture treatment (Z-plasty and Y-V plasty and their modifi-
cations and combinations) is performed with straight (lineal)
incisions of contracted scars at different angles. As a rule, a
triangular wound appears, which is covered with triangular-
pointed flaps (transposition and advancement). The purpose
of the plasty method is to draw on the operating field before
contracture release using a straight line, and the operation is
accomplished with straight incisions. In the case of Z-plasty,
a central line passes along the fold’s crest, and the next two
lines, at 60° to the first one (not perpendicular). With Y-V
plasty, triangular symmetrical figures (flaps) are placed on
each fold’s sheet, beside the fold crest.
When planning the Z-plasty and Y-V plasty techniques,
the scar surface deficit (its location, form, and size) as the
cause of contracture is not taken into account.
In the case of edge joint contracture, the first incision
along the fold crest separates the contracted scar (FL) from
healthy skin on the FM surface; the other edge of the scar
stays tightly connected to the normal skin of the extension (E)
surface. Since contracted scars are tightly connected to the
tissue of the extension surface (E), the lineal (straight) radial
incisions of contracted scars from the fold’s crest to the joint’s
rotation axis form, as a rule, a triangular wound. Divergence
of the triangular wound is incomplete and does not reach the
joint rotation axis, and contracture release is thus not full.
In the case of a joint medial contracture, the first incision
along the fold’s crest separates the scar sheets. The second
radial incision of sheets from the fold’s crest to the fossa
edges (to FL surfaces) forms a triangular wound in every
sheet. At the apex of the triangular wound scars cannot
diverge since they are connected to FL surface, creating an
impression that contracture or surface deficit is absent. But in
fact, surface deficit is present through all of the FM surface
of contracture. Therefore, to separate FM from FL and com-
Scar Surface Deficit as the Real Cause of Contracture

22
pletely diverge the wound - Y-incision is used at the edge of
the FL surface. When Y-incision is used, wound surface takes
trapezoid shape and requires trapeze flap for closure.
Incomplete wound edge divergence causes incomplete con-
tracture release. Therefore, after covering the wound with a
triangular flap, contracture elimination is incomplete.
In other words, dissection of contracted scars with lineal
incisions causes, as a rule, a triangular wound with a pointed
end that does not reflect the real scar surface deficiency form
(Fig. 2.2) since the neighboring tissues of the joint’s exten-
sion surface (Fig. 2.1) are tightly connected to the scar of the
flexion surface. Because the wound has a triangular form and
the wound edges do not diverge enough, the contracture is
not fully released. After dissection of contracted scars with a
lineal incision, the wound that appears generally takes on the
triangular pointed form in all cases of edge and medial scar
contractures.
These observations led to the conclusion that scar surface
deficit is not triangular, and that at the joint rotation axis, it
is still present and is not equal to zero (in cases of edge and
medial contractures). Therefore, it has become clear that for
complete contracture release without incision prolongation
on the neighboring joint extension zone, it is necessary (in
cases of edge contractures) to separate the contracted scars
of the lateral flexion surface from: (1) the healthy skin along
the fold’s crest; and (2) the scars of extension surface along
the joint rotation axis (Figs. 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8,
and 2.9). In the case of medial contractures, the contracted
scars of the flexion medial surface should be separated from
the scars on the lateral flexion surface (Figs. 2.10, 2.11,
2.12, 2.13, 2.14, 2.15, 2.16, 2.17, 2.18, 2.19, and 2.20). This
can be achieved with a T-shaped scar incision along the joint
rotation axis (level contracture) and the edge of the joint
fossa (medial contracture). The Y-shaped incision is more
effective. After the Y-shaped incision, the end of the wound
accepts an M-form that allows the wider scar edges diver-
gence by transforming the M-figure into a straight line.
Therefore, the incision of contracted scars in all cases must
be in a Y shape. Before the joint rotation axis (edge contrac-
ture) and edge of joint fossa (medial contracture), the inci-
sion is split at 45° and lengthened along the joint rotation
axis level or fossa edge to fully release the contracture. The
use of Y-shaped incisions for contracted scar dissection
leads to trapezoid wound formation. The formation of the
trapeze-shaped wound reflects the scar surface deficit form,
size, and location (Figs. 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8,
and 2.9). Therefore, the trapezoid flap is needed for wound
covering. Trapeze-flap plasty allows for the complete use of
the scar surface surplus and edge and medial contracture
elimination with local tissues (Fig. 2.20) in most
contractures.
Consequently, the use of Y-shaped incisions for con-
tracted scar dissection leads to the formation of a trapezoid
wound and demonstrates that straight (lineal) incisions of
contracted scars should not take place.
To cover a trapezoid wound, the trapezoid flap is needed,
and trapeze-flap plasty is necessary for scar surface surplus
and neighboring healthy skin use, and to complete the wound
resurfacing and edge and medial contracture elimination. In
cases of total contracture, the scars’ dissections do not have a
specific form as incisions are aimed at complete contracture
release. Because the surface deficit of the scar sheet of the
fold causes contracture, determining the location, size, and
form is considered the first step in contracture treatment. Scar
surface deficit causing contracture occupies the joint flexion
lateral surface to the joint rotation axis level, posterior neck,
dorsal hand, and cheek (Figs. 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7,
2.8, and 2.9). The size and form of the surface deficit is esti-
mated as follows: the scar sheet is separated from the healthy
skin with an incision along the fold crest; then, the contracted
scars on the flexion lateral (FL) surface are separated from the
scars of the joint extension (E) surface with a 45° Y-shaped
perpendicular incision from the fold’s crest to the joint’s rota-
tion axis, malleoli, or full contraction release if contracture is
cervical or commissural (microstomia and syndactyly). After
joint and neck extension, finger abduction, and mouth orifice
opening, as a rule, the trapeze-shaped wound is formed,
reflecting the scar surface deficit form, size, and location
(Figs. 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, and 2.9). The scar
sheet surface deficit (wound) in length is maximal at the
fold’s crest and spreads, subsiding to the joint rotation axis,
neck, hand, and cheek surface. The trapezoid form of scar
surface deficit (the wound) is preserved (not triangular), inde-
pendent of contracture location and severity. Consequently,
the trapezoid flap (not triangular) is needed for wound cover-
ing and scar-deficit compensation. The optimal donor site for
adequate (trapezoid) flap construction is a healthy medial
fold’s sheet and adjacent undamaged area: joint and commis-
sural fossa, ankle and neck anterior surface. Maximal use of
the local (sheets of the fold) and neighboring tissue (flexion
medial surface of large joints, anterior surface of ankle and
neck and commissural fossa, serving as donor sites) and ade-
quate contracture elimination is achieved with trapeze-flap
plasty (Figs. 2.1, 2.2, 2.3, 2.4, 2.5, 2.6, 2.7, 2.8, and 2.9).
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice

23
a
b
Fig. 2.10 Lateral edge neck contracture caused by trapezoid scar sur-
face deficit. (a) Anatomy before operation: scars on posterior surface of
the neck, fold on lateral neck, Cr crest of the fold; the posterior fold’s
sheet is scar; the medial sheet and anterior neck are healthy skin; plan-
ning of operation: line along the fold’s crest for separation of scars from
healthy skin, FL scars on flexion lateral surface causing contracture;
Y-line for contracture release; FP two lines on the neck anterior surface
are borders of trapezoid flap; (b) after scar dissection with a Y-shaped
incision: Dt trapezoid wound appeared, or trapezoid scar surface defi-
cit—real contracture cause; the end of the trapezoid wound is nearly
7 cm in length. Operation details can be found in Chap. 12
a
b
Fig. 2.11 Microstomia caused by trapezoid surface deficit in the lat-
eral scar sheet of the fold. (a) Anatomy: microstomia caused by scars
covered the cheek and formed the fold in the mouth angles; the lateral
fold’s sheet is scar, the medial sheet is healthy mucosa. Planning: Y-line
incision for contracture release; a line along the fold’s crest—sheet
separation; two-line trapezoid mucosal flap: scars of the cheek caused a
fold in commissural angle; planning of operation; (b) after dissection,
the fold’s scar sheet with a Y-shaped incision and flap mobilization: Dt
trapezoid wound or scar surface deficit or contracture cause; DW donor
wound; FP trapezoid flap. Operation details can be found in Chap. 4
Scar Surface Deficit as the Real Cause of Contracture

24
a
b
Fig. 2.12 Medial axillary adduction contracture caused by trapezoid
scar surface deficit in length of both scar sheets of the fold and scars of
the flexion medial surface (FM). (a) Anatomy: scar covered the axillary
fossa or FM surface; scars formed a fold, both sheets of which are scars;
two axillary trapezoid flaps planned in FM (fossa) surface; FL flexion
lateral surface; (b) two flaps mobilized and contracture released; a large
wound appeared, consisting of Dt scar surface deficit trapezoid form
and DW donor wound, which is smaller than Dt; the flaps’ surface is
enough for deficit compensation and contracture elimination (Chap. 21)
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice

25
a
b
c
Fig. 2.13 Elbow medial scar
contracture caused by
trapezoid scar surface deficit
scars of flexion medial surface
(FM). (a) Contracture
anatomy: scars covered the
joint FM (flexion medial)
surface; scars formed a
crescent fold, the Cr crest of
which passes along the
middle line of cubital fossa;
the sheets of the fold are
scars; three pairs of trapezoid
flaps are marked; (b) scars of
FM surface were dissected by
radial Y-incisions, and
trapezoid wounds appeared or
Dt scar surface deficit—real
contracture cause; and FP
trapezoid adipose-scar flaps;
(c) counter transposed flaps
compensate surface scar
deficit and contracture
elimination
Scar Surface Deficit as the Real Cause of Contracture

26
a
b
Fig. 2.14 Medial wrist contracture (ulnar hand deviation) caused by
scar’s trapezoid deficit of fold’s sheets and scars on ulnar wrist surface.
(a) Anatomy: scars covered FM flexion medial (ulnar) surface of the
wrist and formed semilunar fold, both sheets of which are scars; plan-
ning of three pairs of trapezoid flaps with radial Y-incisions; (b) scars
dissected, appeared: Dt trapezoid wounds or scar surface deficit (real
contracture cause) and FP trapezoid flaps between the trapezoid Dt;
flaps are used for scar surface deficit compensation (Chap. 26)
a
b
Fig. 2.15 Medial adduction contracture of first web space is caused
with scars trapezoid surface deficit of both fold’s sheets in length
(between proximal phalange and second metacarpal bone). (a) Anatomy
of medial contracture of first web space: Scar fold filled out web space
and adducted first finger. Both sheets of the fold are scars, hawing sur-
face deficit in length (along the fold’s crest) and surface surplus in
width (from the fold base to the crest); two trapezoid flaps marked.
(b) Flaps (FP) mobilized and contracture released. Big wound appear-
ing consisted from donor one (DW) and scar surface deficit (Dt) (beside
medial line) trapezoid form (Chapter 27)
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice

27
a
b
Fig. 2.16 Medial perineal contracture caused by scars, which formed
transverse fold; both sheets of fold are scars and have trapezoid surface
deficit in length (contracture cause). (a) Pre-operative view, planning
two pairs of scar trapezoid flaps marked by Y-lines; (b) flaps mobilized
with Y-incisions beside perineal raphe; two trapezoid wounds (one in
every sheet) appeared with common basement (middle strip). Wound
anatomy: FP flap mobilized; DW donor wound; D deficit of scar sheets,
causing contracture. Operation details can be found in Chap. 31
a
b
Fig. 2.17 Knee medial
flexion contracture caused by
scars covering the joint
flexion medial surface (FM).
(a) Scars formed a fold along
medial flexion surface line,
UL ulcer on fold’s crest; both
sheets of the fold are scars;
planning of three pairs of
trapezoid flaps FP; (b) after
radial Y-shaped incisions and
mobilization of flaps to edges
of popliteal fossa, trapezoid
flaps and Dt scar surface
deficit appeared (part of
wound): scar surface deficit
(form and size) is among
mobilized flaps (Dt).
Operation details can be
found in Chap. 33
Scar Surface Deficit as the Real Cause of Contracture

28
a
b
Fig. 2.18 Ankle medial dorsiflexion contracture caused by surface
deficit of scars covering the joint flexion medial (FM) surface. (a)
Contracted scars of FM surface or ankle anterior surface formed the
semilunar fold, both sheets of which are scars and have surface deficit
in length (contracture cause); Cr crest of the fold. Planning of two trap-
ezoid flaps by radial Y-lines; FL ankle flexion lateral surfaces; (b) after
radial Y-incisions and trapezoid flaps mobilization, a large wound
appeared, consisting of two parts according to each fold’s sheet (divided
line along fold’s Cr); every wound part consists of Dt surface deficit and
DW donor wound; the flaps and the Dt scar deficit has trapezoid form.
Common Dt surface is equal to the wound’s surface minus both flaps’
surfaces. Operation details can be found in Chap. 36
a
b
Fig. 2.19 Medial lateral neck contracture caused by scar tissue located
on the lateral cervical surface and formed a fold; in the fold’s sheet
there is a trapezoid scar surface deficit in length, causing contracture.
(a) Contracture anatomy: scars formed a fold, both sheets of which are
scars; two trapezoid adipose-scar flaps are marked; (b) after flap mobi-
lization and contracture release, two trapezoid wounds appeared with
common basement (medial strip), for one flap anteriorly and posteriorly
of the neck. Dt surface deficit; DW donor wound; FP flap; Dt and DW
surfaces are nearly equal in size and have trapezoid form. Therefore, Dt
scar surface deficit of contracted scars is real contracture cause.
Operation details can be found in Chap. 12
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice

29
Scar Surface Deficit Causing Edge Scar
Contractures
Edge contractures are characterized by four anatomical fea-
tures (clinical signs):
(a) Contractures are caused by scars covering the joint flex-
ion lateral surface and forming the fold located along the
large joint fossa: shoulder, elbow, and knee (Figs. 2.1,
2.2, and 2.3); edge of the ankle anterior surface (Fig. 2.4);
first web space (Fig. 2.5); commissural edge of the
mouth orifice (Fig. 2.6); interdigital commissure
(Fig. 2.7); and neck anterior and lateral surfaces
(Figs. 2.8 and 2.9).
(b) The scars of the FL surface, growing distally, form the
fold passing along the joint fossa edge and the edge of
the commissural fossa.
(c) The lateral fold sheet is scar tissue, and the medial sheet
and adjacent area are healthy skin (Figs. 2.1, 2.2, 2.3,
2.4, 2.5, 2.6, 2.7, 2.8, and 2.9); the lateral scar sheet has
a surface deficit in length (contracture cause), and both
sheets have surface surplus in width allowing contrac-
ture treatment with local flaps (Figs. 2.1, 2.2, 2.3, 2.4,
2.5, 2.6, 2.7, 2.8, and 2.9).
(d) The fold’s crest is the edge of the scar (Figs. 2.1, 2.2, 2.3,
2.4, 2.5, 2.6, 2.7, 2.8, and 2.9).
a
b
Fig. 2.20 Medial neck anterior contracture is caused by surface deficit
of scars covering anterior and bilateral neck surfaces. (a) Anatomy:
scars formed a fold; Cr the crest of the fold passes along the middle line
of neck anterior surface; FM each scar sheet covers half of the anterior-
lateral neck surface; “+”—exit of perforator vessels furnishing neck
anterior surface. Pre-operative view, planning of two trapezoid flaps;
(b) incisions up to the neck muscles and mobilization of two scar-
fascial trapezoid FP flaps (one on every side of the neck); a large wound
appeared, consisting of two trapezoid wounds (between strips), each of
which is DW donor wound and Dt scar surface deficit. Scar surface defi-
cit, causing contracture, equals the wound surface of both flaps minus
the flaps’ surface. Flaps compensated scar surface deficit and contrac-
ture was eliminated (see Chap. 13)
Scar Surface Deficit Causing Edge Scar Contractures

30
Scar Surface Deficit Causing Medial Scar
Contracture
Medial scar flexion contractures are characterized and caused
by:
(a) Scars covering the flexion medial surface of large joints:
axillary, elbow, wrist, knee, and ankle (Figs. 2.10, 2.11,
2.12, 2.13, and 2.14); first web space (Fig. 2.15); flexion
surface of interphalangeal joints (Fig. 2.16); nose, ante-
rior and lateral neck (Figs. 2.17 and 2.18); perineum
(Fig. 2.19); and lateral truncal surface (Fig. 2.20).
(b) Scars forming a fold located along the medial line of the
joint flexion surface, nose, anterior and lateral neck, lat-
eral trunk, and perineum (Figs. 2.10, 2.11, 2.12, 2.13,
2.14, 2.15, 2.16, 2.17, 2.18, 2.19, and 2.20).
(c) The sheets of both folds are scars and have surface defi-
cit in the length, causing contracture, and scar surface
surplus, allowing the contracture elimination with local
flaps (Figs. 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16, 2.17,
2.18, 2.19, and 2.20).
The form and size of the scar sheet surface deficit is esti-
mated as follows: The fold’s sheets are separated with an
incision along the fold crest; scar sheets covering scars of the
flexion medial surface (FM) are dissected with a perpendicu-
lar Y-shaped radial incision, which is divided at 45° to the
joint fossa edges or flexion lateral surface (FL) (large joints),
the joint rotation axis of small joints, and full contracture
release on cheek, neck, perineum, and lateral trunk.
The size and form of the scar surface deficit of medial
contracture of the perineum, first web space commissure and
wrist, and anterior and lateral neck and trunk, are estimated
with the same method: The fold’s sheets are separated with
an incision along the fold crest. The contracture is com-
pletely released with a radial cross-cut Y-shaped incision.
The wound (scar surface deficit) and the flap (semilunar
fold) accept, as a rule, the trapezoid form, independent of the
number of cross-cut Y-incisions (Figs. 2.10, 2.11, 2.12, 2.13,
2.14, 2.15, 2.16, 2.17, 2.18, 2.19, and 2.20). Both sheets, in
all their extensions, including the subcutaneous fat layer, are
converted into adipose-scar flaps with radial Y-incisions;
regardless of the number of incisions, wounds (scar surface
deficit) and flaps accept the trapezoid form. As wounds and
flaps have a trapezoid form, the counter-transposition of
which allows the scar surface deficit compensation, wound
covering and full contracture elimination are achieved with a
single procedure (Figs. 2.10, 2.11, 2.12, 2.13, 2.14, 2.15,
2.16, 2.17, 2.18, 2.19, and 2.20).
Uniformity (trapezoid) of scar surface deficiency or
wounds, appearing after edge and medial contracture release
(contracture cause), makes adequate flap planning (semilu-
nar fold) and reconstruction implementation understandable,
simple, safe, and easy.
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice

31
a
b
Fig. 2.21 Total shoulder
adduction contracture is
characterized by vast scars,
tightly surrounding shoulder
flexion (abduction) surface
circularly, absence of a fold
(surface surplus) and severe
scar surface deficit. (a) Total
shoulder adduction
contracture; (b) after
contracted scars dissection,
large wound appeared,
reflecting severe scar surface
deficit, which does not have a
specific form
a
b
Fig. 2.22 Total wrist flexion contracture development after deep burns
and skin grafting, after which a fold or scar surface surplus has not
formed. (a) Severe flexion wrist contracture, no fold, and scar surface
surplus; (b) contracted scars incised and excised, a large wound
appeared without specific form
Scar Surface Deficit of Total Scar Contracture
Scar surface deficit of total scar contracture becomes obvi-
ous after contracted scar dissection at the joint rotation axis
projection; the appearing wound has a different size and
form, the resurfacing of which requires a skin graft, regional
pedicle, or free flaps (Fig. 2.21).
After extensive burns, rough hypertrophic scars often
grow. Large skin surfaces deformed by scars are combined
with scar contracture and injury of donor sites. Vast scar
deformity excludes any type of local and regional flap-plasty
(Fig. 2.22). Rough hypertrophic ulcerous and pathologic
scars undergo excision after their maturation and wound
resurfacing with skin transplants (Chap. 40).
Scar Surface Deficit of Total Scar Contracture

32
Conclusion
The joint rotation axis divides a joint’s surface on flexion
and extension (F and E); curvature of a large joint’s flex-
ion surface (F) is along the joint fossa edge on flexion
lateral (FL) and flexion medial (FM). Contracted scars are
tightly connected when not contracted. For complete con-
tracture release and free divergence of the wound’s edges,
scars that are contracted should be separated from those
that are not contracted. This is achieved by dissecting
contracted scars with a Y-shaped incision; after full con-
tracture release and joint extension, the trapezoid, not tri-
angular, wound appears. This means that at the joint
rotation axis level (edge contractures) and the edge of the
joint’s fossa (medial contracture), the scar contraction
does not equal zero, but has a linear size. As the scar sur-
face deficit (contracture cause) has a trapezoid form, ade-
quate contracture elimination can be achieved with similar
(trapezoid) flaps. Trapeze-flap plasty allows for the effec-
tive use of the fold sheets surface surplus and neighboring
tissue to achieve full edge and medial contracture elimi-
nation (85% of the total number). Trapeze-shaped scar
surface deficit (contracture cause) indicates that local tri-
angular flaps do not match the scar surface deficit, and the
further use of Z-plasty and Y-V plasty is anatomically
unsubstantiated.
Insufficient anatomical study and absence of anatomi-
cal classification has not allowed for development of
anatomically-based surgical techniques for the treatment
of scar contractures. Therefore, Z-plasty and Y-V plasty,
based on triangular pointed flaps, are basic local-flap
techniques that are used despite their imperfection and
disadvantages. Conventional Z-plasty, for example, fre-
quently leads to varying degrees of necrosis of the tips of
the transposed flaps.
The data in the literature show that the most serious
disadvantage of Y-V plasty is the restricted displacement
of the immobilized flaps. After exploring the rehabilita-
tion level of burned patients, Klein [2] concluded that it is
apparent that one should expect an evolution in surgical
techniques and technologies that can improve the func-
tion and appearance of people with burn injuries.
It is impossible to justify the choice of surgical tech-
niques and estimate their efficacy without the use of a
commonly accepted anatomical classification; therefore,
the understanding of postburn scar contracture anatomy,
including the scar surface deficit, is the first and main step
towards surgical rehabilitation and the success of scar
contracture treatment.
References
1. Grishkevich VM, Grishkevich M. Exploration of Scar Surface
Deficit as a Cause of Postburn Scar Contractures. JSM Burns
Trauma. 2018;3(1):1035.
2. Klein MB. Burn reconstruction. Phys Med Rehabil Clin N Am.
2011;22:311–25.
2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice

33
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Single-Stage Upper Lip and Philtrum
Reconstruction in Burned Patients
Introduction
The upper lip is an important functional and esthetic feature
and it has a defining role in the concept of modern beauty.
Therefore, the upper lip, including all three of its subunits
(philtrum and two laterals), should be reconstructed with a
single-stage procedure. Such a technique, as the literature
shows, has not yet been developed. Our new technique of
total upper lip restoration with philtrum reconstruction is
based on creating philtrum columns by preserving thicker
and more rigid strips of scar tissue over the intended location
of the philtrum and excising the rest of the scar of the upper
lip. A single-flap skin graft covers all of the upper lip and the
space between philtrum columns. A dedicated tied-over
compression dressing allows creation of an anatomical
depression between philtrum columns, restoring proper anat-
omy of the upper lip.
Anatomical Features of Burned Upper
Lip and Philtrum
Facial burns cause multiple forms of damage. Total upper lip
and philtrum injury is one of them. Several esthetic units are
involved. The existing methods of reconstructive operations
on the upper lip and philtrum were developed to eliminate
small upper lip defects. The deformed-by-scars contracted
upper lip is narrowed, shortened, and everted (ectropion),
and the philtrum is replaced by scars. The scar excision and
skin-grafting techniques that are currently being applied to
treat the postburn upper lip do not restore the philtrum
(Fig. 3.1b, c).
As a result, the lip receives a rounded smoothed shape,
which distorts the appearance of the face and results in a
major esthetic defect. The secondary re-creation of the phil-
trum dimple, using a composite skin-cartilage graft from an
ear, slightly improves the contour of the lip. McCauley and
Killyon [1] reported: “Reconstruction (of the upper lip)
without a presence of a philtrum is more difficult.
Unfortunately, most of our literature on reconstruction of the
philtrum comes from correction of secondary cleft lip defor-
mities… However, major losses of the philtrum require more
innovative technique…” (p. 323–4).
Based on our assessment of thickness and elasticity of
scars removed from the upper lip, we decided to use scars for
philtrum column restoration. Further experience allowed
development of a new method for rebuilding the upper lip
with philtrum [2, 3]. In this chapter we describe a new, effec-
tive, single-stage method of upper lip and philtrum
restoration.
3

34
a
b
c
d
Fig. 3.1 Anatomy of
postburn face deformity,
including upper lip and
philtrum, before and after
skin grafting. Patient 1: (a)
Before surgery: total postburn
face and neck deformity, the
lip eversion (ectropion), no
philtrum. (b) 10 months after
scar excision and skin grafting
without philtrum rebuilt:
smoothed upper lip. Patient 2:
(c) Follow-up result after
upper lip scar excision and
skin grafting: smoothed,
rounded, but abnormal-
looking upper lip. (d)
Columns formed from scars
and skin transplant, remaining
scars excised; upper lip
covered with skin transplant,
compression in philtrum
groove made with tie-over
dressing
3 Single-Stage Upper Lip and Philtrum Reconstruction in Burned Patients

35
a
b
c
d
e
Fig. 3.2 Philtrum restoration and upper lip reconstruction with local
scars and skin grafting. (a) Before surgery, planning: column location,
scar boundaries to be excised; (b) scars excised laterally and between
columns, the epithelium removed from scar strips (columns); two
expanders inserted in submandibular regions for future total face recon-
struction; (c) upper lip covered with split skin transplant, the compres-
sion bolster placed in the groove between the ridges and fixed with
tie-over dressing; (d) 7 days after surgery: columns and groove are vis-
ible. (e) 2 weeks after reconstruction; skin transplant is stable, philtrum
and upper lip restored
Anatomical Features of Burned Upper Lip and Philtrum

