Phẫu Thuật Tạo Hình Và Tái Tạo Sẹo Bỏng: Atlas Các Kỹ Thuật Mới

98
a
b
c
d
Fig. 10.7  Submandibular
postburn deformity and
contracture elimination with
split ascending neck flap (two
cases). (a, c) Pre-surgery,
planning; (b, d) scars excised
and wound covered with split
ascending neck flaps; scar
deformations removed
10  Medial Neck and Submandibular Scar Contractures: Anatomy and Treatment

99
Conclusion
Reconstruction of the neck medial contracture with the
split neck flaps, in most cases, yields good functional
and cosmetic outcomes. Usually, the operation is one-
staged. With time, skin tension disappears, and the con-
tours of the operated area follow normal anatomical
features.
Suggested Readings
1. Grishkevich VM.  Unilateral cervical burn scar deformity elimi-
nation with contralateral cervicothoracic flap. J Burn Care Res.
2012;33:e26–31.
2. Grishkevich VM, Max G, Menzul VA. Postburn neck anterior con-
tracture treatment in children with scar-fascial local trapezoid flaps:
a new approach. J Burn Care Res. 2015;36:e112–9.
Suggested Readings

101
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Unilateral Neck Scar Contracture
and Deformity Elimination
with Contralateral Split Neck Flap
Introduction
In this chapter, we focus on cases of neck burns and neck
contractures in which only one side of the anterior neck is
injured and the opposite side is largely preserved. Even
though this is a very specific injury scenario, we found it to
be very common among burn patients because the neck is an
exposed area and because it is a natural reflex to turn the face
away from a heat source, which leaves one side of the neck
more exposed to injury.
While burns are healing, scars of one side of the neck
become contracted, drawing surrounding skin toward the
contractures. The scarred surface becomes smaller than the
actual burned surface. Therefore, after scar excision, the
wound opens up, becoming significantly larger than the scar
surface.
Anatomy of Unilateral Neck Scar Contracture
The anterolateral width of the neck scars is from 5 cm in
children to 8 cm in adults (Figs. 11.1 and 11.2). The scars
descend to the corresponding half of the chest wall. The skin
of the opposite anterolateral neck, posterior neck, and oppo-
site half of the anterior chest wall remains undamaged. Scars
that cover all of the anterior chest wall make neck recon-
struction very challenging. In these cases, staged reconstruc-
tion of the chest and neck is needed. During healing of burns,
the scar surface shrinks; the scarred surface becomes smaller
than the real burned surface area (Fig. 11.1b), pulling healthy
contralateral and back-of-neck skin toward the damaged
area. Therefore, after the scar is released and excised, the
wound becomes significantly larger than the scar surface
marked for excision (Fig. 11.1d).
11

102
a
e
f
g
b
c
d
Fig. 11.1  Unilateral neck contracture anatomy and resurfacing with
contralateral split cervico-thoracic flap. (a) Before operation: unilateral
neck and chest wall deformity with contracture; (b, c) planning: solid
line—incisions, dotted line—borders for flap mobilization, and symbol
“+” is a perforator exit location; (d) whole neck split flap mobilized
without platysma and incisions of healthy skin; (e) scars removed,
wound covered with cervico-thoracic split flap; (f, g) 2  years after
reconstruction, neck contracture and scar deformity eliminated
a
b
c
Fig. 11.2  Unilateral neck
resurfacing with split
cervico-thoracic flap with
simultaneous chest wall
deformity excision. (a)
Pre-surgery: half of the
anterior neck surface and
submandibular region is
covered with scars, causing
contracture; scars on anterior
chest wall; (b) planning,
dotted line indicates the
borders of large cervico-­
thoracic flap mobilization,
solid line is border of scar
excision; (c) 6 months after
surgery
11  Unilateral Neck Scar Contracture and Deformity Elimination with Contralateral Split Neck Flap

103
Reconstructive Technique [1]
The cervico-thoracic split flap boundaries (Figs. 11.1b and
11.2b) are marked on the undamaged side of the neck and
chest wall (dotted line) and boundaries of the scars to be
excised (solid line). The symbol “+” indicates the superficial
cervical artery perforator exit (in the middle of the posterior
edge of sternocleidomastoid muscle). Special care is neces-
sary to protect this axial blood supply for the split flap to be
viable. Healthy skin incisions are not planned.
First, the neck flap is mobilized from the incision along the
scar border as outlined, with the thin subcutaneous fat layer,
without platysma (split flap); the perforator exit place (poste-
rior middle of sternocleidomastoid muscle) stays in situ
(Fig. 11.1d; see also Fig. 11.6b). Then, the adipose-­cutaneous
chest wall flap is separated from the clavicle, manubrium, and
pectoralis major muscle fascia down to the level of the second
rib and axillary anterior fold on one or both sides, depending
on the extent of the scar. The skin of the neck and chest wall
is not incised. The under-flap cavity is tightly tamponed with
gauze during neck scar excision to control bleeding and
stretch the mobilized flap. Mobilized tissues are then trans-
posed on the scarred neck surface with tension in order to
determine the neck surface that can be covered by the flap.
After scar excision (nearly 6 cm in width, from mandibula
to clavicle), the flap is advanced on the wound with signifi-
cant tension covering the upper region of the neck first.
Because of the tension created by the flap, the skin of the
back of the neck is displaced forward, covering the donor
site. The chest part of the flap is displaced upward to the
neck, and non-mobilized tissues of the axilla and chest wall
will also shift, covering the chest part of the donor site. As a
result, the flap can advance significantly, resurfacing the
neck surface (Fig. 11.1e). The lower cheek can be resurfaced
(Fig. 11.3) and the chest wall scars excised simultaneously
(Figs. 11.2 and 11.4). If chest skin is damaged, the flap’s
efficacy is restricted; therefore, scars that are only 5 cm in
width are excised. The next reconstruction stage is under-
taken 10–12 months later, after the tissue tension disappears
due to skin growth. Boundaries of the repeat mobilization of
a
b
c
Fig. 11.3  Unilateral neck
and low cheek resurfacing
with split cervico-thoracic
flap. (a) Before
reconstruction; (b) planning;
(c) 6 days after contracture
elimination with a cervico-­
thoracic split flap
Reconstructive Technique

104
a
b
Fig. 11.4  Neck and chest
wall reconstruction with a
split cervico-thoracic flap. (a)
Before operation, planning;
(b) 4 weeks after surgery
the adipose-cutaneous cervico-thoracic flap are somewhat
wider as the skin’s elasticity decreases. Additional scar exci-
sions are not more than 4–5 cm wide. The flap is not fixed to
the underlying tissue. The wound edges are closed with two
rows of sutures (the inner row is non-absorbable) to prevent
wound dehiscence. The under-flap space is actively drained.
Neck splinting is not required.
Localization of scars on the neck and spreading on the
face and chest wall differ from case to case. A specific recon-
structive technique is used depending on the anatomy and
size of the contracture. Some variants in pathology, methods,
and results of their elimination with split neck flap are pre-
sented in Figs. 11.3, 11.4, 11.5, 11.6 and 11.7.
a
b
Fig. 11.5  Neck and chest
wall reconstruction with a
split cervico-thoracic flap. (a)
Before surgery; planning the
neck and chest wall
reconstruction; (b) 2 weeks
after surgery
11  Unilateral Neck Scar Contracture and Deformity Elimination with Contralateral Split Neck Flap

105
a
b
c
Fig. 11.6  A variant of
resurfacing half the neck
anterior surface with
contralateral split flap. (a)
Pre-surgery view; the right
side of the neck is covered
with contracted scars; (b) scar
excision; (c) end of operation:
scars replaced with neck split
flap
Reconstructive Technique

106
a
b
c
Fig. 11.7  Result of unilateral
neck deformity and
contracture elimination with a
cervical split flap. (a, b)
Pre-surgery view; (c) 3 weeks
after reconstruction
11  Unilateral Neck Scar Contracture and Deformity Elimination with Contralateral Split Neck Flap

107
Conclusion
Because of the flap transposition with tension, the adipose-­
cutaneous layer of the chest wall, axilla, shoulder joint,
and the back of the neck are displaced on the donor wound
(scar excision site). The soft tissues of the neck are
squeezed, the neck becomes thinner, and the wound
becomes narrower. With a single procedure, neck contrac-
tures are eliminated completely and the skin in the man-
dibular zone is restored. Chest wall scars are excised
simultaneously with cervical reconstruction. No tissue
failure or flap loss occurs if axial circulation of the neck
flap is preserved. Mild flap microcirculation disorders
(edema, venous stasis) gradually disappear over 2–4 weeks
after surgery. Good cosmetic results are observed after
single-stage reconstruction. No breast displacement is
noticed at long-term follow up. A two-stage or three-stage
reconstruction of the neck, using the same technique,
yields good long-term results. Flap skin preserves its prop-
erties (elasticity, color, and texture) and continues to grow.
The donor site remains undamaged; there are no operation
scars on the anterior surface of the neck.
Reference
1. Grishkevich VM.  Unilateral cervical burn scar deformity elimi-
nation with contralateral cervicothoracic flap. J Burn Care Res.
2012;33:e26–31.
Reference

109
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Lateral Neck Contractures: Anatomy
and Treatment
Introduction
Our observations of hundreds of burned patients showed that
in lateral and posterior neck burns, contracture folds usually
form along the lateral surface of the neck. Thick contracture
cords severely restrict head motion and require surgical cor-
rection, especially in children. Both sheets of the contracture
fold have a surface deficit in length (actual cause of contrac-
ture) and surface surplus in width. During release of the scar
contracture, the surgical wound usually takes a trapezoidal
form. The conclusion was drawn that scar surface surplus in
width can be used to compensate for the scar surface deficit
in length. Contracture elimination thus became possible
using trapeze-flap plasty.
Lateral Neck “Edge” Contracture Anatomy
Edge neck contractures are typically caused by burns and scars
located on the posterior neck surface (Figs.  12.1 and 12.2).
Contracture is characterized by a crescent-shaped fold that forms
along the medial line of the lateral neck surface (Fig. 12.1a, b).
The fold spreads from head to shoulder and consists of two sheets
with distinctive anatomical qualities: (1) the posterior sheet of the
fold is scar (S), which covers the posterior neck surface; and (2)
the anterior sheet of the fold is healthy skin (H), continuing to the
uninjured skin of the anterior neck surface. The crest of the fold is
the edge of the scar (thus the name of the deformity: edge con-
tracture). Scars have a surface deficit in length, which causes the
contracture, and both sheets—scar and skin—have surface sur-
plus that allows contracture treatment with local flaps.
The scar surface deficit in length and surplus in fold’s sheets
must be determined since reconstruction is aimed to compen-
sate the scar surface deficit with flaps of corresponding/match-
ing form and size. The form and size of the scar surface deficit
is estimated using the following steps: After planning the opera-
tion, the sheets are divided with an incision along the fold crest.
Then the posterior (scar) sheet is dissected with a perpendicular
Y-incision from the fold crest until complete contracture release.
Incision ends with a Y-split at approximately 45° for easy scar
edge divergence. After neck extension, the wound, as a rule,
takes on a trapezoid form (Fig. 12.1c–f), reflecting the shape
and size of the scar surface deficit (contracture cause). In other
words, the cause of the contracture is scar surface deficit, which
has a trapezoid shape. Scar surface deficit is maximal at the fold
crest and gradually diminishes toward the posterior neck. This
means that the form and size of the flap needed to cover the
surface deficit to eliminate contracture must correspond to the
deficit and thus have a trapezoid form (not triangular). In sum-
mary, the four anatomical features that characterize the contrac-
ture type we call edge contracture are (1) the scar location on the
posterior surface of the neck; (2) the fold is formed along the
lateral neck surface; (3) different qualities of the sheets of the
fold; and (4) the edge of the scar is at the fold crest.
12

110
a
b
c
d
e
f
i
j
g
h
Fig. 12.1  Neck bilateral edge contracture anatomy and treatment
with adipose-cutaneous flaps. (a, b) Bilateral edge contractures after
posterior neck burns caused contracture folds in which the anterior
sheet is healthy skin and the posterior sheet is scar and contracture
cause; (c, d) planning of operation: on the anterior neck two trapezoid
flaps are outlined, Y-shaped incisions for scar dissection; (e) after con-
tracted scar dissection, trapezoid wound appeared (scar surface defi-
cit); (f) adipose-cutaneous trapezoid flap mobilized; (g) end
trapeze-flap plasty, contracture released; (h) right side of the neck
reconstruction: scars dissected with Y-shaped incision, resulting trap-
ezoid wound is scar surface deficit and contracture cause; (i, j) results:
contracture totally eliminated, neck contours restored with excellent
functional and cosmetic outcomes (7 days after surgery). Dt deficit,
FP flap, H healthy skin, S scars
a
b
Fig. 12.2  Lateral neck edge
contracture elimination with
three trapezoid flaps. (a)
Pre-surgery, planning: main
flap planned from the healthy
sheet of the fold (H) and the
anterior surface of the neck;
two adipose-scar flaps from
the posterior (scar) sheet of
the fold for donor wound
covering; (b) end of
operation; contracture totally
released with counter-­
transposed trapezoid flaps. S
scar, H healthy skin, FP flap
12  Lateral Neck Contractures: Anatomy and Treatment

111
Lateral Neck “Edge” Contracture Treatment
Technique
Edge Contracture Elimination with One
Trapezoid Flap (Fig. 12.1a–j)
The presence of surface surplus in both sheets of the fold and
healthy skin on the anterior neck surface allows contracture
treatment with one local adipose-cutaneous trapezoid flap.
The flap is prepared from the anterior (healthy) sheet of the
fold and anterior surface of the neck. Planning of bilateral
edge contracture elimination (Fig. 12.1c, d) consists of the
following mapping: (1) line along the crest of the fold; (2)
perpendicular line on the posterior (scar) sheet with Y-shaped
end; and (3) two lines on anterior (healthy) sheet outlining
the borders of the flap.
With the first incision along the fold crest, the sheets are
separated. The following perpendicular Y-incision dissects
the scar sheet contracted scars, and subcutaneous fat layer
on the posterior neck surface. After full neck extension, as
a rule, a trapezoid wound is formed (Fig.  12.1e, f).
According to the wound shape and size, although wider by
about 30%, the adipose-cutaneous trapezoid flap is mobi-
lized from the anterior (healthy) sheet and the anterior
neck surface (Fig. 12.1f). Only the superficial subcutane-
ous fat layer (without platysma) is included in the flap. The
upper incision passes along the mentocervical angle; the
lower incision passes above the clavicle. The end of the flap
is about 6 cm wide, depending on the fold length, contracture
type, and the patient’s age. The length of the flap is about
6–8 cm. The end of the flap is cut 2 cm deep to match the
M-shaped edge of the wound. The flap is transposed on the
wound with tension and fixed to the wound borders. After
that, contracture of the opposite side of the neck is released
with the same technique (Fig. 12.1h–j). As a result of ten-
sion, the flap’s base displaces toward the scars. The soft
tissues of the neck are squeezed, and the mobilized skin of
the anterior neck is displaced toward the injured cervical
surface (posteriorly), covering the narrowed donor wound,
compensating for the scar deficit, and eliminating contrac-
ture in full (Fig. 12.1g, j).
Reconstruction of Severe Edge Contracture
with Three Trapezoid Flaps (Fig 12.2)
In extensive burns, scars on the chest wall may restrict neck
tissue transposition and limit adipose-cutaneous flap mobi-
lization. Insufficient surface of the anterior (healthy skin)
trapezoid adipose-cutaneous flap is compensated by addi-
tional adipose-scar trapezoid flaps prepared from the poste-
rior (scar) sheet of the fold (Fig. 12.2a, b). Such a severe
scar surface deficit is compensated for with a three-flap
trapeze-­plasty. One (main) adipose-cutaneous flap is pre-
pared from the healthy skin of the anterior surface; two
other adipose-­scar flaps are prepared from the posterior scar
sheet of the fold for covering the donor wound on both sides
of the main flap.
Lateral Neck “Edge” Contracture Treatment Technique

112
Lateral Neck “Medial” Contracture Anatomy
“Medial” neck contracture is caused by burns and scars
located on the lateral cervical surface (Fig. 12.3a, b). The
contracture is characterized by the presence of a crescent-­
shaped fold located along the medial line of the lateral sur-
face of the neck on all its extent. Both sheets of the fold are
scars (main feature of “medial” contracture) that spread on
the neck anteriorly and posteriorly.
a
b
c
d
e
f
Fig. 12.3  Medial type scar contracture of lateral neck anatomy and
treatment with trapeze-flap plasty. (a, b) Pre-operative view: contrac-
ture caused by the fold, in which both sheets are scars; (c) one pair of
adipose scar trapezoid flaps planned; (d) adipose-scar flaps mobilized,
counter-transposed, covered the wound; contracture released in full; (e,
f) results (left side): contracture eliminated, neck contours restored,
scar surface leveled (3 months after surgery). FP flap, FM flexion
medial surface, Cr crest of the fold
12  Lateral Neck Contractures: Anatomy and Treatment