36
a
b
c
d
Fig. 3.3 Results of the philtrum, lip, and nose reconstruction. (a, b)
Before surgery: severe deformity of the upper lip, nose, and philtrum
destruction; (c, d) 2 months after reconstruction: scars have been
excised and the wound covered with skin transplants; the restored phil-
trum adorns the upper lip and the whole face
Surgical Technique of Upper Lip
and Philtrum Restoration
The surgery is performed only when the scars are mature
(Fig. 3.2). The positioning of the ridges and the boundaries
of scars to be excised are outlined (Fig. 3.2a, b). The width
of the scar strips, which will later serve as the tops (crests) of
the philtrum’s ridges, need to be around 4 mm. Incisions on
the lateral and medial sides of the marked ridges are directed
at a 45° angle away from the ridge. Scars, lateral to the ridges
and between them, are excised, allowing the remaining scar
strips to stand out as ridges. Epithelium is then removed
from the scar ridges and the lip is covered with a continuous
split skin transplant.
After the skin graft is sutured in place, the two U-shaped
sutures are led through the skin transplant through both ridges
and under the groove’s soft tissues. Gauze bolster is prepared in
accordance with the length of the groove between the ridges. It
is then placed in the groove and tied-over by previously inserted
U-shaped sutures. This dressing generates proper compression
to allow proper attachment of the graft and formation of the
anatomical shape of the philtrum groove. The tie-over dressing
for both sides of the upper lip and the philtrum are carried out
separately. The dressings are replaced for the upper lip in
5 days, and for the philtrum in 7 days (Fig. 3.2d).
In most cases, restoration of the upper lip and philtrum is part
of a much larger facial reconstruction. For example, reconstruc-
tion of the nose may be performed simultaneously (Fig. 3.3).
3 Single-Stage Upper Lip and Philtrum Reconstruction in Burned Patients

37
a
b
c
d
Fig. 3.4 Simultaneous elimination of multiple face deformities with
upper lip and philtrum restoration. (a) Before surgery: multiple face
deformities (absence of the philtrum, severe contracture of the lips,
nose, cheeks, and chin deformity; (b) planning: bilateral partial cheek,
chin, nose, and upper lip scar excision and philtrum restoration; (c, d)
6 months after philtrum restoration and partial face reconstruction
When the upper lip and philtrum are part of a larger lower
facial deformity, reconstruction is accomplished with an
ascending neck flap (Fig. 3.4) or skin transplants (Fig. 3.5).
Philtrum restoration is a very important part of the recon-
struction of a deformed perioral region (Fig. 3.5).
In case of total face deformity, the philtrum and upper lip
restoration are performed as a part of total face reconstruc-
tion (Fig. 3.6).
Surgical Technique of Upper Lip and Philtrum Restoration

38
a
b
c
Fig. 3.5 Result of philtrum, upper lip, and perioral region reconstruction. (a) Philtrum absent, planning; (b) 7 days after surgery; (c) 2 months
after reconstruction
a
b
Fig. 3.6 Results of face
reconstruction with skin
transplants, including upper
lip and philtrum. (a)
Pre-surgery view, planning;
(b) 7 months after face
reconstruction, including lips
and philtrum
3 Single-Stage Upper Lip and Philtrum Reconstruction in Burned Patients

39
Conclusion
This technique carries a very low risk of complications.
The use of this method allows for the achievement of nor-
mal esthetic characteristics and shape of the upper lip as
well as the philtrum. The skin transplant is usually well
grafted, preserving both the crests of the ridges and the
groove of the philtrum. The ridges and the groove become
clearly visible. The ridges maintain their height and
length, since mature scars did not thin out or dissolve. The
depth of the groove may become shallower over time, yet
it remained visible at long-term follow-up. The upper lip
contours and shape were within normal limits. The trans-
plant acquired the properties of healthy skin without
shrinking or lip contracture (ectropion) recurrence. No
special pressure garment was used. Columns from scars,
covered with skin transplant, do not dissolve, and the
effect appears to be stable. Long-term follow-up results
were good, and patient satisfaction was high. This simple
technique solved the problem of restoration of shape and
surface of a burned upper lip and philtrum without signifi-
cant technical difficulties or complications.
Suggested Readings
1. McCauley RL, Killyon GW. Reconstruction of the upper lip and
commissure. In: McCauley RL, editor. Functional and aesthetic
reconstruction of burned patients. Boca Raton: Taylor & Francis;
2005. p. 319–30.
2. Grishkevich
VM.
Post-burn
philtrum
restoration.
Burns.
2010b;36:698–702.
3. Grishkevich VM. Postburn philtrum and upper lip reconstruction.
Plast Reconstr Surg. 2010a;125:10–2e.
Suggested Readings

41
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Postburn Microstomia: Anatomy
and Elimination with Trapeze-Flap
Plasty
Introduction
After facial burns, the commissural mucosa remains undam-
aged and scars form on the external surface of the mouth
corners where the scar fold forms, narrowing the oral orifice
and causing microstomia. The lips grow together, and the
angles become obliterated. A small oral opening restricts
oral intake, routine oral hygiene, dental procedures, and intu-
bation in case of surgery. According to most authors, the scar
tissue must be removed from the commissural angle; the
wounds are closed with Y-V plasty or with the use of muco-
sal flap variations. Scars located in the corner of the mouth
orifice have a trapezoid surface deficit and their removal
increases the defect.
Therefore, we developed a method that consists of con-
tracture release by scar dissection with a Y-incision up to the
normal size of the orifice. After opening the mouth, a trape-
zoid wound appeared (scar surface deficit), and this was cov-
ered with a trapezoid mucosal flap.
Anatomy
The fold that causes microstomia (oral commissure contrac-
ture) consists of two sheets: the lateral sheet (or external
sheet in the case of the mouth cavity) consisting of scars, and
the medial sheet, which is healthy mucosa (Fig. 4.1). Usually,
the lips’ vermilion borders are injured and replaced by pale
scars; the vermilion borders become smoothed. This is a
typical edge contracture according to our classification. It is
caused by the surface deficit of the lateral scar sheet and the
scars of the oral commissure zone. The crest of the fold is the
edge of the scars. The size and shape of the scar deficit that
causes contracture can be determined in the following way:
The fold’s sheets are divided with an incision along the crest
of the fold, then the scar sheet is dissected with a Y-shaped
incision to the normal commissural level; the oral orifice is
opened manually. A Y-shaped incision allows divergence of
the scar edges, and complete contracture release and micro-
stomia elimination, without going off the normal oral angle
level. The incision can be extended for a complete contrac-
ture release. In case of incomplete contracture release, the
rough scar borders are separated from the orbicular oris
muscle. As a rule, the trapeze-shaped wound that is formed
matches the size and form of the scar-surface deficit
(Fig. 4.2b). There is no scar surface surplus at the oral angle.
The bottom of the wound consists of a mucosal medial sheet
and orbicularis oris muscle. The medial (internal) fold’s
sheet and the neighboring mucosa can be used for covering
the wound and restoring the commissure. Consequently, the
oral angle restoration, or commissural contracture release, or
microstomia elimination, should consist of the dissection
(not excision) of the contracted scars with a Y-shaped inci-
sion and wound coverage with the mucosal trapezoid flap
(Fig. 4.2).
4

42
a
b
Fig. 4.1 Anatomy of
postburn scar microstomia.
(a) Severe oral orifice
constriction; (b) microstomia
caused by scars located on the
cheek, which form a
crescent-shaped fold; the
external sheet of the fold is
scar, the internal sheet is
mucosal tissue. Surgery
planned: one-flap trapeze-flap
plasty
a
b
c
d
e
f
Fig. 4.2 Microstomia release and oral angle restoration with trapeze-
flap plasty. (a) Pre-surgery, severe microstomia, anatomy; SL scar lat-
eral fold’s sheet; M mucosa; planning: lines: fold’s sheets division
along the fold crest, Y line of scar dissection, two lines on mucosa and
medial fold’s sheet—flaps borders; (b, c) after scar dissection and con-
tracture release: wound (Dt) scar surface deficit accepts a trapezoid
form; trapezoid flap (FP) mobilized; (DW) donor wound; (d) flap
advanced on the wound; (e) 10 days after operation: microstomia elimi-
nated, oral commissures restored; (f) scheme of trapeze-flap plasty
4 Postburn Microstomia: Anatomy and Elimination with Trapeze-Flap Plasty

43
Surgical Technique
The oral angle contractures are of the edge type and are
caused only by the lateral scar sheet of the fold (Fig. 4.1).
Because the scar surface deficit has a trapezoid shape, the
reconstruction is accomplished by dissecting scars and cov-
ering wounds with a trapezoid flap prepared from the medial
fold’s sheet and neighboring mucosa.
The surgical plan consists of drawing several lines: (1)
along the fold’s crest; (2) Y-shaped (slight upward direction)
line of the scar’s incision to the normal commissural level
(vertical mid-pupillary line); and (3) lines outlining a trapeze-
shaped flap on the mucosa (Fig. 4.2a). Drawing these lines
allows one to estimate the size of the wound and the required
flap size. The flap is designed to be larger than the wound
surface by approximately 30–40%.
At first, the fold sheets are separated (scars from mucosa)
with an incision made along the fold’s crest; then, the scars
are dissected and the contracture is released with the
perpendicular Y-shaped incision. The Y-shaped end of the
incision helps additional scar divergence and full contracture
release. As a rule, a trapeze-shaped wound is formed
(Fig. 4.2b). The scar’s border is separated from the orbicu-
laris oris muscle. If the scars are thick, the inner scar layer is
removed, leaving a scar that is 2–3 mm thick. Then, the trap-
ezoid flap is mobilized from the medial sheet (oral mucous
membrane) (Fig. 4.2c). After adequate oral opening is
achieved, the trapezoid flap is sutured in place, covering the
oral commissure and the trapezoid-shaped wound that
formed after Y-dissection of the scar contracture of the lateral
mouth corner.
Surgical Technique