113
Anatomy of Contracture Cause (Fig. 12.4a, b)
Both sheets of the scar fold have a surface deficit in length,
causing contracture, and surface surplus in width, allowing
contracture treatment by means of surface deficit compensa-
tion with local trapezoid flaps. The shape and size of the con-
tracted scar surface deficit in length is estimated the following
way. The fold sheets are divided with an incision along the fold
crest; contracture is released by a perpendicular Y-shaped inci-
sion to the fold until contracture is fully released. After neck
extension in the opposite direction, the wounds of both sheets,
as a rule, take on a trapezoid form (Fig. 12.4b). This means that
the cause of a “medial” type contracture of lateral neck is a scar
surface deficit that has a trapezoid form. Consequently, ade-
quate contracture treatment can be performed by means of sur-
face deficit compensation with trapezoid flaps (not triangular).
a
d
e
b
c
Fig. 12.4  Lateral neck “medial” type scar contracture anatomy and
treatment in children using trapeze-flap plasty. (a) Pre-surgery: medial
contracture of lateral neck surface caused by the scar fold; concomitant
edge shoulder adduction contracture; planning: neck: FP trapezoid
flaps planned; SC scars; shoulder: FL flexion lateral surface, scars; both
sheets of the fold are scars; planning of medial neck and edge shoulder
contractures elimination; (b) mobilized adipose-scar flap (FP), the
wound between the middle and lateral strips consists of: scar surface
deficit (Dt) of trapezoid form and DW donor wound; (c) 5 days after
operation, counter-­transposed flaps—neck contracture released; axil-
lary trapezoid flap edge shoulder contracture eliminated; (d, e) 2 weeks
after: medial neck and edge shoulder contractures eliminated
Lateral Neck “Medial” Contracture Anatomy

114
Treatment of medial contracture of lateral neck
Medial Contracture Treatment (Figs. 12.3, 12.4,
and 12.5)
Planning consists of several mapping lines: one line along
the crest of the scar fold and two radial lines that outline two
trapezoid flaps in the central cervical zone. The radial lines,
as a rule, form a trapezoid shape as the fold has a crescent
form. The distance between radial lines (incisions) at the fold
crest is about 5 cm depending on the patient’s age, contrac-
ture severity, and the length of the fold. The flap’s length
depends on the fold’s width and contracture severity. The
fold is converted to the trapezoid figures with radial lines.
After mapping, completed sheets are divided with an inci-
sion along the fold crest, and the pair of trapezoid flaps are
mobilized, including the subcutaneous fat layer, which
secures a steady blood circulation. The adipose-scar flaps are
counter-transposed with tension covering the wound and
elongating the lateral neck surface by more than 100%. The
flap’s free end reaches the base of the opposite flaps, and
fully covers the wound. In this position, flaps are sutured
together and to the wound’s edge. Bilateral neck contractures
can be reconstructed simultaneously using the same tech-
nique. Frequently, other contractures are eliminated simulta-
neously using trapeze-flap plasty (Figs. 12.4a and 12.5a).
Lateral neck contractures of the “medial” type are fre-
quently observed in children; they may be combined with
shoulder joint damage and anterior edge adduction contrac-
ture (Fig. 12.4a). Both contractures are eliminated simulta-
neously: the neck by one pair of adipose-scar trapezoid flaps
(Fig. 12.4a–e); the shoulder contracture is released with an
adipose-cutaneous trapezoid flap, mobilized in axillary fossa
(Fig. 12.4a, c, d).
Vast burns to one side of the body cause different types of
scar contractures; the “medial” type lateral neck contracture
is combined with edge contractures of shoulder and elbow
(Fig. 12.5a–d). Multiple contractures are eliminated in one
stage using specific variants of trapeze-flap plasty for treat-
ment of medial and edge contractures (Fig. 12.5a, d).
a
b
c
d
Fig. 12.5  Result of lateral
neck “medial” contracture
and “edge” shoulder
contractures treatment with
trapeze-flap plasty. (a) Before
operation: severe lateral neck
contracture and shoulder
adduction and elbow flexion
contractures; FL joint flexion
lateral surface covered with
scars, scars formed fold; FM
fold on lateral neck surface;
both sheets of the fold are
scars; (b) planning: two
opposite trapezoid flaps on
the neck (and one trapezoid
flap in axilla and elbow fossa,
not shown); (c) neck
contracture eliminated with
one pair of trapezoid
adipose-scar flaps; (d) edge
shoulder contracture
eliminated with one axillary
adipose-cutaneous flap,
elevated in axillary fossa. S
scars, CR crest of the fold,
FM scars, flexion medial
surface. “+” joint rotation
axis; FD fold, FL flexion
lateral surface
12  Lateral Neck Contractures: Anatomy and Treatment

115
Conclusion
Lateral neck scar flexion contracture is less common and
anatomically different from anterior contracture. There
are two forms (types) of lateral contractures: edge and
medial. Both types are characterized by a fold formation
along the central lateral cervical zone. In the fold sheets,
there is surface surplus that allows contracture treatment
and scar surface deficit (contracture cause) compensation,
which has a trapezoid form. As the scar sheet surface defi-
ciency has a trapezoid form (contracture cause), the opti-
mal reconstructive anatomically substantiated technique
for both types is based on trapezoid flaps (not triangular),
yielding excellent functional and good cosmetic
outcomes.
Suggested Reading
1. Grishkevich VM. Postburn neck lateral contractures: anatomy and
treatment. A new approach. J Burn Care Res. 2015;36:e294–9.
Suggested Reading

117
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Total Neck Anterior Scar Contracture:
Anatomy and Treatment with Local
Scar-Fascial Trapezoid Flaps
Introduction
One of the consequences of neck burns is neck scar defor-
mity and contracture. Cervical contracture in children leads
to functional impairment and has a profound psychological
impact on the child; it inhibits mandibular growth, deforms
the face, and creates kyphosis. Therefore, early surgical
reconstruction is indicated. Skin grafting has a higher rate of
contracture recurrence; in these cases, a flap seems to pro-
vide a durable solution. Despite the existence of multiple
neck reconstruction methods, successful elimination of neck
contracture remains a challenge for surgeons. A complete
neck reconstruction aims to (1) eliminate the contracture and
(2) restore the neck’s skin using pedicle (expanded and not
expanded) or free flaps.
There are cases, however, when it is simply impossible to
complete both tasks simultaneously. For these patients, con-
tracture elimination using local tissues seems to be a suffi-
cient and satisfactory solution. Because triangular flap plasty
methods do not allow for complete elimination of severe and
moderate neck contractures, we propose reconstruction
using scar-fascial trapezoid flaps. The flaps and reconstruc-
tive trapeze-flap technique are found to be reliable and suc-
cessful; this procedure allows for the scar contracture release
and neck contour restoration using local tissues [1, 2].
Anatomy of Postburn Total Neck Anterior
Contracture
Besides causing disfigurement of the burned open body part,
neck contractures have several anatomical features that pre-
determine the choice of plasty method (Fig. 13.1a–c). The
length of the anterior neck surface is shortened, the mento-
cervical angle is smoothed, and the scars protrude forward
mostly in the middle neckline forming the fold. Therefore,
the anterio-posterior neck distance becomes longer, the neck
thicker, and the lateral neck surface, larger. The crest of the
fold corresponds with the neck’s middle line. Both fold
sheets are scars that spread from the fold’s crest to the lateral
neck surfaces. In both fold sheets, there is a surface deficit in
length that causes a contracture, and a surface surplus in
width that allows for contracture elimination with local tis-
sues. The anterior neck contracture is of the “medial” type
and can be effectively eliminated with local trapezoid flaps.
Skin with the subcutaneous fat layer of anterior and lateral
neck surfaces was found to have an adequate axial blood
supply through perforators of the superficial cervical artery
(branch of subclavian artery, Fig. 13.2; see also Chap. 6). A
perforator exit is located posteriorly to the middle of the ster-
nocleidomastoid muscles (Fig. 13.1a, b; “+” symbol), as was
reported from research on cadavers (Chap. 6). Therefore,
healthy neck skin could be extensively mobilized without
platysma. Deep burns of the neck can also damage the sub-
cutaneous fat layer with perforators. In these cases, platysma,
deep cervical fascia, and sternocleidomastoid muscle fascia
are included in the flap, making the mobilization safe (scar-­
fascial trapezoid flap).
13

118
a
b
Fig. 13.1  Anatomy of neck anterior medial/total contracture and scar-­
fascial neck flap. (a, b) Vast scars cover the neck, face, and chest wall;
smoothed mentocervical and mentosternal angles; scars protruded for-
ward, forming the fold and making the neck anterio-posterior distance
longer; the crest passes along the middle cervical line; Symbol “+” per-
forator exit. (c) Two scar-fascial trapezoid flaps mobilized; exposed
sternocleidomastoid and neck muscles. Each flap includes half of the
anterio-lateral neck surface: scars, fat layer, plathysma, and fascia, cov-
ering the neck and sternocleidomastoid muscles
Fig. 13.2  Blood supplying the neck’s adipose cutaneous layer with a
perforator from the superficial cervical artery, the exit of which is
behind of middle part of sternocleidomastoid flap (see Chap. 6)
13  Total Neck Anterior Scar Contracture: Anatomy and Treatment with Local Scar-Fascial Trapezoid Flaps

119
Substantiation of the Scar-Fascial Flaps Use
in Neck Moderate Anterior Contracture
Treatment [1, 2]
The flap’s base is located at the level of the middle of the
sternocleidomastoid muscle and spreads from the mandibu-
lar angle to the clavicle middle point. As a rule, two trapeze-­
shaped figures (flaps) are outlined (Fig. 13.3a, b). The “+”
symbol indicates the cervical superficial artery perforator
exit. The flaps are mobilized from their top to their bases
(Fig. 13.3c). The anterior jugular veins remain in situ. The
deep fascia is separated from the neck muscles; the sterno-
cleidomastoid muscles are separated from the fascial sheet
on all their borders by incision of fascia along the anterior
edge of muscle. Thus, the anterior sheet of fascia is included
in
the
flap. Along
the
posterior
edge
of
the
­sternocleidomastoid muscle, the fascia is not incised.
Outside the mentioned muscles, the flaps were mobilized
only above the clavicles in order to preserve the perforators.
Consequently, the flaps include the scars, the fat layer, the
platysma, and the deep cervical fascia (scar-fascial flap).
After mobilization of trapezoid scar-fascial flaps, two trap-
ezoid wounds appear on the neck beside the medial strip
(Fig. 13.3c). The wound consists of: Dt–scar surface deficit
beside the donor wound (DW). Scar surface deficit is located
beside the DW; the surface deficit and donor wound have
trapezoid form. The mobilized opposite flaps (FP) are trans-
posed toward each other with tension, and the flap’s end
approaches the base of the opposite flap (Fig. 13.3d). The
tension should not cause an increase of resistance to air
movement in the endotracheal tube. The flaps are kept one
above the other (Fig. 13.3c–f). Some scars of the triangular
form in the submandibular zone are excised to shorten the
wound perimeter.
a
b
c
d
e
f
Fig. 13.3  Treatment of moderate neck anterior contracture with one
pair of scar-fascial trapezoid flaps. (a, b) Before surgery, vast scars,
smoothed neck angles, deformed mandibula; planning: FP two scar-­
fascial trapezoid flaps; “+” site of perforator exit; (c) scar-fascial trap-
ezoid flaps mobilized, two trapezoid wounds appeared beside the
medial strip: Dt scar surface deficit, DW donor wound, and FP flaps
have trapezoid form; (d–f) contracture fully released and neck contours
restored with counter-transposed flaps
Substantiation of the Scar-Fascial Flaps Use in Neck Moderate Anterior Contracture Treatment

120
Moderate-To-Severe (Total) Neck Medial
Contracture Elimination
The signs of contracture are more severe: scars protrude for-
ward and there is significant loss of mentocervical and men-
tosternal angles. Two trapezoid flaps are planned, one on
each side of the neck (Fig. 13.4a, b). Reconstruction is per-
formed in a manner similar to the previous case. After trap-
ezoid scar-fascial flaps mobilization (Fig.  13.4b), the
trapezoid wound appears on the neck (depicted with stripes).
Counter-transposed flaps covered the wound, scar surface
deficit compensated, and contracture was eliminated
(Fig. 13.4c–f). Two years later, the neck skin was restored
with expanded suprascapular flaps (Fig. 13.4g–i).
a
b
c
d
e
f
g
h
i
Fig. 13.4  Two-stage elimination of moderate-to-severe neck anterior
(total) contracture with one pair of scar-fascial trapezoid flaps; first- and
second-stage skin restoration with expanded scapular flaps. (a) Pre-­
operation view: the neck’s anterior-lateral surfaces are covered with
rough thick scars; planning: borders of one pair of trapezoid flaps
marked (FP); SC scars; in submandibular triangular figure of scars to be
removed; (b) scar-fascial trapezoid flap mobilized, a large wound
appeared consisting of two trapezoid wounds reflecting trapezoid scar
surface deficit (contracture cause) and trapezoid donor wound; neck
muscles exposed; (c) flaps counter-transposed; (d) 5 days after the oper-
ation; flaps covered the wound, scar surface deficit is compensated, and
contracture is eliminated; (e, f) result of first stage: contracture released,
the neck contours restored, and scars stay in situ; (g–i) result of second
stage operation (neck skin restoration) with expanded scapular flaps
13  Total Neck Anterior Scar Contracture: Anatomy and Treatment with Local Scar-Fascial Trapezoid Flaps

121
Severe Neck Contracture Treatment: Variants
of Wounds (Scar Surface Deficit) Covering
the Submandibular Region and Over
Clavicles and Manubrium
As seen in Figs. 13.5, 13.6, and 13.7, severe contracture is
eliminated with a pair of the trapezoid flaps in combination
with skin transplants. As mentosternal distance is greatly
shortened (Fig. 13.5a), the width of the flap becomes shorter
than in the previous variant. The planning (Fig. 13.5b, c)
and mobilization (Fig. 13.5d, e) are the same as described in
previously discussed cases. Counter-transposed flaps resur-
face the anterior cervical surface, but the small residual
wound in the submandibular area or just above the sternum
and clavicles, or in both these areas, remain uncovered by
the flaps and are skin grafted (Fig. 13.5f, g). A full range of
head motion and rotation are achieved (good functional
results) (Fig. 13.5h, i). Stooped posture due to neck contrac-
tures disappears after neck contracture elimination
(Fig. 13.5j, k).
a
b
c
d
e
f
g
h
i
j
k
Fig. 13.5  Case 1: Severe neck anterior medial contracture elimination
with scar-fascial trapezoid flaps and skin transplants. (a) Severe anterior
neck contracture; (b, c) flaps planning; (d) first two incisions in men-
tosternal angle projection and over clavicles and manubrium; (e) scar-
fascial trapezoid flaps are mobilized, which are narrower than usual; (f)
flaps (F) counter transposed; wounds above and below the flaps are not
covered, scar surface deficit (D) is larger than the flaps’ surface; (g) TR
wounds covered with skin transplants; FP flaps alive (2 weeks after sur-
gery); (h, i) result of surgery: contracture released, function and contours
of the neck restored, flap surface leveled; (j, k) stooping disappeared after
surgery. Case 2: Total severe neck anterior contracture elimination with
two-scar-fascial trapezoid flaps and two small wounds above clavicles,
which were skin grafted. (l, m) Pre-­surgery, planning; (n) scar fascial
flaps mobilized; (o) counter-­transposed flaps covered wound of neck,
small wounds above clavicles; (p, r) FP neck anterior surface covered
with flaps; TR small isolated wounds above clavicles were covered with
skin transplants; 7 days after reconstruction, flaps and skin transplants are
alive, contracture is eliminated, and the mentocervical angle is restored
Severe Neck Contracture Treatment: Variants of Wounds (Scar Surface Deficit) Covering the Submandibular Region

122
l
m
n
o
p
q
Fig. 13.5  (continued)
13  Total Neck Anterior Scar Contracture: Anatomy and Treatment with Local Scar-Fascial Trapezoid Flaps

123
a
b
c
d
e
f
g
i
j
h
Fig. 13.6  Mentosternal
fusion treatment with
adipose-scar trapezoid flaps
and skin grafts in children. (a)
Pre-surgery view; (b, c)
planning; (d) scar-fascial
flaps, shorter and narrower
than usual, mobilized on
lateral surfaces of the neck;
(e) 7 days after the operation:
flaps covered the central zone
of the neck anterior surface,
wounds beside the counter-­
transposed flaps connected
flaps covered with skin
transplants; (f) result; (g)
mild-to-moderate contracture
developed 10 years later,
planning of second stage
operation; (h) adipose-scar
trapezoid flaps mobilized and
counter-transposed; (i, j)
1 year after reconstruction:
contracture removed, neck
contours restored, good
common appearance
Severe Neck Contracture Treatment: Variants of Wounds (Scar Surface Deficit) Covering the Submandibular Region

124
a
b
c
e
d
f
g
Fig. 13.7  Mentosternal
fusion treated with two
scar-fascial trapezoid flaps
and skin transplant above
clavicle and sternum. (a, b)
Pre-surgery; view after burns
skin grafting; TR skin
transplant; SC scars; (c)
planning operation with two
flaps; (d) two scar-fascial
flaps mobilized; (e) flaps (FP)
covered the most part of the
wound, starting from the
submandibular area;
clavicular zone of the wound
was covered with skin
transplant (TR); 13 days after
surgery: flaps and transplant
are alive, contracture is
released, and the neck
contours restored; (f, g)
2 months after operation;
contracture is released and
neck contours are restored
significantly
13  Total Neck Anterior Scar Contracture: Anatomy and Treatment with Local Scar-Fascial Trapezoid Flaps

125
Mentosternal Scar Fusion: Anatomy
and Treatment
In cases of mentosternal scar fusion (Fig. 13.6, child; Fig. 13.7,
adult), where the central part of neck surface is obliterated,
trapezoid scar-fascial flaps are planned and mobilized on the
lateral cervical surfaces (Fig.  13.6a–c). Treatment of men-
tosternal fusion with scar fascial trapezoid flaps is particularly
effective in children. With transverse incision, the chin is sepa-
rated from the manubrium; then, the flaps are elevated on the
lateral neck surfaces using the usual procedure. Short flaps
cover the central part of the wound. In the submandibular and
supraclavicular regions, wounds are resurfaced with skin
transplants (Fig. 13.6d, e) with good results (Fig. 13.6f). In
children, the flap’s surface becomes larger with time, but re-
contracture can appear. This is removed with mobilization and
counter-transposition of the same enlarged scar-fascial flaps
prepared on all neck anterior surfaces (Fig.  13.6g–j). Scar-
fascial flaps continue to grow, which allows complete contrac-
ture release without using skin transplants. The flap’s growth
is accompanied with changes in the flap scar surface, the qual-
ity of which improves common appearance.
In adults, at the first stage of the operation, scar-fascial flaps,
harvested from the lateral cervical surfaces, can cover only the
medial part of the neck anterior surface; wounds beside the
flaps are skin grafted (Figs. 13.7a–g and 13.8). If the scars are
immature and, therefore, contracture is not completely released
because the scars continue to undergo contraction, the second
stage of reconstruction is indicated 1 year later.
Chin-manubrium fusion should be released early, after the
wound has healed (Fig.  13.8a–e). Adipose-scar trapezoid
flaps, taken on both lateral surfaces of the neck, cover a cen-
tral part of the neck anterior surface. The wounds beside the
flaps are skin grafted (Fig. 13.9a–c). Since the scar is imma-
ture, flaps and skin grafts continue to shrink; therefore, a sec-
ond, similar, operation is indicated after tissue maturation.
a
b
d
e
c
Fig. 13.8  Results of
mentosternal scar fusion
treatment in adults with two
scar-fascial (in mature scars)
trapezoid flaps, prepared on
the lateral neck surfaces, the
wounds beside the flaps
covered with skin transplants.
(a, b, c) Pre-surgery,
trapezoid flaps (FP) planned
(one flap includes tissue of
each lateral surface) flap;
(d, e) result of first stage
(2 months after
reconstruction)
a
b
c
Fig. 13.9  Follow-up results
(5 years after surgery) after
severe total neck contracture
treatment with scar-fascial
trapezoid flaps; microstomia
(edge contracture) released
with trapezoid flaps. (a)
Pre-surgery, planning; (b, c),
contracture released, neck
contours and submandibular
angle restored
Mentosternal Scar Fusion: Anatomy and Treatment

126
Conclusion
Neck total (anterior) contracture is fully eliminated with
one pair of local new scar-fascial trapezoid flaps alone or
in combination with skin transplants. This technique is
single-stage, can be performed early after burns and is
indicated if reconstruction with adipose-cutaneous flaps
is impossible or not desired. Two factors prevent contrac-
ture recurrence: the trapezoid scar-fascial flaps continue
to grow, and the shrinkage of skin transplants is of a
degree that does not cause recurrence.
References
1. Grishkevich VM. Trapeze-flap plasty: effective method for postburn
neck contracture elimination. Burns. 2010;36:383–8.
2. Grishkevich VM, Max G, Menzul VA. Postburn neck anterior con-
tracture treatment in children with scar-fascial local trapezoid flaps:
a new approach. J Burn Care Res. 2015;36:e112–9.
13  Total Neck Anterior Scar Contracture: Anatomy and Treatment with Local Scar-Fascial Trapezoid Flaps

127
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Lateral Truncal Medial Contractures:
Anatomy and Treatment with Local
Adipose Scar Trapezoid Flaps
Introduction
Trunk burns result in various complications, deformities, and
contractures. Contracture of the lateral surface of the trunk is
a serious complication that limits movements of the spine; in
children, scoliosis can develop. Therefore, lateral truncal
contracture should be the subject of early surgical treatment.
The method currently used is stage-by-stage incisions on the
contracture scars and skin grafting or Z-plasty. Skin grafts
tend to shrink. Triangular flaps are too short to completely
eliminate contracture. The need for a more effective surgical
technique is apparent. Lateral truncal contracture is caused
by scars located on the truncal lateral surface, which form a
crescent fold. Both sheets of the fold are scars and according
to our classification this contracture belongs to medial type.
The fold’s sheets have a trapezoid-shaped surface deficit in
length, which causes the contracture and creates the scar sur-
face surplus in width, which allows contracture elimination
with local trapezoid flaps and leads to good outcomes.
Anatomical Features of Lateral Truncal
Contractures
Contracted scars on the lateral truncal surface form a
crescent-­shaped fold in adults and children (Figs. 14.1 and
14.2). Both fold sheets are scars (medial contracture, flexion
medial surface). If the fold is short, or involves trunk anterior
and posterior surfaces, breast, axilla, shoulder, and pelvis, it
causes shoulder adduction and inguinal contractures. The
scars spread from the fold’s crest to the anterior and posterior
truncal surfaces, smoothing the waist excavation; the breast
is deformed and displaced downward (Fig. 14.1). Scoliosis
may develop in children. Each scar sheet and contracted
neighboring scars have a surface deficit in length, which
causes the contracture and creates the scar’s surface surplus
in width, which allows contracture elimination with local tis-
sues (Fig.  14.2a, b). After transverse fold dissection with
Y-incisions (Fig. 14.2c) and trunk straightening, the appear-
ing wounds, as a rule, take the trapezoid form. Consequently,
the size and form of the wound is a scar surface deficit and a
cause of contracture. The local flaps must therefore be of a
trapezoid shape and match the size and form of the scar sur-
face deficiency (Fig.  14.2c–e). Contracture treatment with
local tissue can be described as scar surface deficit compen-
sation with local adipose-scar trapezoid flaps.
14

128
Fig. 14.1  Anatomy of lateral scar truncal contracture. Vast scars
caused multiple contractures (trunk, shoulder joint, breast). Scars
formed a long fold (Fd), both sheets of which are scars (FM); crest of
the fold (Cr). The crescent fold spreads from iliac bone to elbow; both
sheets of the fold are scars—sign of medial contracture
14  Lateral Truncal Medial Contractures: Anatomy and Treatment with Local Adipose Scar Trapezoid Flaps

129
a
b
d
e
c
Fig. 14.2  Scar surface deficit as real cause of truncal medial contrac-
ture. (a, b) Trunk covered with skin transplants; fold along lateral sur-
face of trunk caused medial contracture: both sheets are scars; planning
two pairs of adipose-scar trapezoid flaps (FP); FM flexion medial sur-
face, scars; (c) flaps mobilized; anatomy of wound: FP flap; Dt scar
surface deficit in both halves of the wound, which has trapezoid form;
DW donor wound; (d) flaps counter-transposed; (e) end of operation,
contracture released
Anatomical Features of Lateral Truncal Contractures

130
Elimination of Lateral Truncal Medial Scar
Contracture with Trapeze-Flap Plasty [1]
For contracture release and trapezoid wound closure with
local tissues, the fold and neighboring contracted scars
should be converted into trapezoid flaps. This is achieved by
Y-shaped radial incisions of contracted tissues, because the
fold has a crescent form (Figs. 14.2, 14.3, and 14.4). The
radial incisions and flaps are marked prior to surgery. The
distance between the lines at the fold’s crest is 4–5 cm, which
determines the width of the flaps’ end. The number of flaps
to be planned depends on the contracture severity and the
length of the fold. Since the fold is crescent-shaped, the end
of the flap is narrower than the flap’s base, thus forming the
trapezoid shape.
Mild-to-moderate contracture has a short fold that is
located below and lateral to the breast (Fig. 14.3). The long
fold along its extent is converted into trapezoid flaps; shoul-
der adduction contracture is reconstructed simultaneously,
using a specific local-flap trapezoid procedure (Figs.  14.4
and 14.5). Scars located proximally and distally from the
opposite transposed flaps can be excised and the wound is
primarily closed or skin grafted (Fig. 14.4). The fold on its
extent is converted into trapezoid adipose-scar flaps. The flap
surfaces are usually enough for elimination of both contrac-
tures (Fig. 14.3).
Surgical details (Figs. 14.2 and 14.3): The sheets of the
fold are divided by an incision along the fold’s crest. With
radial Y-shaped incisions corresponding to the marked lines,
both sheets are transected. The flaps are mobilized with the
full subcutaneous fat layer, which guarantees a steady blood
circulation. Contracted fascia covering truncal muscles can
also be transected as part of the flap. After adipose-scar flap
elevation, the trunk straightens with some over-correction.
The wound accepts a trapezoid shape. The flaps are then
transposed one toward another with tension until the flap end
reaches the base of the opposite flap. Because of flap tension,
the bases of the opposite flaps come closer; the neighboring
skin of anterior and posterior truncal surfaces is displaced on
a wound; the wound becomes narrower and the soft tissues
are squeezed. As the wound surface is diminished, the flap
surface becomes sufficient for wound closure, and contrac-
ture is eliminated without skin grafting. If the contracture is
not completely released by one flap pair, one or two pairs of
adipose-scar flaps are additionally elevated, until the con-
tracture is eliminated completely. After complete contracture
release and counter flaps transposition, rough scars can be
excised. It was also observed that operational scars among
burn scars have no tendency for hypertrophic growth.
The contracted scar and fold located on the truncal lateral
surface smooths waist excavation and changes the form and
position of the breast. The breast is displaced laterally/poste-
riorly and downward. Therefore, the trapezoid adipose-scar
flaps are planned below the submammary fold level and pos-
terior to it (Fig. 14.4a, c). After contracture release and trap-
ezoid adipose-scar flap counter transposition, the lateral
trunk accepts the normal form, and the position of the breast
is normalized (Fig. 14.4b, d).
Scars covering the trunk and axillary region can form sev-
eral contractures along the long fold. The fold in axilla can
split, forming an anterio-posterior edge shoulder adduction
contracture. Since the contracted scar can cause scoliosis in
children, early operation is indicated. Both contractures are
eliminated in one stage, as shown in Fig. 14.5.
14  Lateral Truncal Medial Contractures: Anatomy and Treatment with Local Adipose Scar Trapezoid Flaps

131
a
b
e
b
Fig. 14.3  Elimination of lateral truncal medial contracture and poste-
rior axillary edge contracture with trapeze-flap plasty. (a) Before sur-
gery, contracture anatomy: Fd fold, FM scar sheets of the fold; Cr crest
of the fold; (b) planning truncal contracture elimination with one pair of
adipose-scar trapezoid flaps (FM); (c) axillary contracture was first
removed with two trapezoid flaps; truncal adipose-scar trapezoid flaps
mobilized, two trapezoid wounds appeared; flaps and wounds (scar sur-
face deficit or contracture cause) marked; (d) 5 days after reconstruction
of the truncal and axillary contractures; (e) 2 years after reconstruction:
contractures eliminated, good functional and cosmetic outcomes
Elimination of Lateral Truncal Medial Scar Contracture with Trapeze-Flap Plasty

132
d
e
Fig. 14.3  (continued)
14  Lateral Truncal Medial Contractures: Anatomy and Treatment with Local Adipose Scar Trapezoid Flaps

133
a
b
c
d
Fig. 14.4  Lateral truncal
medial contracture
elimination with one pair of
adipose-scar trapezoid flaps
(two cases). (a, c) Before
surgery: right-side lateral
truncal contracture, flaps
planning below submammary
fold level; (b, d) 2 weeks and
1 week after reconstructions:
contracture is eliminated,
waist excavation and breast
form and position are
restored; flaps are alive
Elimination of Lateral Truncal Medial Scar Contracture with Trapeze-Flap Plasty

134
a
b
c
d
Fig. 14.5  Anatomy and
treatment of medial severe
truncal lateral contracture and
bilateral edge shoulder
adduction contracture in
children. (a) Anatomy; FM
flexion medial surface, both
fold sheets are scars; Fd fold;
Cr fold crest; planning: three
pairs of adipose-cutaneous
trapezoid flaps marked on
lateral trunk; (b) adipose-scar
trapezoid flap mobilized from
left (anterior) fold sheet;
anatomy of wound: FP flap;
DW donor wound; Dt scar
surface deficit. Right
(posterior) sheet dissected
with Y-incision, trapezoid
wound (Dt-deficit) appeared;
(c) truncal contracture is
eliminated with counter flaps
transposition; the shoulder
contracture is eliminated with
quadrangular subcutaneous
pedicle flap; (d) 2 weeks after
surgery: flaps are alive,
contractures completely
removed; contours of the
trunk and axilla are restored
14  Lateral Truncal Medial Contractures: Anatomy and Treatment with Local Adipose Scar Trapezoid Flaps

135
Conclusion
Immature keloid scars do not present a contraindication
for surgery; after reconstruction, the scars become more
level, softer, and thinner. The lateral truncal contractures
are completely eliminated with the single-stage trapeze-
flap plasty. Tissue necrosis, flap loss, or other postopera-
tive complications did not occur. The flap’s tension and
soft tissue compression disappear 2–3 months after sur-
gery due to growth of the stretching tissues. The surface
of the trapezoid adipose-­scar flaps does not decrease. In
children, the flaps continue to grow, preventing contrac-
ture recurrence and scoliosis. Surgical scars become
scarcely visible among the mature burn scars.
Reference
1. Grishkevich VM. Trapezoid adipose scar local flap: postburn lateral
truncal contracture elimination with trapeze-flap plasty. J Burn Care
Res. 2010;31:949–54.
Reference

137
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Restoration of the Shape, Location,
and Skin of Severely Burn-Damaged
Breast
Anatomy of the Burn-Damaged Breast
Burns of the anterior chest wall in prepubescent females
result in scar contracture. The scars covering the breast bud
are unyielding and stretching. If the release of the contrac-
ture is ill-timed, during the period after puberty, the breast
parenchyma develops and grows under scars, acquiring a
hypoplastic and flattened form. The breast is deformed, and
the mound is often partially or completely smoothed out. The
breast shifts toward the area of least resistance, and the con-
tours of the breast are undefined (Figs. 15.1 and 15.2). Scar
contractures lead to significant breast asymmetry and dis-
placement of the nipple-areolar complex. Often, the opposite
breast and lateral truncal surface are deformed by contracted
scars that are removed simultaneously. This is the most
severe form of postburn breast deformity, the resurfacing of
which still poses a challenge for plastic surgeons.
15
Fig. 15.1  Anatomy of postburn right breast: tissue defect, contracture,
and deformity (flattened breast, inframammary fold smoothed out)

138
a
b
c
e
f
h
i
g
j
k
l
m
n
d
Fig. 15.2  New technique of postburn damaged breast reconstruction
using scar excision, parenchyma mobilization, forming sutures, and skin
grafting. (a) Before surgery. Right breast flattened and hypertrophic, con-
tracture of the left breast; (b) borders of scar excision; (c, d) deformed
scars excised and scar areolar island is preserved; breast parenchyma is
mobilized; (e, f) forming sutures are placed; suture ends pierce the skin
beyond the wound; (g) the breast formation is complete, abdominal scars
are excised, primary wound closure is done; (h) breast covered with split
skin transplants; (i) tie-over dressing, sutures tied over tampons (arrows);
(j) forming suture placement (scheme); (k) 7 days after operation, three
forming sutures tied over tampon, transplant and abdominal flaps alive; (l)
3 months after surgery; (m, n) result (1 year and 5 years after surgery)
15  Restoration of the Shape, Location, and Skin of Severely Burn-Damaged Breast

139
Surgical Technique [1]
The most adequate and effective method for treating severe
breast contractures should be able to restore all three compo-
nents of the deformity: shape, location of the breast and
nipple-­areolar complex, and breast skin.
The breast parenchyma borders are visually and palpably
defined and marked (Fig. 15.3a). A round scar area is marked
in the nipple-areolar area corresponding (matching) to the
diameter of the undamaged breast; the suture is led through
the round-scar area (Fig. 15.2c, d). This suture will serve as
a breast holder during surgery.
The mild-to-moderate edge anterior axilla contrac-
ture is eliminated in one stage with breast reconstruction
(Fig.  15.3a–d); the severe total axilla contracture release,
which lessens the breast scar tension, should precede the
actual breast reconstruction (Fig. 15.4). Then, all the scars
are excised over the entire parenchyma surface (Fig. 15.2b,
c). The incision is made down to the chest wall fascia
(Fig. 15.2c). The displaced part of parenchyma along with
the fat layer is detached from the fascia to the borders of
the undamaged opposite or normal breast (Fig. 15.2d, e) (in
cases of bilateral deformities). The symmetrical form and
positioning are achieved by circularly led sutures, using
the mattress stitches, which are led through the fat layer
through different levels of the breast (Fig. 15.2e, f; see also
Fig. 15.6d). The suture ends are led out through the skin and
beyond the wound area and are affixed in a place opposite
the breast displacement.
The first forming suture is led out near the scar-areola,
and with the use of tension the nipple-areolar complex posi-
tioning is normalized. Using the second or second and third
forming sutures led out near the base and the middle area of
the breast, the symmetrical form and positioning corre-
sponding to the positioning of the undamaged breast is
achieved. Special attention is given to the recreation of the
inframammary fold. At this preliminary stage of correction,
the ends of the strained sutures are led out and tied into
untightened knots around tampon (Fig. 15.2e). The wound
around the breast is then narrowed down with the transposi-
tion of mobilized adjacent chest or abdominal wall tissues
(Fig. 15.2f). The breast wound is covered with a thick split-
thickness skin graft, which is affixed to the adjacent tissues
using the tie-­over bolster dressing in the compression state
for 5 days (Fig. 15.2d, e). Prolene (3/0) sutures are used;
they are left in for about 3 months. During this time the form
and the positioning of the breast can be corrected if neces-
sary using traction of the untied sutures; the skin transplants,
under which the scar tissue is being formed, are stabilized.
Skin transplant and the scar tissue growing under the skin
graft hold the shape and positioning of the breast; the sutures
can be removed at this stage. The result is shown in
Fig. 15.2i–k, and the scheme of reconstruction in Fig. 15.2j.
The use of forming sutures is indicated in all cases of severe
breast deformity (Figs.  15.2, 15.3, 15.4, 15.5, 15.6, 15.7,
15.8, and 15.9) regardless of the method used for wound
coverage (skin grafting, flap expansion, free flap, etc.)
(Figs. 15.3 and 15.4).
There are many variations of breast skin and parenchyma
deformities, depending on the extent and depth of injury. In
all cases, the ultimate goal is to preserve healthy skin, which,
if possible, should undergo expansion. Regardless of the
method selected for wound covering, the technique of paren-
chyma formation remains unchanged (Fig. 15.5a–f).
Often, the opposite breast and lateral truncal surface are
deformed by contracted scars, which are removed simultane-
ously (Figs. 15.2 and 15.6a–h).
The deficit of breast parenchyma is compensated for by
mobilization of a fat flap laterally and below from borders of
the normal breast where the flap’s pedicle is located
(Fig.  15.7). The fat flap includes a deep subcutaneous fat
layer, which is separated from the fascia, covering the tho-
racic muscles. Mobilized from the periphery, the flat fat flap
is displaced to the parenchyma, modeling the needed form.
The flap is fixed to parenchyma with catgut; only after that
are the modeling sutures used (Figs. 15.7c, 15.8, and 15.9).
Surgical Technique

140
a
b
c
e
f
g
d
Fig. 15.3  Restoration of the severely deformed left breast using form-
ing sutures, and edge anterior axilla contracture elimination with one
adipose-cutaneous trapezoid flap elevated from axillary fossa (trapeze-­
flap plasty). (a) Pre-surgery: scar boundaries and axilla trapeze-flap
plasty delineated: FP flap, “+”—joint rotation axis; FL scars on joint
flexion lateral surface; (b, c) axilla contracture released, scar excised,
parenchyma mobilized, forming circular suture is led through fat layer;
(d) formed breast covered with adjacent tissue displacement and skin
transplant; the axillary contracture is released with trapeze-flap plasty;
(e) compression by tie-over bolster dressing; (f, g) 3 weeks after sur-
gery, two forming sutures tied over gauze tampons, small zones of
transplant necrosis, and wound skin grafted
15  Restoration of the Shape, Location, and Skin of Severely Burn-Damaged Breast

141
a
b
d
e
c
Fig. 15.4  Severe deformed breast reconstruction after severe total
shoulder adduction contracture elimination. (a) Before surgery, severe
right breast deformation and total shoulder adduction contracture; (b)
first, total shoulder adduction contracture eliminated with quadrangular
subcutaneous pedicle flap and skin transplants (10 days after surgery);
(c) 6 months later: scars over breast parenchyma are excised, the breast
is formed from flattened parenchyma and the subcutaneous fat layer;
lateral truncal contracture is released with local tissues and skin trans-
plants; the large wound is covered with skin transplants; (d, e) 2 years
after surgery
Surgical Technique

142
a
b
c
d
e
f
Fig. 15.5  Postburn breast reconstruction with expanders, parenchyma
formation, and skin transplant. (a, b) Severe deformities of both breasts,
remnant and adjacent tissue extension with expanders; (c–e) 10 days
after surgery. (f) Forming sutures restored the symmetrical shape and
positioning of both reconstructed breasts despite the use of various skin
resurfacing methods: extended healthy tissues (left breast) and skin
transplants (right breast)
15  Restoration of the Shape, Location, and Skin of Severely Burn-Damaged Breast

143
a
b
c
d
e
f
g
h
Fig. 15.6  Reconstruction of the breast was accomplished using form-
ing sutures; and severe abdominal scar deformity excision with pri-
mary wound closure. (a) Before surgery: severely contracted,
deformed, and displaced right breast, severe trunk deformation; (b)
planning, borders of scar excision; (c, d) scars removed, flattened
parenchyma connected with forming sutures; (e) during operation; (f)
breast covered with skin transplants; (g) 1 month after surgery, ends
of forming sutures connected over gauze tampons beside the skin
transplant; (h) 1 year after operation: breast grows; its size, form, and
skin are close to normal
Surgical Technique

144
a
b
c
d
e
f
Fig. 15.7  The deformed
breast with severe soft tissue
deficit reconstructed by
addition to parenchyma
neighboring fat layer and the
forming sutures. (a, b) Before
surgery: flattened left breast,
inframammary fold smoothed
out, planning of scar excision;
(c) scars excised, flattened
parenchyma and neighboring
fat layer separated from
thoracic muscles
symmetrically with the
borders of the undamaged
breast; (d) due to forming
sutures, parenchyma and fat
layer accepted a form similar
to that of the undamaged
breast; (e, f) follow-up result:
breast continued to grow and
preserved normal shape,
position, and skin (3 years
after surgery)
15  Restoration of the Shape, Location, and Skin of Severely Burn-Damaged Breast

145
Fig. 15.8  Reconstructed right breast has normal shape, size, and posi-
tioning. The breast grows during pregnancy. Two years and 6 months
after surgery
a
b
c
Fig. 15.9  Two examples of results of left breast restoration with forming
sutures and skin grafting; left shoulder edge anterior contracture elimination
with trapeze-flap plasty. (a) Case 1: 5 days after breast reconstruction and
shoulder joint contracture release; two forming sutures support the breast’s
form; edge shoulder adduction contracture eliminated with one axillary
adipose-cutaneous trapezoid flap; skin transplants without complication; (b)
6 months after surgery: breast form, location, and skin close to contralateral
healthy breast; edge anterior shoulder adduction contracture eliminated;
breast-axillary region has good appearance. (c) Case 2: 2  months after
reconstruction; forming sutures support the normal shape of the breast
Surgical Technique

146
Conclusion
The mobilized breast parenchyma did not die off. The
form and the positioning of the breast and nipple-areo-
lar complex remaind stable. The breasts enlarged over
time, which decreased or smoothed the asymmetry of
the breasts. It was noticed that the earlier the recon-
struction surgery took place in the post-pubertal period,
the lower the occurrence of hypoplasia and the better
the results. During pregnancy, the reconstructed breast
was enlarged symmetrically with the undamaged breast.
Skin transplants gradually transformed into well-func-
tioning skin with regard to all its characteristics (color,
elasticity, and texture), and the breast surface was
leveled.
Reference
1. Grishkevich VM. Restoration of the shape, location and skin of the
severe burn-damaged breast. Burns. 2010;35:1026–35.
15  Restoration of the Shape, Location, and Skin of Severely Burn-Damaged Breast

147
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Shoulder Edge Anterior Adduction
Contracture: Anatomy and Treatment
with Axillary Adipose-Cutaneous
Trapezoid Flap
Introduction
The shoulder adduction contracture is the most common of
all large joint contractures; it restricts all upper limb func-
tion. Therefore, much attention is given to treatment of its
postburn outcome. Because the shoulder rests in the adducted
position, skin graft shrinkage becomes inevitable, and tech-
niques based on triangular flaps are anatomically not sub-
stantiated and contracture is often not released fully. Based
on careful study of the anatomical features of contractures, a
more efficient surgical technique for edge scar shoulder
adduction contracture elimination was developed.
Shoulder Edge Adduction Contracture
Anatomy
Functional Zones of the Shoulder Joint Surface
Before surgery, the surface of the shoulder joint is divided
into functional zones: extension surface (E) and flexion sur-
face (F) (Fig.  16.1). The boundary between them passes
along the joint rotation axis level (“+”). The joint F-surface
has a curvature (Cr) of nearly 90°, caused by the pectoralis
major muscle edge. The curvature divides the F-surface into
two zones: flexion lateral (FL) and flexion medial (FM). The
dividing line passes along the anterior edge of the axillary
fossa (Cr). The FL surface spreads from the anterior edge of
the axillary fossa to the joint rotation axis (“+”). The FM
surface lies between the fossa edges (axillary fossa).
Anatomy of Shoulder Joint Edge Anterior
Adduction Contracture
Edge shoulder contracture is caused by scars covering the
flexion lateral surface (FL) and forming scar sheet of the fold
(Fd) (Fig. 16.2a, b). Contracture has specific anatomical fea-
tures and clinical signs: (1) contracted scars are located on
the joint anterior flexion lateral surface, which includes the
fold (FL and Fd); (2) the fold presence, which passes along
the anterior edge of axillary fossa; (3) the fold consists of
two sheets having different qualities: the lateral sheet is scar,
a continuation of scars of the flexion lateral surface; the
medial sheet is healthy skin, a continuation of the axillary
fossa skin; and (4) the crest of the fold is the edge of scars.
The fold is a new anatomical formation, tissue surface sur-
plus of scars and healthy skin, participating in scar surface
deficit compensation and contracture elimination.
16

148
Fig. 16.1  Functional zones of joint surface and edge shoulder contrac-
ture anatomy. E extension surface; “+” joint rotation axis. F flexion
surface is divided by curvature on flexion lateral (FL) and flexion
medial (FM) surfaces; scars of FL surface grow distally and form the
Fd fold along the fossa’s edge; Cr crest of fold is edge of scars
a
b
Fig. 16.2  Anatomy of edge shoulder anterior adduction contracture.
(a) E extension surface; FL flexion lateral surface. Scars located on
flexion lateral surface form the fold along an edge fossa, which has
crescent shape; “+” joint rotation axis; Fd the fold consists of two
sheets; the lateral sheet of the fold is scars and continuation and a part
of the flexion lateral (FL) surface and scar surface surplus; Cr crest of
the fold is the edge of scars and is located between the flexion lateral
and flexion medial surfaces. (b) FM the flexion medial surface is axil-
lary fossa, healthy skin; Fd the medial fold’s sheet is healthy skin, con-
tinuation of FM surface, healthy skin surplus
16  Shoulder Edge Anterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap

149
Scar Fold’s Sheet Surface Deficit Is True
Contracture Cause
Contracture is caused by the scars covering the FL surface
and spreading from the fold crest to the joint rotation axis.
Thus, the fold elongates the contracted scars in width.
Simultaneously, growing distally, scars of the flexion lateral
surface and fold undergo contraction, and scar surface in
length, between the shoulder and chest wall, becomes insuf-
ficient and the scar surface deficit appears, which causes a
shoulder adduction. Contracture treatment is aimed at scar
surface deficit compensation. Therefore, it is important to
know scar surface deficit form, size, and location in order to
choose an adequate flap and technique. The size and form of
the surface deficit is estimated in the following way: The
fold’s sheets are divided with an incision along the fold
crest. Then, the scar is dissected with a perpendicular
Y-incision from the fold’s crest to the joint rotation axis.
After shoulder abduction, as a rule, the trapezoid-shaped
M-wound appears on the anterior shoulder joint surface or
scar surface deficit (Dt), or real contracture cause (Figs. 16.3,
16.4b, and 16.5c). The wound or scar surface deficit in
length is maximal at the fold’s crest and spreads, subsiding,
to the shoulder joint rotation axis where a M-lineal size
equals 4–5  cm in length. With shoulder abduction, the
wound edge divergence is more severe and the M–end of the
wound becomes twice as long and straight. Consequently,
the adequate contracture elimination technique consists of
scar surface deficit compensation with the corresponding
(trapezoid) form and size of the flaps.
a
b
Fig. 16.3  Trapezoid scar surface deficit of anterior FL flexion lateral
surface and lateral fold’s sheet is contracture cause. (a) E extension
surface; “+” joint rotation axis; FL flexion lateral surface from the
fold’s crest to the joint rotation axis; the lateral fold’s sheet is scar tis-
sue, the medial sheet is healthy skin; the crest of fold is edge of scars;
FM the flexion medial surface or axillary fossa is healthy skin. Scars of
FL surface, growing distally, form a fold along the fossa edge; the lat-
eral sheet of the fold is scars and part of the FL surface; the medial
fold’s sheet is part of the FM or fossa’s skin. Defining contracture cause
and planning of operation: solid lines: Y—scars of FL surface incision
from the fold crest to the joint rotation axis; line of sheet division; bor-
ders of the trapezoid flap in axilla or FM surface; (b) the fold’s sheets
divided with an incision along the crest, contracted scars dissected with
a Y-incision to the joint rotation axis (symbol “+”), a large wound
appeared, which is Dt—scar surface deficit trapezoid form (upper of
line), maximal deficit is at fold crest and spreads to the “+”—joint rota-
tion axis, where it is nearly 5 cm in length; trapezoid adipose-cutaneous
flap—FP—mobilized; DW donor wound
Shoulder Edge Adduction Contracture Anatomy

150
a
d
e
c
b
Fig. 16.4  Shoulder edge mild-to-moderate anterior adduction con-
tracture elimination with one axillary adipose-cutaneous trapezoid
flap. (a) Pre-surgery, planning; (b) the fold’s sheets are separated with
an incision along the fold crest; contracted scars of the FL surface are
dissected with a Y-incision, a trapezoid wound (scar deficit [Dt] and
contracture cause) appeared (upper strip), trapezoid adipose-cutane-
ous flap (Fp) mobilized; DW donor wound; (c) 10 days after opera-
tion: contracture released, flap alive; (d) follow-up results: normal
joint function and contours; (e) scheme of trapezoid-flap plasty with
one flap
16  Shoulder Edge Anterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap