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

152
Surgical Technique [1]
Several variants of trapezoid-flap plasty were developed
depending on contracture and scar surface deficit severity.
Mild-to-Moderate Contracture Reconstruction
with One Trapezoid Flap
Planning consists of marking four lines: (1) a line along the
fold’s crest; (2) a perpendicular line for scar dissection; and
(3) two trapezoid flap borders (Fig. 16.4a). With experience,
it became clear that the flap had to be planned to be 30–40%
wider than the estimated wound width. With the first incision
along the fold’s crest, the sheets are divided, and the scars are
separated from healthy skin; next, the perpendicular Y-shaped
incision dissects the scar and subcutaneous fat layer to the
pectoralis major muscle fascia from the fold’s crest to the
joint rotation axis. Nearly 3 cm to the joint rotation axis level,
the incision is split at 45°, forming a 90° angle. The Y-shaped
incision separates the scars on the lateral joint extension sur-
face (FL) from the tissue of the joint extension (E) surface,
and thus allows for an easy scar edge divergence and com-
plete contracture release. At the time of shoulder abduction,
the scar’s edges diverge, and the wound accepts an M-shape
(Figs. 16.4c, d and 16.5c). Pectoralis major fascia is incised
(not excised) if it restricts shoulder adduction. Then, the flap,
including the medial sheet and axillary fossa adipose-cutane-
ous layer, is elevated to the opposite axillary edge (latissimus
dorsi muscle). The deep axillary fat layer and lymph nodes
covered with superficial fascia remain in situ. The flap’s end,
nearly 6  cm in width, is perpendicularly dissected, nearly
3 cm in depth, to correspond to the M-shaped wound’s end.
The flap’s width should exceed the wound, because during
traction the flap becomes narrower and longer.
The flap is advanced on the wound with moderate ten-
sion and sutured to the wound’s border. As a result of flap
advancement with tension, the flap’s base and axillary edge
approached the opposite axillary edge, diminishing the
donor wound; axillary fossa become narrower or obliter-
ated as latissimus dorsi and pectoralis major edges reach
each other. Then, the angles of the scar sheet are connected
to the flap’s base, covering the donor wounds beside the
flap (Fig. 16.4c). This is trapezoid-flap plasty with one flap
(Fig. 16.4e).
Elimination of Shoulder Edge Contracture
with Two Trapezoid Flaps
In cases of more severe contractures and scar surface defi-
ciency, two-flap plasty is performed (Fig.  16.5). After the
division of the sheets, scar dissection with a Y-incision, and
shoulder abduction, the wound’s edges are separated, and
the trapezoid wound appears (Fig. 16.5b, c, upper strip).
The trapezoid flap mobilization and its transposition on the
wound are similar to the previous variant, but more severe
scar surface deficit does not allow for the angles of scar sheet
to reach the flap’s base and cover the donor wounds beside
the flap (main adipose-cutaneous flap). In such a condition,
the one trapezoid adipose-scar flap is prepared from the scar
sheet with a radial incision. The adipose-scar flap has to
include a full subcutaneous fat layer; the width of the flap’s
end is nearly 4 cm, and the flap’s length is usually shorter
than the main flap. The end of the scar flap approached the
flap’s base of the main adipose-cutaneous flap, and borders
of the flaps are sutured covering the donor wound beside the
main adipose-cutaneous flap. Donor wounds of the adipose-­
scar flap are covered with transposition of healthy skin
(Fig. 16.5d).
16  Shoulder Edge Anterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap

153
Elimination of Severe Shoulder Edge
Contracture with Three Trapezoid Flaps
When the surface deficit is large, the axillary flap resurfaces
only part of the wound (Fig. 16.6d); the donor wounds beside
the main flap are covered with two adipose-scar trapezoid
flaps prepared from the lateral scar sheet (Fig. 16.6e–g); the
scheme of reconstruction with three trapezoid flaps is shown
in Fig. 16.6h.
Results of severe shoulder edge adduction contracture
treatment are shown in Fig. 16.7; a large fold creates scar
surface surplus sufficient for severe scar surface deficit com-
pensation and contracture elimination with local trapezoid
flaps (three-flap plasty).
a
b
c
d
e
f
g
Fig. 16.6  Edge shoulder anterior adduction contracture elimination
with three trapezoid flaps (continuation of Fig. 16.3). (a) Pre-surgery
view. Scars covered FL joint flexion lateral surface; scars, growing dis-
tally, formed the fold located along the fossa’s edge; axilla fossa undam-
aged. (b) Anatomy contracture and operation planning. E joint extension
surface, “+” joint rotation axis; FL surface spreads from the fold’s crest
to the joint rotation axis; lateral sheet of the Fd fold is part of FL surface;
Cr crest of the fold; FM flexion medial surface is healthy skin and donor
site. Planning three-flap plasty: main adipose-cutaneous trapezoid flap
from axilla and two adipose trapezoid-scar flaps from FL surface and
fold (Fd). Lines of incisions for three-flap plasty, Y—line for contracted
scar dissection from the fold crest to the joint rotation axis: (c) scars of
FL surface dissected, not all trapezoid wound covered with axillary trap-
ezoid flap; adipose-scar trapezoid flaps planned; (d) wound anatomy: FL
scar dissected; Dt scar surface deficit; FP flaps; DW donor wound; FP
axillary adipose-cutaneous flap and adipose-scar trapezoid flaps; (e)
7 days after contracture elimination with three-flap trapezoid-flap plasty;
(f) follow-up result; (g) scheme of three-flap plasty
Surgical Technique

154
a
b
c
d
Fig. 16.7  Results of severe
edge anterior contracture
treatment with three trapezoid
flaps. (a) Pre-surgery,
anatomy: contracture caused
with scars of FM flexion
lateral surface and Fd fold’s
scar lateral sheet; Cr crest of
the fold; E joint’s extension
surface: (b) medial fold’s
sheet and FM axillary fossa is
healthy skin; adipose-­
cutaneous trapezoid flap from
all axilla marked;
(c) planning: FL flexion scar
lateral surface dissection with
Y-incision; two adipose-scar
trapezoid flaps marked for
donor wound covering beside
the main flap; (d) 6 months
after surgery: contracture
eliminated, contours of axilla
restored, surface of axillary
flap increased
16  Shoulder Edge Anterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap

155
Severe Edge Contracture Treatment with 
Axillary Adipose-Cutaneous Flap and Skin
Transplants in Children and Adults
When the scar surface deficit is very significant, it is impos-
sible, after axillary flap transposition, to prepare flaps from
the scar sheet and cover the donor wounds beside the flap.
The operation consists of elevation of a trapezoid adipose-­
cutaneous flap, including the medial fold’s sheet and entire
axillary fossa, and using them to cover the central wound
zone; rough scars on the shoulder and chest wall are excised,
and wound is skin grafted (combined trapezoid-flap plasty)
(Figs. 16.8a–c and 16.9a–f). The flap’s end is sutured to the
end of the wound; the lateral edges of the flap are fixed to the
wound’s soft tissues; the wounds beside both sides of the flap
are covered with skin transplants and tie-over dressings. The
adipose-cutaneous flap, harvested from axilla, is drained; for
small adipose-scar flaps, thin passive silicone tubes are used.
No upper limb immobilization is needed. The operated limb
is placed in the abduction position with the patient in bed;
further abduction is supported by the patient himself.
Excellent functional and good cosmetic outcomes are
achieved (Fig. 16.9f). Scars on the shoulder and chest wall
are excised and wounds are skin-grafted. Edge elbow con-
tracture is released simultaneously using trapezoid-flap
plasty (Fig. 16.8c). The axilla’s edge suspension and wound
division on the shoulder and thoracic wall prevent negative
influence of skin graft shrinkage on outcomes of axilla
reconstruction; these two factors prevent axillary contracture
recurrence in case of treatment by combined technique.
Therefore, neither compression nor abduction devices are
needed after surgery.
a
c
b
Fig. 16.8  Severe edge shoulder anterior adduction and edge elbow flex-
ion contracture elimination in a 5-year-old girl, using axillary and elbow
adipose-cutaneous trapezoid flaps; rough scars excision on chest wall
and shoulder and wound’s skin grafting. (a) scars covered shoulder joint
anterior FL and elbow FL surface, causing edge contractures, lateral sur-
face of the trunk and inner surface of upper extremity; (b) operation:
contracted scars dissected with a Y-incision from the edge fold crest to
the joint rotation axis in axilla and elbow, rough scars excised; axillary
and elbow adipose-cutaneous trapezoid flaps mobilized and transposed
on wounds of FL surfaces, ends of flaps sutured to the wound border; the
lateral edges of the axillary flap are fixed to the wound tissue; edge
elbow contracture is eliminated with two-trapezoid-­flap plasty; (c)
7 days after surgery: flap (F) and skin transplants (G graft) alive, both
contractures removed completely. The flap suspends axilla at a normal
level, the big wound divided into two: shoulder and chest, every wound
skin grafted separately; skin transplants look normal
Surgical Technique

156
a
d
e
f
g
c
b
Fig. 16.9  Severe edge shoulder adduction contracture was com-
pletely eliminated with one trapezoid flap and skin transplants: (a, b)
before surgery, anatomy: FL flexion lateral surface; FM flexion medial
surface; E- extension surface; Fd fold; Cr crest of the fold; “+” joint
rotation axis; trapezoid flap planning; Y-line for contracted FL scar
dissection, trapezoid flap from FM flexion medial surface or axilla; (c)
contracted scars dissected and FP adipose-cutaneous flap mobilized,
Dt severe scar surface deficit (large wound); (d) central wound zone
covered with FP trapezoid flap; flap divided large wound in two,
shoulder and thoracic, located beside the axilla; (e) both wounds
beside the flap covered with skin grafts; (f) result (2 years after opera-
tion); total contracture eliminated, flap’s surface was increased sig-
nificantly, hairs growing in normal location; (g) combined
trapezoid-flap plasty (scheme)
16  Shoulder Edge Anterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap

157
Conclusion
Edge shoulder contractures were completely eliminated
and shoulder abduction (180°) was achieved with an axil-
lary adipose-cutaneous trapezoid flap. Mild-to-moderate
contractures were eliminated with one flap. Moderate con-
tractures were released with two or three trapezoid flaps:
in addition to the main flap, one or two adipose-scar trap-
ezoid flaps were mobilized for the donor wound covering
beside the main flap. The fold is converted in the flaps on
all its extents. Severe adduction contracture is eliminated
with one axillary trapezoid flap in combination with skin
transplants: the wounds beside the flap were skin-grafted.
The flap suspended the axilla and divided the large axillary
wound into two separate areas—shoulder and thoracic.
These two factors prevented shrinkage of skin transplants
and recurrence of contracture.
Reference
1. Grishkevich VM.  Postburn edge shoulder adduction contracture:
anatomy and elimination with trapeze-flap plasty—a new approach.
J Burn Care Res. 2012;33:e234–42.
Reference

159
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Edge Shoulder Adduction
Contracture in Pediatric Patients:
Anatomy and Treatment
Introduction
Shoulder adduction contractures in children restrict upper
limb motion, which delays joint development and curves the
shoulder bone and spine; therefore, surgical reconstruction
should be performed as soon as contracture forms. Scars on
the chest wall in children are prone to excessive abnormal
growth and severely disturb the child and parents. Most edge
axillary contractures are treated with techniques based on tri-
angular flaps (Z-plasty and their modifications and combina-
tion), but few articles have been devoted to follow-up
outcomes. Triangular-flap techniques have many known dis-
advantages, skin transplants are prone to shrinkage, and
regional pedicle flap use is traumatic for pediatric patients. In
pediatric patients, edge shoulder anterior contracture and
scar deformity of the shoulder joint anterior surface are fully
eliminated with the use of the whole axillary adipose-­
cutaneous flap. This new technique and its results are pre-
sented in this chapter.
Contracture Anatomy (Fig. 17.1)
Edge shoulder adduction contracture in children and adults
is caused by scars that cover and deform the anterior shoul-
der joint flexion lateral (FL) surface from the fossa edge to
the joint rotation axis (“+”) and neighboring regions of the
shoulder and trunk (Fig. 17.1). The scars, growing distally on
the shoulder and chest wall, involve the skin of the axillary
fossa (flexion medial [FM] surface), forming the crescent
fold located along the anterior of the axillary fossa edge. The
fold consists of two different quality sheets: the lateral
(according to axilla) sheet is scar tissue and part (continua-
tion) of FL surface scars; the medial sheet and axilla are
healthy skin and the best donor site. The crest of the fold (Cr)
is the edge of scars (Fig. 17.1b).
These four anatomical and clinical signs are pathogno-
monic for edge shoulder contractures. Contracted scars,
spreading from the fold crest to the joint rotation axis, can be
nearly 8 cm in width. Part of this length is the fold, which is
a new anatomical structure, presenting surplus surfaces of
scars, healthy skin, and good plasty tissue allowing treatment
of edge contracture with local flaps. At the same time, in the
lateral scar sheet and scars of FL surface, there is a surface
deficit in length (cause of the contracture). Scar surface defi-
cit spreads from the fold crest to the joint rotation axis and
has trapezoid form (Fig. 17.2a, b; see also Fig. 17.7b). Scars,
covering the anterior joint surface, the shoulder, and trunk
surface, are rough, uneven, and present a serious cosmetic
defect. Consequently, the contracture elimination can be
achieved via two methods: (1) with scar dissection and sur-
face deficit compensation with axillary trapezoid flap, scars
remain in situ; and (2) contracture release and part of con-
tracted deformed scars on the anterior surface of the joint,
shoulder, and thoracic wall are excised, and the wound is
resurfaced with whole adipose-cutaneous axillary flap (Fig.
17.3a–d).
17

160
a
b
Fig. 17.1  Anatomy of
shoulder edge scar anterior
adduction and edge elbow
flexion contracture and its
treatment with whole axillary
adipose-cutaneous flap. (a, b)
Two pediatric patients, left
shoulder severe edge
contractures caused by scars
covering anterior FL left
shoulder joint flexion lateral
anterior surface, chest wall,
and lateral neck. E joint
extension surface; “+” joint
rotation axis; FL flexion
lateral surface; Fd fold scar
ulcer; Cr crest of the fold with
ulceration; FM flexion medial
surface
a
b
c
d
Fig. 17.2  Edge shoulder anterior adduction contracture treatment by
immature contracted scar excision and wound covered with axillary
whole adipose-cutaneous flap. (a) Pre-operative view (two-year-old
girl): edge shoulder contracture with fresh scars, covering FL—shoul-
der joint anterior flexion lateral surface, thoracic, and abdomen walls;
borders of scars marked to be excised; (b) scars excised, whole axillary
adipose-cutaneous flap mobilized; (c) flap transposed on the wound; (d)
1 month after operation: contracture eliminated, scar deformity reduced
17  Edge Shoulder Adduction Contracture in Pediatric Patients: Anatomy and Treatment

161
a
b
d
e
c
Fig. 17.3  Shoulder and elbow edge contractures and deformation
treatment with axilla flap (shoulder) and elbow with trapezoid-flap
plasty. (a, b) Scars of FL surface formed crescent-shaped fold along
anterior axillary edge and flexion lateral surface of elbow; lateral scar
fold sheet is a continuation and part of FL surface; medial sheets and
FM axillary and elbow fossa surface are healthy skin; E joint exten-
sion surface; “+” joint rotation axis; (c) scar of FL surfaces (includ-
ing lateral scar sheet) excised, whole adipose-cutaneous flap of
axilla, chest wall and inner shoulder surface mobilized and trans-
posed on the wound with tension and covered the wound; edge elbow
contracture eliminated with elbow trapezoid adipose-cutaneous flap;
(d) shoulder edge contracture eliminated, contours of axilla region
preserved; maturation of operation scars not complete (3  months
after surgery) (e) Next case: 1 year after reconstruction of patient
from fig 17.1: excellent functional and aesthetic outcomes
Contracture Anatomy

162
Technique for Simultaneous Removal of Scar
Shoulder Contracture and Deformity
and Elbow Edge Flexion Contracture [1]
Anatomy and surgery planning is shown in Fig.  17.2a,b:
(solid line—scars incision; dotted line—scars excision;
“+”—joint rotation axis; E—extension surface; FL—flexion
lateral surface; FM—flexion medial surface). Scars that cause
contracture (FL) are separated from the healthy skin (FM)
with an incision along the fold crest and then dissected with a
perpendicular Y-incision from the fold crest to the shoulder
joint rotation axis (“+”) and separate scars from the tissue of
joint extension surface (E) for complete contracture release
(incision lines in Fig. 17.3b; see also Fig. 17.5a). A trapezoid
wound appeared on the anterior joint flexion lateral surface
(Fig. 17.2b; see also Fig. 17.7b). The whole axillary adipose-
cutaneous flap is elevated without cutting healthy skin. The
flap includes the healthy medial fold sheet, the adipose-cuta-
neous layer of axilla to the latissimus dorsi edge, and neigh-
boring inner shoulder and lateral truncal regions. The deep
axillary fat layer with lymphatic nodule remains in situ. The
flap is advanced on the anterior shoulder joint surface with
tension (Fig. 17.2c and 17.3c). According to the surface that
was covered with the flap, the scars on the anterior shoulder
joint surface and neighboring areas of the shoulder and chest
wall were excised. The flap is transposed on the wound again
and sutured with two-layer sutures, starting from the joint
rotation axis level. Deep tissue layers are connected to the
wound edge with non-­absorbable sutures to prevent the
growth of excessive operation scars.
Due to tissue/flap tension, the adjacent healthy adipose-­
cutaneous layer of shoulder extension surface (E) and
chest wall is displaced, covering the wounds on the shoul-
der and chest wall; the posterior edge of axillary fossa (m.
latissimus dorsi) is moved to the anterior axillary edge,
narrowing or obliterating the axillary fossa and reducing
the donor wound. All these factors allow for transposition
of the flap on the anterior shoulder joint surface up to the
joint rotation axis, covering the wound and restoring the
shoulder joint and neighboring zones. Thus, almost the
entire axillary adipose-­cutaneous layer is transposed on
the joint anterior FL surface, compensating for the scar
surface deficit, eliminating the contracture, and reducing
the scar deformity in cosmetically important zones. The
wound is drained and shoulder immobilization is not
needed. Edge elbow contracture is eliminated simultane-
ously with trapezoid-flap plasty (Fig. 17.3). The extended
adipose-cutaneous layer grows since the squeezed tissue
plays the role of expander; the transposed skin did not
change natural properties; axillary fossa accepts normal
contours (Figs. 17.3d and 17.2e).
Scars covering the breast and shoulder can be excised; the
wound, covered with the flap, decreases deformity of the
breast and shoulder (Figs.  17.4 and 17.5). A wide scar
excised on the shoulder zone of a 5-year-old girl is shown in
Fig. 17.6a, b.
This method is effective for treatment of severe shoulder
edge adducted contractures and scar deformity (Figs. 17.7
and 17.8). Neck contracture can be removed simultaneously
(Fig. 17.9).
17  Edge Shoulder Adduction Contracture in Pediatric Patients: Anatomy and Treatment

163
a
b
c
e
d
Fig. 17.4  Edge shoulder
contracture and scar
deformity (breast included)
treatment. (a) Pre-surgery
view: scars covered FL—
flexion anterior surface, edge
shoulder anterior adduction
contracture, shoulder joint
anterior surface and breast
deformity, planning of
operation; (b) flap mobilized;
(c) scars excised, including
breast area and shoulder,
wound closed with axillary
healthy tissue; (d) end of
operation; (e) result
(18 months after surgery):
adduction contracture and
breast deformity eliminated
a
b
Fig. 17.5  Shoulder edge
adduction contracture,
deformity of joint surface and
breast treatment with axilla
adipose-cutaneous flap (a, b)
Technique for Simultaneous Removal of Scar Shoulder Contracture and Deformity and Elbow Edge Flexion Contracture

164
a
b
Fig. 17.6  Results of edge
shoulder scar adduction
contracture treatment and
deformity by scar excision on
shoulder joint anterior surface
and shoulder; the wound
covered with axillary
adipose-cutaneous whole
layer. (a) Planning: solid
line—scar excision; dotted
line—borders of adipose-­
cutaneous layer elevation; (b)
7 days after operation:
transposed tissue alive;
operation scars beside the
anterior edge of axillary fossa
a
c
b
Fig. 17.7  Severe edge shoulder adduction contracture treated with
axilla flap and neck lateral contracture release with counter-­transposition
of trapezoid adipose-scar flaps. (a) Pre-surgery, contracture, and defor-
mity anatomy: E joint extension surface; “+” joint rotation axis; FL
scarred FL surface; Fd fold; Cr crest of the fold; FM joint FM surface
(axilla fossa); (b) anatomy of wound after scar release and flap mobili-
zation: Dt scar surface deficit of FL surface; DW donor wound; (c)
5 days after surgery
17  Edge Shoulder Adduction Contracture in Pediatric Patients: Anatomy and Treatment

165
a
c
d
b
Fig. 17.8  Severe contracture
and deformity treatment with
new technique. (a, b)
Pre-surgery, severe
contracture, edge of axilla
descended; (c) anatomy of
severe shoulder contracture
(accepted marks); (d) good
functional and cosmetic
outcomes after treatment with
axillary adipose-cutaneous
flap
Fig. 17.9  Result of shoulder joint contracture and deformity treatment
with axilla flap (FP) and neck contracture with thoracic lateral flap
(2 weeks after surgery)
Technique for Simultaneous Removal of Scar Shoulder Contracture and Deformity and Elbow Edge Flexion Contracture

166
Conclusion
In children, there are possibilities for the simultaneous
removal of the edge shoulder adduction contracture and
a decrease in deformity of the joint surface, shoulder, and
breast with scar excision and using an adipose-cutaneous flap
of axilla and neighboring regions. No flap loss or other seri-
ous postoperative complications were observed. Squeezed
by the flap, the underlying soft tissues play the role of an
expander, ensuring active growth of distended skin.v Two to
three months after surgery, the flap surface becomes larger;
tissue tension of the flap and neighboring tissue gradually
disappears; axillary fossa accepts normal outlines. Follow-up
results are good: full shoulder abduction (180°) and rotation
are normal, and the donor site is not injured.
Reference
1. Grishkevich VM. Shoulder edge anterior adduction contracture in
pediatric patients after burns: anatomy and treatment: a new approach.
Burns Open.
17  Edge Shoulder Adduction Contracture in Pediatric Patients: Anatomy and Treatment

167
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Shoulder Edge Posterior Adduction
Contracture: Anatomy and Treatment
with Axillary Adipose-Cutaneous
Trapezoid Flap
Introduction
The shoulder posterior adduction contracture is of the edge
type. In the literature, however, this contracture has several
names and falls under numerous classifications that do not
reflect the true contracture anatomy. The main surgical tech-
nique for posterior contracture treatment is Z-plasty, based
on triangular flaps that are small/short and cannot fully reach
the joint rotation axis and release contracture. Moreover, the
triangular, propeller, rectangular, or rhomboid flaps do not
match the scar surface deficit. As a result, surgical rehabilita-
tion of a burned patient with shoulder scar contracture is far
from perfect. Our observations showed that the edge poste-
rior scar contracture can be successfully treated with undam-
aged tissue from the axilla region. This newly developed
technique was tested on many patients and yielded excellent
outcomes. Thus, the technique based on axillary adipose-­
cutaneous trapezoid flap(s) and trapezoid-flap plasty is the
best option to treat shoulder edge posterior contracture.
Anatomy, details of the technique, and results are presented
in this chapter.
Functional Zones of the Shoulder Joint
Surface in Edge Posterior Contracture,
Formation, and Anatomy
Functional Zones of the Shoulder Joint
(Fig. 18.1)
When planning surgery, it is necessary to divide the shoulder
joint surface into flexion (F) and extension (E) (Fig. 18.1a, b);
the boundary between them passes along the joint rotation axis
level (“+” symbol). This aspect is not highlighted in the litera-
ture, but it is the basis for understanding joint contracture for-
mation and type. The flexion zone (F) of big joints has anterior
and posterior curvatures of nearly 90° caused by the latissimus
dorsi and pectoralis major muscle edges, which divide it into
two parts: flexion lateral (FL) and flexion medial (FM) sur-
faces. The dividing line passes along the edge of the axillary
fossa (the muscle edges create the edge of the axillary fossa).
The curvatures form two zones: FL anterior and posterior,
which spread from the edge of the fossa to the joint rotation
axis. The zone between the fossa’s edges (axillary fossa) is the
FM surface. With burns to this area, the shoulder adducts to
the chest wall and thus prevents the fossa or joint FM surface
from sustaining injury. The FL surface spreads from the poste-
rior edge of the joint fossa, or crest (Cr) of the fold (Fd) (in the
case of edge posterior contracture) to the joint rotation axis
level. The flexion medial surface lies between the fossa edges.
Edge Posterior Contracture Formation (Fig. 18.1)
Contracture-type formation depends on the location of the
contracted scars: shoulder edge posterior contracture is caused
by scars covering the posterior flexion lateral surface; the FM
and extension surfaces remain undamaged (Fig.  18.1a–e).
Attempts to abduct the shoulder traumatizes scars and they
begin to progressively grow distally, between the shoulder and
chest wall, approaching them and forming adduction shoulder
contracture. Scars, growing distally, involve the skin of the
18

168
axilla fossa. As a result, the crescent fold is formed (Fold),
connecting and moving the shoulder to the chest. The fold
continues to grow extensively (Fig. 18.1a, b).
Anatomy of Edge Shoulder Posterior
Contracture (Fig. 18.1)
(a) Joint posterior FL surface covered with scars; (b) scars
form the fold that passes along the joint fossa’s posterior
edge. (c) The fold consists of two sheets; the lateral sheet is
scars and continuation of scars of flexion lateral (FL) sur-
face. The medial sheet is healthy skin and is part of the axilla
fossa skin or flexion medial (FM) surface; (d) the crest (Cr)
of the fold is the edge of the scars. The fold is a new anatomi-
cal structure made up of surface surplus scar and healthy
skin. The fold’s sheet, or tissue surplus, plays a decisive role
in edge contracture elimination with local flaps. The scars of
the FL surface and lateral scar sheet of the fold have surface
surplus in width (from the crest fold to the joint rotation axis)
and surface deficit in length—the distance between the
shoulder and chest wall—which causes contracture.
Thus, the shoulder posterior adduction contracture has the
following specific anatomical features and clinical signs:
(a) The shoulder edge posterior contracture is caused by con-
tracted scars that cover the shoulder joint posterior flexion
lateral surface and form the fold (FL and Fold; Fig. 18.1b).
(b) The fold passes along the posterior axillary fossa edge.
(c) The sheets of the fold are of different quality: the lateral
fold sheet (according to axilla) is scar tissue and continu-
ation of scars of FL surface; medial fold sheet and axil-
lary fossa (FM) is healthy skin (Fig. 18.1a, b).
(d) The crest of the fold (Cr) is the edge of scars
(Fig. 18.1a–c).
The fold’s sheets are new anatomical structures, tissue
surface surplus scars and healthy skin—capable of, in con-
junction with the axillary flap, scar surface deficit compensa-
tion and contracture elimination.
a
b
d
e
c
Fig. 18.1  Functional zones, anatomy, and scar surface deficit of shoul-
der edge posterior adduction contracture. (a) Anterior view: all sur-
faces: FL, FM, and medial fold sheet are healthy skin; E extension
surface; FL flexion lateral surface; Cr crest of the fold; Fold; “+” joint
rotation axis. (b) Posterior view: vast fold; FL—flexion lateral surfaces
and fold’s lateral sheet is scar tissue and contracture cause. E joint
extension surface; “+” joint rotation axis. (c) Scar of FL—flexion lat-
eral surface and lateral sheet of the fold are scars. Joint zones, anatomy
and contracture cause: “+” joint rotation axis; FL flexion lateral surface
covered by scars that form the fold; the lateral sheet of the fold is part
of FL surface and scars, FM flexion medial surface is skin. Planning
trapezoid flap in axilla and Y-line for scars dissection from fold crest to
the joint rotation axis and separated scars from tissue of joint extension
(E) surface. (d) Scars dissected with Y-incision from the Cr—fold crest
to the joint rotation axis and separated from FM—flexion medial sur-
face by an incision along the fold crest; FP—flap mobilized; DW—
donor wound; contracture released; large wound or Dt—trapezoid scar
surface deficit appeared, which is the real cause of contracture. (e) The
flap transposed on the wound and scar surface deficit compensated; scar
sheet covered the donor wounds beside the flap
18  Shoulder Edge Posterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap

169
Trapezoid Scar Surface Deficit Is the Real
Cause of Contracture
Scars, growing distally and forming the fold, increase the
flexion lateral surface (FL) from the fold crest to the joint
rotation axis. Simultaneously, the scars undergo contraction
in length, which shortens the scar’s distance between the
shoulders and the chest wall, causing the contracture
(Figs. 18.1c–e and 18.2a, b). Planning trapezoid-flap plasty
and defining scar surface deficit is shown in Figs.  18.1c,
18.2a, and 18.4c). After dissection of contracted scars of the
flexion lateral surface, from the fold crest to the joint rotation
axis with Y-incision, a large trapezoid wound appears, con-
sisting of: Dt—scar surface deficit; DW—donor wound;
FP—flap. Consequently, the treatment lies in the scar sur-
face deficit compensation with a trapezoid flap—FP
(Figs. 18.1d, e, 18.2b, c, f, and 18.3c, d).
Scar surface deficit is determined as follows: (1) with an
incision along the fold crest, the sheets of the fold are sepa-
rated, and scars are separated from healthy skin; (2) then,
contracted scars are dissected with a Y-incision, the splitting
end of which separates contracted scars from healthy skin of
the joint extension (E) surface. Separation of contracted scars
from both sides, healthy skin of the joint fossa and tissue of
the extension surface (E), is the basis of complete contracture
release using trapezoid flaps and trapezoid-flap plasty.
During shoulder abduction, the wound edges diverge, and
the M-form wound straightens to nearly 5–6 cm in length. If
needed, the split ends of the Y-incision during surgery are
lengthened along the joint rotation axis level.
a
b
c
d
e
f
g
Fig. 18.2  Treatment of severe left shoulder edge posterior contracture,
caused by scar surface deficit of joint FL—flexion lateral surface and
lateral fold sheet, by three trapezoid flaps. (a) Pre-surgery, anatomy of
edge contracture and surgery planning: E—extension surface; “+”—
joint rotation axis; FL and Fd (fold)—flexion lateral surface and lateral
sheet of the fold are scars and contracture cause. FM—flexion medial
surface and medial fold sheet is healthy skin and donor site; Cr—crest
of the fold. Axillary trapezoid flap includes all fossa (FM surface);
Y-line of contracted scar dissection of posterior FL surface and fold
(Fd) from fold crest (Cr) to the joint rotation axis (“+”); (b) contracted
scars dissected by Y-incision and contracture released; large trapezoid
wound Dt—scar surface deficit appeared (right from strip), M-form
wound’s end on joint rotation axis level, nearly 5 cm in length; DW—
donor wound. FM—healthy skin of fossa or FM surface; (c–e) trape-
zoid flap mobilized, transposed on the wound; large donor wounds
beside the flap are covered by adipose-scar trapezoid flaps taken from
the scar sheet, fully compensating for the deficit and fully eliminating
contracture. (f) Three weeks after reconstruction and (g) 2 years after
surgery: excellent functional and cosmetic outcomes
Trapezoid Scar Surface Deficit Is the Real Cause of Contracture

170
a
b
c
d
Fig. 18.3  Moderate shoulder edge posterior contracture treatment
with one trapezoid flap. (a, b) Before operation, contracted scars of
posterior FL surface formed the fold, lateral sheet of which is scars;
planning: one trapezoid adipose-cutaneous flap in axillary fossa marked
and mobilized; (c) flap covered the wound and compensated for the scar
surface deficit; (d) donor wounds beside the flap primarily closed by
transposition of scar sheet angles to the flap’s base
18  Shoulder Edge Posterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap

171
Edge Shoulder Posterior Contracture
Treatment Is Scar Surface-Deficit
Compensation with Trapezoid Flaps [1]
Common technical details that are used in all cases are as
follows (Fig. 18.2):
(a) The fold’s sheets are separated on all fold borders with
an incision along the crest of the fold up to the edge of
the latissimus dorsi muscle;
(b) The scar of the flexion lateral (FL) surface and lateral
fold sheet is dissected with a Y-shaped incision from the
fold crest to the joint rotation axis; after shoulder abduc-
tion, Dt—trapezoid wound appears, as a rule, reflecting
the form and size of the surface deficit of scar fold sheet;
(c) Adipose-cutaneous flap (FP) is mobilized from the
medial fold sheet and axillary fossa according to the size
and form of the wound (Figs. 18.1d and 18.2c, d);
(d) The trapezoid flap is transposed on the wound with ten-
sion, thus compensating for the surface deficit and elimi-
nating
contracture
with
excellent
outcomes
(Figs. 18.2d–g and 18.4e).
For donor wound coverage beside the main flap, adipose-­
scar and adipose-cutaneous trapezoid flaps are prepared
from both fold sheets and neighboring tissues and are
counter-­transposed, covering the donor wounds (Figs. 18.2c–
e, 18.3d, and 18.5d, e). Depending on the severity of the con-
tracture, the fold’s length, and its protrusion, the reconstructive
technique has technical peculiarities.
a
b
d
e
c
Fig. 18.4  Elimination of moderate edge shoulder adduction contrac-
ture with three trapezoid flaps. (a, b) Anatomy: scars on flexion lateral
surface (FL) and scar fold sheet (Fd) cause adduction contracture; flex-
ion medial surface (FM) and medial fold sheet is healthy skin; (c) plan-
ning: Y-lines for contracted scar dissection from the fold crest to the
joint rotation axis (“+”); line along the crest for scars separating from
the healthy skin, trapezoid flap marked in axilla; (d) three-trapezoid-­
flap plasty performed: flaps alive, contracture released (2 weeks after
surgery); (e) follow-up results (2 years after reconstruction): complete
function and axillary contours restored
Edge Shoulder Posterior Contracture Treatment Is Scar Surface-Deficit Compensation with Trapezoid Flaps

172
a
c
d
b
e
g
f
Fig. 18.5  Severe edge shoulder posterior contracture elimination with
multiple adipose-cutaneous and adipose-scar trapezoid flaps. (a) Pre-­
surgery view; (b) zones: FL flexion lateral posterior surface, covered by
scars that formed the fold; Cr crest of the fold; “+” joint rotation axis;
FM flexion medial surface and medial fold sheet is healthy skin; three-­
flap plasty planning; (c) contracted scars dissected by Y-incision from
the fold crest to the joint rotation axis, Dt—trapezoid wound or scar
surface deficit (contracture cause) of FL surface and lateral scar sheet
appeared with M-shaped end; axillary adipose cutaneous flap mobiliza-
tion; (d, e) for complete contracture release and scar surface deficit
compensation, several additional adipose-cutaneous and adipose-scar
trapezoid flaps elevated; end of operation; (f) 2 weeks after surgery:
contracture eliminated, flaps alive; (g) excellent functional and cos-
metic outcomes (3 years after reconstruction)
18  Shoulder Edge Posterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap

173
Shoulder Edge Adduction Contracture
Treatment with One Adipose-Cutaneous
Axillary Flap
Posterior edge shoulder contracture elimination with one
axillary trapezoid flap is shown in Figs. 18.2 and 18.3. An
excellent donor site for this flap is the axillary fossa and
medial fold sheet, which are used in all cases. Planning of the
operation is shown in Figs. 18.2a and 18.5b. It is often neces-
sary to increase the size of the trapezoid flap at the time of
the operation for complete contracture elimination. The
operation consists of separation of the crescent fold sheet,
and the scar sheet and subcutaneous fat layer are dissected
from the fold crest to the shoulder joint rotation axis
(Figs. 18.2b and 18.5c). After shoulder abduction, the scar
border divergence forms a trapezoid-shaped wound
(Figs. 18.1d, 18.2b and 18.5c). The trapezoid flap is mobi-
lized according to the wound’s form and size. The medial
fold sheet and the axillary fossa’s adipose-cutaneous layer,
up to the pectoralis major muscle, are included in the flap. A
deep axillary fat layer and lymphatic nodules remain in situ.
The flap’s end includes a part of the fold crest; its width is
nearly 5–6 cm. The trapezoid flap is transposed on the wound
with tension. As a result of flap tension, the axillary edges
approach the donor wound. The flap’s tension displaces
neighboring E-tissues to the joint’s FL surface, contributing
to in FL surface and donor wound covering and contracture
elimination. The M-shaped flap end is sutured with the scar’s
M-form wound end. The wound beside the flap is covered
with lateral sheet angles (Figs. 18.2c–e and 18.5c).
Posterior Edge Shoulder Contracture
Elimination with Three Trapezoid Flaps
If contracture and scar surface deficit are severe (Fig. 18.4a–
c), the angles of the scar sheet cannot approach the flap’s
base; therefore, two additional trapezoid adipose-scar flaps
were mobilized from the scar sheet and transposed on the
wounds beside the main flap (Fig. 18.4b–d). Beside the scar
flaps, wounds are covered with flaps of the medial healthy
sheet (Fig. 18.4c, d).
Posterior Edge Shoulder Contracture Elimination with Three Trapezoid Flaps

174
Shoulder Edge Severe Posterior Adduction
Contracture Treatment with Multiple
Adipose-Cutaneous and Adipose-Scar Flaps
Severe contractures are usually caused by a long, well-­
protruded crescent fold. At first, the central zone of contrac-
ture is reconstructed in the usual manner, with three trapezoid
flaps (Fig. 18.5a–d). Then the fold’s sheets on all its extents
are converted to the trapezoid flaps, which resulted in full
contracture release with some over-correction (Fig. 18.5e–g).
Severe edge posterior contracture (next case) causing a
long and wide crescent fold is treated with several adipose-­
cutaneous and adipose-scars trapezoid flaps. At first, the
reconstruction is directed towards contracture release and
restoration of axilla using typical three-flap plasty (see plan-
ning in Fig. 18.6a, b). The entire semilunar fold is converted
into trapezoid flaps by radial Y-dissections. The flap’s sur-
face is usually enough for complete scar surface deficit com-
pensation and contracture elimination (Fig. 18.6c).
a
b
c
Fig. 18.6  Severe edge posterior shoulder adduction contracture,
caused by scar of FL posterior surface and long and wide fold. (a) Pre-­
surgery, posterior view, anatomy: Extension surface; “+”—rotation
axis, FL—scar flexion lateral surface and fold (fold’s lateral scar sheet
is part of FL surface); planning: Y-line from the fold crest to the joint
rotation axis for contracted scar dissection and two adipose-scar flaps
from the lateral fold sheet and FL surface. (b) Anterior view: anterior
FL and FM surfaces and medial sheet of big fold is healthy skin; three
flaps from heathy skin—one axillary and two from medial fold sheet.
(c) Counter-transposed flaps, scar surface deficit compensated, contrac-
ture eliminated, and axillary region restored; flaps alive (7 days after
operation)
18  Shoulder Edge Posterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap

175
Severe Axillary Posterior Edge Adduction
Contracture Treatment in Children
After severe edge posterior contracture release in children, it
is useful to excise the wide strips of rough scars on the shoul-
der and chest wall with primary wound closure (Fig. 18.7).
Contracture in a pediatric patient, caused by severe scar
surface deficit, is eliminated with a combined technique:
axillary trapezoid flap and skin transplants (Fig. 18.8). After
complete contracture release with a Y-incision, a large trap-
ezoid wound or scar surface deficit appears. A severe scar
surface deficit does not allow the use of the scar sheets for
donor wound covering because of the severe divergence of
the dissected scars (Fig. 18.8c). In the presented children, the
axillary adipose-cutaneous flap was elevated from the fossa
and medial fold sheet (FM, Fd) and transposed on the wound
with tension, covering the central joint axillary zone; with
wounds beside the flap, on the chest wall and shoulder, skin
grafted (Fig.  18.8d, e). Adipose-cutaneous flap was stable
and suspends the axilla and posterior fossa edge. The wounds
beside the flap are displaced on the shoulder and chest wall
(Fig. 18.8c–e). Since the axilla is protected (suspended) with
the flap, shrinkage of the skin transplants (T.t) does not lead
to contracture recurrence.
a
b
c
Fig. 18.7  Severe posterior edge contracture elimination and deformed
scar excision on the shoulder and chest wall. (a, b) Pre-surgery view:
severe adduction contracture, scars covered the posterior surface of the
joint FL surface, chest wall, and shoulder; planning: Y-shaped line of
FL surface scars dissection and borders of axillary trapezoid adipose-­
cutaneous flaps, scars excision on shoulder and chest wall; (c) contrac-
ture released with axillary adipose-cutaneous trapezoid flap, deformed
scars removed, and wounds primarily closed; stitches of inner row
were hidden; contracture eliminated, significant improvement in
appearance
Severe Axillary Posterior Edge Adduction Contracture Treatment in Children

176
a
b
d
e
c
Fig. 18.8  Severe edge shoulder posterior contracture of 7-year-old
girl; treatment with an adipose-cutaneous axillary trapezoid flap and
skin transplants. (a) Anatomy; (b) planning axillary trapezoid flap; (c)
contracted scars dissected, large wound appeared; mobilized axillary
trapezoid flap; (d, e) 2 weeks after surgery: central joint zone of flexion
lateral surface covered with the flap (F), wounds on chest wall and
shoulder skin transplants (TR); flap and transplants alive
18  Shoulder Edge Posterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap

177
Conclusion
Shoulder edge posterior contracture is caused by trapezoid
surface deficit of scars, covering the joint’s flexion lateral
posterior surface, and the scar sheet of the crescent fold.
The fold is a surface surplus, which in conjunction with
the axillary fossa’s flap and (rare) skin transplants, can be
used to completely eliminate posterior edge contracture of
all grades of severity. Mild-to-moderate contracture is
eliminated with a local adipose-cutaneous flap only; severe
contracture is eliminated using a combined method. An
axillary trapezoid flap covers the wound on the FL surface
and compensates for scar surface deficit, suspends axilla,
and divides the large wound on the shoulder and thoracic
area, where shrinkage of skin transplants is insignificant.
The flap preserves a stable position for axilla and prevents
recurrence of contracture. All these factors explain why
the new method yields excellent outcomes without re-con-
tractures and repeated reconstructions.
References
1. Grishkevich VM, Grishkevich MV. Postburn shoulder edge poste-
rior adduction contracture: anatomy and treatment–new approach.
JSM Burns Trauma. 2017;2(3):1019.
com/Burns/burns-2-1019.pdf. Accessed 9 Dec 2017.
References

179
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Bilateral Shoulder Edge Adduction Scar
Contractures: Anatomy and Treatment
Edge Shoulder Bilateral Contracture
Formation and Functional Zones
Bilateral shoulder adduction contracture is a result of wide-
spread, deep burns, with the scars covering the shoulder joint
but not the axillary fossa. The literature lacks information on
treatment. Triangular techniques do not yield satisfactory
outcomes. The scars on the shoulder and chest wall restrict
the use of propeller and other local flap forms. Therefore,
fasciocutaneous and musculocutaneous flaps become an
alternative technique to correct bilateral shoulder contrac-
tures [1, 2]. Our experience proved that shoulder bilateral
adduction contracture is successfully eliminated with axil-
lary trapezoid flaps, using one- or two-stage trapezoid-flap
plasty [3].
Edge shoulder bilateral adduction contracture is caused
by burns and scars, covering both the joint flexion lateral
(FL) surfaces (flexion anterior and posterior) from the crests
(Cr) of the fold to the joint rotation axis (“+”) and neighbor-
ing surfaces of the shoulder and thoracic wall. During wound
healing, scars grow distally between the shoulder and chest
wall anteriorly and posteriorly (Fig. 19.1). Moving distally,
scars involve the healthy skin of the axillary fossa. As a
result, crescent-shaped folds form along the anterior and
posterior edges of the axillary fossa. The scars’ lateral fold
sheets are part of the FL surfaces, which become wider (dis-
tance from the fold crest to the joint rotation axis).
19
Fig. 19.1  Anatomy and functional zones of the shoulder joint surface
in a case of bilateral edge shoulder adduction contracture. Contracture
caused by scars covering the flexion lateral anterior and (FL) forming
posterior sheets of the folds. Scars, growing distally between the shoul-
der and chest wall, form the semilunar folds (Fd) along the edges of the
axillary fossa; Cr—crest of the fold. Lateral fold sheets are scars and
part of FL anterior and posterior surfaces; these scars cause the contrac-
ture. E—Joint extension surface; “+”—joint rotation axis. The flexion
medial surface (FM) or axillary fossa and medial sheets of the folds as
part of the flexion medial surface, are healthy skin and the donor site.
The folds are new tissue formations and present a surface surplus of
scars and healthy skin, allowing the elimination of bilateral edge shoul-
der adduction contractures with local tissues

180
Anatomy of Shoulder Edge Bilateral
Adduction Contracture
Shoulder edge bilateral contracture has specific anatomical
and clinical features and signs (Figs. 19.2 and 19.3) [3].
(a) Contracture is caused by scars that cover the joint flexion
lateral (FL) surfaces, shoulder, and chest wall.
(b) Scars of the flexion lateral surfaces grow distally, involv-
ing the healthy fossa skin and forming the folds (Fd),
which pass along the edges of axillary fossa between the
flexion lateral (FL) and flexion medial (FM) surfaces.
(c) The fold consists of two different quality sheets: the lat-
eral fold sheets are scars and are the continuation of the
flexion lateral surfaces; the medial fold sheets and axil-
lary fossa (flexion medial surface, FM) are healthy skin.
(d) The crest of the fold (Cr) is the edge of scars.
These four anatomical features and clinical signs deter-
mine the scar contracture name, edge. These features are
always present regardless of edge contracture location and
severity. Scars located on the joint’s extension surface do
not participate in contracture formation. The symbol “+”
marks the joint rotation axis. In the case of edge shoulder
bilateral contracture, the distance from the fold crest to the
joint rotation axis (the width of contracted scars covering
the joint flexion lateral surface) is 6–8 cm in children and
10–12 cm or longer in adults. The fold becomes a new ana-
tomical formation that creates the surface surplus scars
and skin used for contracture elimination. At the same
time, scars are contracted in length and shorten the dis-
tance between the shoulder and chest wall, causing adduc-
tion contracture. The axillary fossa stays undamaged; the
medial sheets of the fold increase the skin surface of the
axilla.
a
b
c
d
e
f
Fig. 19.2  Definition of scar surface deficit of anterior and posterior flexion
lateral surfaces (form, size, and location) as the real cause of contracture. (a)
Anatomy and joint’s functional zones: E—Joint extension surface; “+”—
joint rotation axis; FL—flexion lateral surface from the fold’s crest to the
joint rotation axis; scars of FL surface, growing distally, involve skin of FM
surface and form the fold (Fd). Therefore, the lateral fold sheet is scars and
part of FL surface, and the medial fold sheet is healthy skin. The crest (Cr) of
the fold is the edge of scars. Contracture caused by scars covering the FL
surfaces and scars of the lateral fold sheet; (b) planning: borders of the quad-
rangular flap involves all healthy skin of FM—flexion medial surface or
axilla; Y-lines for scar dissection from fold crests to the joint rotation axis; (c)
dissected scars of the anterior FL surface and the fold’s scar sheet, large
trapezoid wound or surface deficit (Dt) appeared; DW donor wound; FP flap;
(d) flap (FP) mobilized from periphery and displaced on the axilla bottom;
(e) posterior FL surface and scar sheet dissected, Dt of FL scar surface deficit
or wound appeared; shoulder abduction is at 90°. (f) Then, shoulder abducted
to 180°—the scar edge divergence changes the M-wound into a lineal form,
the wound doubled in size, because the wound’s edges freely diverged. These
trapezoid wounds (anterior and posterior) are the real size and form of scar
surface deficit (Dt) and are the cause of the bilateral contracture
19  Bilateral Shoulder Edge Adduction Scar Contractures: Anatomy and Treatment

181
a
b
c
d
e
f
Fig. 19.3  Bilateral severe shoulder adduction contracture treatment
using one-stage trapezoid-flap plasty and result. Case 1: (a, b) Pre-­
surgery posterior and anterior views: joint zones and contracture
anatomy: Extension; FL flexion lateral surfaces and lateral sheets of
both folds (Fd) are scars; Cr crest of the fold; “+” joint rotation
axis; FM flexion medial surface; planning posterior and anterior
edge contracture release: solid lines—incisions; dotted lines—con-
tracture anatomy; FM—flexion medial surface or axillary fossa,
where two trapezoid flaps with common pedicle are marked, lines of
the fold sheets division, Y-lines for scars of FL—flexion lateral sur-
faces and lateral scar fold sheets dissection from the fold crest to the
joint rotation (“+”) axis; (c) end of operation: trapezoid adipose-
cutaneous flaps compensated trapezoid scar surface deficit, donor
wounds beside the flap covered with flexion lateral fold sheet dis-
placement. Contracture released and contours of axilla restored.
Case 2: (d) Bilateral mild-to-moderate shoulder edge contracture
caused by scars of FL—flexion lateral surfaces and scars of the lat-
eral fold sheets; FM—axilla, flexion medial surface; medial fold
sheet is continuation of joint FM surface. Planning of one-­stage
operation; (e) trapezoid scar surface deficit of FL surfaces was cov-
ered with trapezoid adipose-cutaneous axillary flaps, which consist
of one-third of fossa and medial sheets; donor wounds beside the
flaps are covered with lateral scar fold sheets, whole or adipose-scar
trapezoid flap prepared from scar sheet; (f) good follow-up result
Anatomy of Shoulder Edge Bilateral Adduction Contracture

182
Surface Deficit of Contracted Scars Is
Contracture Cause
The scars of FL surfaces, growing distally, form the folds
(Fd), and thus increase scar flexion lateral surfaces in width
from the fold crest (Cr) to the joint rotation axis on the lateral
scar sheet of the fold (Figs. 19.1 and 19.2a). At the same
time, these scars undergo contraction in length and adduct
the shoulder to the chest wall, causing contracture. This sce-
nario leads to scar surface deficit in length, between the
shoulder and the chest wall. In other words, the edge contrac-
tures are caused by the scar surface deficit (Dt) in length,
covering the flexion lateral surface from the fold crest to the
joint rotation axis (Fig. 19.2b–f).
Scars of flexion lateral surfaces include the fold, and it
becomes wider (from fold crest to joint rotation axis).
Simultaneously, these scars undergo contraction in length
(between shoulder and chest wall) and this shortens the dis-
tance between the shoulder and the chest wall. After dissec-
tion of contracted scars from the fold crest to the joint
rotation axis with Y-incision scars, a large trapezoid wound
appears (Fig. 19.2b, c, e, f). Contracture treatment is con-
cluded in scar surface deficit compensation by converting the
healthy axillary skin to the trapezoid subcutaneous pedicle
flaps and transposition of these flaps on the joint’s anterior
and posterior surfaces and axilla suspension.
Bilateral Shoulder Edge Contracture
Treatment [3]
Depending on contracture severity and axillary fossa condi-
tion, reconstruction of bilateral edge shoulder adduction con-
tractures is performed using one-stage or two-stage
procedures, with local flaps alone or in combination with
skin transplants.
One-stage reconstruction is performed if contractures are
mild-to-moderate, the deficit in the lateral fold sheets is not
severe, and the axillary region has enough healthy skin for
the bilateral contracture elimination with local flaps in one
stage (Fig. 19.3).
Two-stage bilateral shoulder adduction contracture treat-
ment is indicated for severe shoulder bilateral edge contrac-
tures (Fig.  19.4). First, the more severe contracture is
released, and the wound is covered with a large adipose-­
cutaneous trapezoid flap, prepared from axilla as in cases of
one-sided contracture treatment (Fig.  19.4a). Four to six
weeks later, after skin tension has disappeared due to growth
of stretching skin, the contracture of the other axilla side is
removed with the same procedure (Fig. 19.4a–c, left joint;
Fig. 19.4d–g, right joint).
Bilateral edge shoulder contractures in children are suc-
cessfully eliminated with a quadrangular subcutaneous pedi-
cle flap (Fig. 19.5). If the scars cover a wide surface, only the
axillary fossa has healthy skin. The scars displace the axillary
tissue downward, which increases the scar surface deficit
(Fig.  19.5a). The planning of the operation is shown in
Fig. 19.5b. With incisions along both fold crests, the sheets are
divided, and scars are separated from healthy skin; all axillary
healthy skin is included in a quadrangular flap (Fig. 19.5d).
Using perpendicular Y-shaped incisions, scar sheets are dis-
sected anteriorly and posteriorly to the joint rotation axis.
Y-incisions also separate contracted scars of FL surfaces from
tissue of the joint extension surface (E), which has not partici-
pated in contracture formation, and thus facilitates the diver-
gence of the scar edges and completes contracture release
(Figs. 19.2, 19.4e, and 19.5d, e). The flap of healthy axillary
fossa tissue (skin and subcutaneous fat layer) is separated
from the scars and mobilized from the periphery; the tissues in
19  Bilateral Shoulder Edge Adduction Scar Contractures: Anatomy and Treatment

183
the central zone of the axillary fossa remain in situ and serve
as a subcutaneous pedicle. The flap has steady blood circula-
tion and severe stretches of the flap in the anterio-posterior
direction allow its ends to connect with the wounds’ edges
anteriorly and posteriorly on the shoulder joint level
(Fig.  19.5d–g). The wounds beside the flap are primarily
closed, starting from the flap’s ends (Fig. 19.5f–h). Truncal
medial (Fig. 19.5i) and elbow edge contracture (Fig. 19.5c)
are eliminated simultaneously using trapezoid-­flap plasty,
with good results (Fig. 19.5j).
Bilateral shoulder edge adduction contracture can be
eliminated with an island of healthy skin preserved in axil-
lary apex (Fig. 19.6). After a widespread burn of the axillary
region, the island of healthy skin in the cupola can be pre-
served with a round (Fig. 19.6a–c) or quadrangular shape
(Fig.  19.6d–g). In both cases, the severe anterio-posterior
shoulder adduction contracture in adults is also treated with
the subcutaneous pedicle flap and primary wound closure or
skin grafting. The island axillary flap is mobilized from the
periphery, displaced on the axilla’s bottom, and transposed in
an anterio-posterior direction with tension. Due to flap ten-
sion, (a) the edges of pectoralis major and latissimus dorsi
muscles approach each other and the axillary fossa is obliter-
ated; and (b) the healthy tissue of the axilla is used for sur-
face deficit compensation and wound covering in the anterior
and posterior joint’s flexion lateral surface. As a result, the
flap’s ends reach the wound edges at the joint rotation axis
level and thus suspend the axilla at the normal level or with
some overcorrection. The axilla suspension with the trape-
zoid subcutaneous pedicle flap prevents contracture recur-
rence (Fig.  19.7a–d). The presented flaps and techniques
allow elimination of the bilateral adduction contracture with
local tissues, and avoid skin grafting per se, as well as the use
of complex regional pedicle and free flaps, in most cases.
a
b
c
d
e
f
g
Fig. 19.4  Case 1: Two-stage bilateral axillary edge contractures treat-
ment with trapezoid adipose-cutaneous flaps. (a) Left shoulder joint:
anterior contracture removed 3 weeks before, planned trapezoid flap for
posterior contracture release; (b, c) contracture eliminated, axillary
contours restored. Case 2: Two-stage bilateral edge right axillary con-
tracture treatment with trapezoid adipose-cutaneous flaps. (d) Anterior
edge contracture released before; scars on posterior FL surface and scar
sheet dissected with Y-incision, Dt—trapezoid wound appeared (scar
surface deficit and real contracture cause), FP—trapezoid adipose-­
cutaneous flap mobilized; DW—donor wound. Anatomy: E—joint
extension surface; “+”—joint rotation axis; Dt—scar surface deficit;
Cr—crest of the fold; (e) mobilized flap covered wound and scar sur-
face deficit compensated; (f) donor wounds beside the flap covered with
adipose-scar trapezoid flaps prepared from the scar sheet and FL—scar
flexion lateral surface; contracture released; (g) follow-up (2 years after
surgery): excellent functional and cosmetic outcomes
Bilateral Shoulder Edge Contracture Treatment

184
a
b
c
d
e
f
g
i
h
j
Fig. 19.5  One-stage elimination of contractures, different form and
location, with trapezoid-flap plasty in children: two big joints and lat-
eral truncal contractures. (a) Pre-surgery, anatomy of bilateral left axil-
lary adduction contracture: E extension, Fl flexion lateral and FM
flexion medial surfaces; “+” joint rotation axis, Fd fold; Cr crest of the
fold. (b, c) Planning bilateral shoulder contracture treatment with a
quadrangular subcutaneous pedicle flap, edge elbow contracture release
first (c) with cubital adipose-cutaneous trapezoid flap; (d–h) lateral
truncal elimination with three pairs of adipose-scar trapezoid flaps; (i)
end of all operations; (j) 2 weeks after surgery: all contractures elimi-
nated without complications
19  Bilateral Shoulder Edge Adduction Scar Contractures: Anatomy and Treatment

185
a
b
c
d
e
f
g
Fig. 19.6  Case 1: Shoulder adduction contracture treatment using an
island of healthy skin in axillary cupola. (a) Pre-surgery, functional
joint zones, planning; E joint extension surface; “+” crest of the joint;
FL flexion lateral surfaces; FM flexion medial surface, axilla island of
healthy skin; (b) contracture released by Y-incisions of FL surfaces
anteriorly and posteriorly; island of healthy skin mobilized on periph-
ery; (c) ends of the flap extended in anterio-posterior direction and
sutured to the wound’s edges; 7 days after operation: flap alive, contrac-
ture fully released; central axilla is the healthy skin or subcutaneous
pedicle flap, which extended in anterio-posterior direction; wounds
beside the flap covered with neighboring adipose-scar tissues, starting
from flaps’ ends; contracture released with island of healthy skin and
surrounding scars. Case 2: (d) Severe shoulder anterio-posterior edge
adduction contracture elimination with the quadrangular subcutaneous
pedicle flap containing healthy skin and scars; pre-surgery view: (e)
planning; (f) scars on anterior and posterior FL—flexion lateral sur-
faces dissected with Y-incision; flap mobilized from the periphery, dis-
placed on axillary bottom, extended in anterior and posterior direction
and sutured with wound borders; donor wounds primarily closed, dis-
placing neighboring adipose-scars; (g) follow-up results: contracture
completely released, axilla restored
Bilateral Shoulder Edge Contracture Treatment

186
a
b
c
d
Fig. 19.7  Results of bilateral
edge shoulder adduction
contracture treatment with
axillary subcutaneous pedicle
flap. (a, b) Pre-surgery:
anatomy of anterior and
posterior view of contracture
and planning: E joint
extension surface; “+” joint
rotation axis; FL flexion
lateral surfaces and lateral
sheets of the fold (Fd) are
contracted scars, which
caused the contractures;
FM—healthy skin of fossa
included the medial sheet of
the Fd—fold; Y- line of
contracted scars dissection
from fold crest to the joint
rotation axis; Cr crest of the
fold; (c) 2 weeks after
reconstruction; (d) follow-up
results: contracture eliminated
and axillary region restored
19  Bilateral Shoulder Edge Adduction Scar Contractures: Anatomy and Treatment

187
Conclusion
Bilateral edge shoulder adduction contractures are fully
eliminated with axillary trapezoid subcutaneous pedicle
flaps in one or two stages, and shoulder abduction is com-
pletely achieved. Despite severe tension, the adipose-­
cutaneous
axillary
fossa
flaps
are
alive. After
reconstruction, stretching of the flaps and surrounding tis-
sues gradually diminishes owing to skin growth; axillary
fossa accepts normal shape. Follow-up results and general
appearance of the shoulder joint region are improved sig-
nificantly with time. No contracture recurrence takes
place, and reoperation is not required.
References
1. Walash A, Kishk T, Ghareeb F. Treatment of postburn axillary con-
tracture. Menoufia Med J. 2014;27(2):278–83.
2. Chen B, Xu M, Chan J, Song H, Gao Q. Treatment of severe or
moderate axillary burn scar contracture with transverse island scap-
ular flap in adult and children. Burns. 2015;41:872–80.
3. Grishkevich VM.  Bilateral shoulder edge adduction contracture:
anatomy and treatment with axillary adipose-cutaneous trapezoid
flaps, a new approach. JSM Burns Trauma. 2017;2(1):1009. https://
Accessed 10
Dec 2017.
References

189
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Total Shoulder Adduction Contracture
Treatment with Preserved Skin in Axilla
Apex: Anatomy and Treatment
Introduction
Total shoulder adduction contracture is caused by extensive
scars covering the flexion lateral and flexion medial shoulder
joint surfaces and neighboring and regional areas. In some
cases, a small island of healthy skin is preserved in the axilla
apex because, during the burn, the shoulder takes an adducted
position. Because of severe scar surface deficit, a large
wound appears after contracture release; therefore, a large
flap is needed for reconstruction. Treatment is complicated
by shrinkage of skin transplants in the axillary region, which
causes re-contracture. If the chest wall (donor site) is injured,
the flaps can’t be used, and this further complicates recon-
struction. The problem is more apparent in pediatric patients.
For such cases, we developed a new reconstructive technique
based on the use of island skin in the form of a subcutaneous
pedicle flap by which, after releasing contracture, the axilla
is suspended and the large wound is divided into two parts:
shoulder and thoracic. This simple and safe method prevents
transplants from shrinking and contractures from recurring.
Contracture Anatomy
Shoulder adduction contractures are characterized by scars
that cover the joint from three sides: flexion lateral anterior
and posterior, and flexion medial (axillary) (Fig. 20.1a, b).
Wide-spreading scars on neighboring areas involve the
shoulder and lateral truncal surface. The island of healthy
skin is confined by these scars. As a result, a cavity is formed,
connecting with the outside space through a small round ori-
fice 2–3 cm in diameter (Figs. 20.1, 20.2, and 20.3). The cav-
ity bottom and lateral wall are healthy skin surface, of which
no more than half is the fossa’s surface. The entire axillary
region is turned downwards. The hairs continued to grow,
which is seen through the orifice (Fig. 20.4a). In most cases,
the island of healthy skin in the cupola is open, located
deeper than the surrounding scarred skin transplant
(Figs. 20.5b). The qualities of the surrounding scars and skin
transplants are also varied (e.g., even, rough, thin, thick, less
or more matured, mildly or severely contracted).
20

190
a
b
c
d
e
f
Fig. 20.1  Total (severe)
shoulder adduction
contracture treatment with
confined island of healthy
skin of the axillary apex and
skin grafting. (a, b)
Contracture anatomy: E joint
extension surface; “+” joint
rotation axis; FL flexion
lateral surface; FM flexion
medial surface; Fd fold.
Pre-surgery: total severe
adduction contracture,
wide-spreading scars, scars
displaced axilla downward;
small orifice leading to
confined skin; planning: line
around orifice and lines for
contracture release by scar
dissection with Y-shaped
incisions from the orifice to
the joint rotation axis; (c)
I—island skin; after scar
dissection, and freed orifice
from scars, a large wound
appeared and healthy skin
seen in the axillary center; (d)
FP—flap; Dt—scar surface
deficit with confined healthy
skin converted into a narrow
subcutaneous pedicle flap, its
ends connected with wound
edges on the anterior and
posterior joint surfaces, the
large wound divided into two:
thoracic and shoulder, flap
suspended axilla to normal
level; (e) wounds beside the
flap were skin grafted; (f)
2 years after reconstruction:
full shoulder abduction, flap
(island healthy skin) became
doubled in width, hair grows;
skin transplants (Tr) look like
normal skin; axillary fossa
restored
20  Total Shoulder Adduction Contracture Treatment with Preserved Skin in Axilla Apex: Anatomy and Treatment

191
a
b
c
d
f
e
Fig. 20.2  Conversion of confined island of healthy skin into a narrow
flap and fixation of it in the central axilla. (a, b) Before the operation,
joint zones and contracture anatomy are marked: E joint extension sur-
face; “+” joint rotation axis; FL flexion lateral surfaces covered by
scars (contracture cause); FM flexion medial surface covered by scars;
planning: Y-lines of contracted scar dissection on FL surfaces anteri-
orly and posteriorly from the island skin to the joint rotation axis; (c)
the skin of the cavity is converted into a flap (FP), the ends of which
are sutured to the wound’s borders anteriorly and posteriorly. The flap
suspends the axilla with over-correction and divides the wound into
shoulder and thoracic segments, which are the cause of Dt—scar sur-
face deficit and contracture; (d) end of operation, wounds (scar surface
deficit) beside the flap are primarily closed, starting from the flap’s
ends; (e) results: contracture fully released with local tissues, axillary
region restored (f) converting the cavity’s healthy skin into subcutane-
ous pedicle flap (scheme)
Contracture Anatomy

192
a
b
c
d
Fig. 20.3  Result of total
shoulder adduction
contracture treatment using
confined island of healthy
skin and local tissue. (a, b)
Before operation and
planning, Y-lines for
contracted scar dissection
anteriorly and posteriorly
from the orifice to the joint
rotation axis; (c) healthy skin
of the cavity was isolated
from scars and converted into
FP—flap oriented in
anterio-posterior direction;
wound or Dt—scar surface
deficit appeared around the
flap; E—joint extension
surface; “+”—joint rotation
axis. (d) Ends of the flap
connected with wound
borders anteriorly and
posteriorly; the wound beside
the flap primarily closed; the
flap covered the central
axillary zone; contracture was
eliminated with the flap from
island skin and neighboring
tissues of the shoulder and
chest wall, transposed to
axilla for the donor wound
covering
a
b
c
Fig. 20.4  Result of total shoulder adduction contracture treatment with
confined island of healthy skin, being converted to a long subcutaneous
pedicle flap. (a, b) Pre-surgery view; hairs of cupola in the orifice; plan-
ning: Y-lines from the orifice to the joint rotation axis of contracted scar
incision; (c) healthy skin of the cupola is mobilized from the periphery
and converted into lineal adipose-cutaneous subcutaneous pedicle flap, the
ends of which connected with the wound’s borders anteriorly and posteri-
orly; wounds or scar surface deficit covered with local tissues, starting
from the flap’s ends; 2 weeks after reconstruction: the flap is alive, the
axillary region restored, and contracture is completely eliminated
20  Total Shoulder Adduction Contracture Treatment with Preserved Skin in Axilla Apex: Anatomy and Treatment

193
a
b
e
f
g
c
d
Fig. 20.5  Small confined island of healthy skin incorporated into
quadrangular adipose subcutaneous pedicle flap. (a) Before surgery:
small confined island of healthy skin; (b) borders of scar quadrangular
subcutaneous pedicle flap, scars attached to healthy skin; Y-lines of
contracted scar dissection from the flap’s borders to the joint rotation
axis; (c) contracture released, rectangular scar flap mobilized, the scars
of the anterior end of the flap incised, so that healthy skin was exposed
and formed the anterior part of the flap; the flap is displaced to the bot-
tom of the axilla; (d) the flap extended in anterior-posterior direction,
its ends sutured with the wound borders at joint rotation axis level; (e)
large wounds or scar surface deficit beside the flap are covered with
skin transplants; (f) result (3 weeks after surgery): the flap and skin
transplant are alive, contracture is released completely; (g) scheme of
operation
Contracture Anatomy

194
Surgical Technique
Three forms of the surgical procedure were elaborated and
used depending on the contracture severity and its anatomi-
cal features.
Surgery of Total Severe Shoulder Contracture
with Confined Island Skin
The planning line around the orifice and two Y-shaped lines
from the orifice anteriorly and posteriorly up to the joint
rotation axis level or to the healthy skin borders (Figs. 20.1a,
b and 20.2a, b). Following the lines, the scars are dissected;
after shoulder abduction, a big wound is formed; the skin
that formed a cavity remains in situ (Figs. 20.1c and 20.3c).
Then, the island skin was separated from scars near the ori-
fice; skin which formed a cavity is dissected from the shoul-
der and trunk, leaving a nearly 3  cm bridge, and the
half-cavity walls are converted in a pedicle flap of nearly
4 cm in width (Fig. 20.1d). The healthy skin is additionally
crosscut from the shoulder and trunk sides for all healthy
skin conversion in the strip-shaped subcutaneous pedicle
flap. All island skin is converted into the subcutaneous pedi-
cle flap. The flap is transposed in anterior and posterior
directions with tension, and the flap’s ends are sutured first
with the anterior and then with the posterior wound borders
(Fig. 20.1d). The extended flap, having steady blood circula-
tion, covers the central axillary zone, suspends the axilla,
divides the large wound on the shoulder and thoracic,
squeezes soft tissues, and approaches the axillary fossa’s
edges, making the wound smaller. Due to flap tension, the
adipose-cutaneous layer of the upper shoulder joint exten-
sion surface (E) is displaced downward, reducing the wound
in anterior-posterior direction; the distance between the ante-
rior and posterior wound edges is shortened. The stable sus-
pension of the axilla and divided wound is the key for a
successful operation and basis of new surgical method
(Figs. 20.1d, 20.2c, and 20.5d).
Shoulder Contracture and Scar Surface Deficit
with Confined Island Skin Is Moderate
The donor wounds beside the flap are primarily closed, start-
ing from the flap’s ends (Figs. 20.3 and 20.4). As a result, the
axilla is restored, and contracture is eliminated in full
(Figs. 20.3d, e and 20.4c).
Small Island Axillary Skin can be Incorporated
in Quadrangular Scar Flap (Fig. 20.5a, b)
The small island of skin is added to the quadrangular adipose-­
scar subcutaneous pedicle flap. The island skin located inside
the flap is freed by the scars’ excision from the periphery; the
skin located at the end of the scar flap is freed with a scar inci-
sion from the end (Fig. 20.5c, d). Then the flap is displaced
anteriorly and posteriorly with tension. The axilla is elevated
with some over-correction. Because the flap steadily suspends
the axilla and the large wound is divided into two (shoulder
and thoracic), the skin transplants, covering the wound on the
chest wall and shoulder inner surface, are less prone to shrink-
age, which prevents contracture recurrence (Fig. 20.5f).
20  Total Shoulder Adduction Contracture Treatment with Preserved Skin in Axilla Apex: Anatomy and Treatment

195
Conclusion
The shoulder scar adduction contractures are released
completely using the island of healthy skin of the axillary
apex. Despite severe tension, all flaps are alive. Depending
on scar surface deficit severity, the wounds beside the
flap, on the shoulder and trunk, are covered with skin
grafts. Skin transplants grow well with the underlying
wound tissues; its shrinkage is minimal. The extended
flap and surrounding tissue continue to grow, its tension
disappears, and axillary contours are gradually restored.
Over time, the skin transplant converts into well-function-
ing skin, tolerating an axillary condition without ulcer-
ation. Thus, the longer the period after reconstruction, the
better follow-up results are observed. The flap’s surface
size enlarges significantly; hairs grow well, and the skin
transplant has an even surface without visible shrinkage.
This new method of contracture release, axilla suspension
and wound resurfacing with skin transplants or local
tissues-makes surgery simple, safe, and prevents contrac-
ture recurrence.
Reference

197
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Shoulder Medial Adduction Contracture:
Anatomy and Treatment with Local
Adipose Scar Trapezoid Flaps
Introduction
The axillary fossa rarely suffers burns because the shoulder
takes an adducted position during injury. Considering that
shoulder contractures comprise 38% of the total number of
burn contractures of the big joint [1], 8–10% of them are
shoulder medial adduction contractures. The shoulder medial
adduction contracture is not highlighted in existing classifi-
cations or in articles focusing on treatment of scar contrac-
tures of the shoulder. This factor is the reason we know
almost nothing about shoulder medial adduction contracture,
including its anatomy, clinical pictures, and methods of sur-
gical treatment. Therefore, our task was to explore all aspects
of this burn’s consequences in adults and children.
Shoulder Medial Adduction Contracture
Anatomy and Scar Surface Deficit
Medial shoulder-adduction contracture is a result of burns and
scars of the joint axillary fossa, or joint flexion medial (FM)
surface, and the inner surface of the shoulder and truncal lateral
surfaces (Fig. 21.1). Scars are traumatized when the shoulder is
in abduction, and this stimulates connective scar tissue to grow.
Therefore, scars of the axilla, growing distally and contracting,
smooth the fossa and descend the axilla and form a crescent
fold, the crest (Cr) of which passes along the medial line of the
axilla. Shoulder medial contracture is considered to be total con-
tracture; therefore, specific reconstructive techniques to elimi-
nate shoulder medial contractures have not yet been developed.
Protrusion of the pectoralis major and latissimus dorsi mus-
cles’ edges forms a curvature of the joint surface. The axillary
fossa, formed between the muscle’s edges, covered by scars,
looks like a big fold (Fig. 21.1a). The sheets of the crescent fold
are scars, spreading from the fold’s crest (Cr), which pass along
the medial line of the joint FM surface to the pectoralis major and
latissimus dorsi muscles’ edges. The crescent fold is a new ana-
tomical structure, scar surface surplus that allows medial con-
tracture elimination with local flaps without skin grafts and
pedicle flaps [1]. The joint flexion lateral (FL) and extension (E)
surfaces are healthy skin or covered with scars, and do not par-
ticipate in shoulder adduction contracture formation. At the same
time, scar contraction leads to scar deficit formation in length
between the shoulder and the chest wall (Fig. 21.2), causing the
contracture. For adequate reconstructive technique choice and
the flap’s form, it is necessary to determine the form and size of
the scar sheet surface deficiency. This is estimated using the fol-
lowing steps: scar sheets are divided with an incision along the
fold’s crest; the sheets are cross-cut from the fold’s crest to the
axillary fossa edges with radial (perpendicular) Y-incisions. After
shoulder abduction, the wound of each sheet and flap accepts, as
a rule, a trapezoid form, consisting of trapezoid parts: FP flap; Dt
deficit; and DW donor wound (Figs. 21.1 and 21.2). As the fold
has a crescent form, radial incisions, as a rule, convert the fold’s
sheets into trapeze-­shaped flaps (FP).
21

198
Fig. 21.2  Anatomy of shoulder medial adduction contracture
Fig. 21.1  Functional zones of the shoulder joint and anatomy of shoul-
der medial-adduction contracture. (a, b) Shoulder adduction is caused by
scars covering the axillary fossa or flexion medial surface (FM) up to the
axillary edges or the flexion lateral (FL) surface and forming the semilu-
nar fold, the crest of which (Cr) passes along the medial axillary line.
With time, all the fossa or FM surface is transformed in the crescent fold,
both fold sheets are scars; the axilla is shifted downward; scars on the
shoulder joint’s flexion lateral surface (FL) and extension surface (E) do
not participate in contracture formation; Symbol “+” is the joint rotation
axis level. Planning of operation: two trapezoid flaps are marked
a
b
21  Shoulder Medial Adduction Contracture: Anatomy and Treatment with Local Adipose Scar Trapezoid Flaps

199
Surgical Reconstruction of Medial Shoulder
Adduction Contracture with Adipose Scar
Trapezoid Flaps [2]
Shoulder Medial Adduction Contracture
Elimination with One Pair of Trapezoid Flaps
(Fig. 21.3a–d)
This technique is used when contracture is mild and the scar’s
fold is short. One pair of trapezoid flaps is planned in the
central axillary region (Figs. 21.1b and 21.3a). The first inci-
sion passes along the fold’s crest and divides the fold’s sheets;
then, with two radial (perpendicular) Y-incisions, the fold
sheets (scars and subcutaneous fat layer) are dissected from
the fold’s crest to the axillary fossa’s edges or the flexion lat-
eral surface (FL). The Y-shaped incision allows for maximiz-
ing the release while minimizing the need for further
prolongation of the scars dissection on the flexion lateral sur-
face (FL). The distance between incisions at the fold’s crest is
about 5–6  cm (flap end’s width). The flaps are mobilized,
including a superficial axillary fat layer; the deep fatty layer
with lymphatic nodules remains in situ. The flaps are elevated
up to the muscles, forming axillary edges (pectoralis major
and latissimus dorsi). The fat layer provides for the flap’s
steady blood circulation and prevents the flap from shrinking
after surgery. Mobilized flaps, located opposite each other,
advance toward each other with tension until the flap’s ends
approach the base of the counter flap. Then, the flap’s ends are
sutured to the wound’s edges and with each other, and the
flap’s end to the flap’s base (Fig. 21.3b, c). The wounds that
remain near the flap’s base had been primarily closed, con-
necting the edges along the shoulder and trunk. The scars,
forming “dog ears,” are excised. Owing to flap tension, the
flap’s bases and muscles’ edges, forming axillary edges,
approach each other and shorten the distance between axil-
lary edges. The donor wound becomes smaller and narrower,
which allows for connecting the flap’s ends to the base of the
opposite flaps. As a rule, a good result is achieved (Fig. 21.3d).
a
b
d
c
Fig. 21.3  Medial shoulder adduction contracture elimination with one
pair of adipose-scar trapezoid flaps. (a) Contracture anatomy: scars
cover FM surface or fossa, all fossa are converted into semilunar fold,
both sheets of the fold are scars; FL flexion lateral and E extension
surfaces are healthy skin; Cr crest of the fold; planning: one pair of
trapezoid flaps involved all of the FM surface; (b) after cross-cutting of
the fold with radial Y-incisions and an incision along the fold crest, the
two adipose-scars flaps are mobilized and counter transposed on the
wound; flaps covered the axillary fossa’s zones; shoulder adduction, the
common wound appeared, which is divided by the central strip on two
trapezoid wounds reflecting the form and size of the scar surface deficit
and donor wound (DW); technique of wound covering with two adi-
pose-scar trapezoid flaps; (c) the donor wounds primarily closed start-
ing from flap’s end and base; counter transposed flaps covered the
wound, scar surface deficit compensated, and contracture eliminated in
full; (d) follow-up result
Surgical Reconstruction of Medial Shoulder Adduction Contracture with Adipose Scar Trapezoid Flaps

200
Trapeze-Flap Plasty with Two Pairs
of Trapezoid Flaps (Fig. 21.4a–d)
Medial-to-severe shoulder medial-adduction contracture in
children is eliminated with three pairs of adipose-scar trape-
zoid flaps (Fig. 21.4). If the contracture is more severe and
the fold is long, two pairs of adipose-scar flaps are planned
(Fig. 21.4a, b) and elevated. The main pair of flaps covers the
central axillary region, and the other two pairs are placed
beside the main pair (Fig. 21.4c). Counter-transposed flaps
cover the wound, and scar surface deficit is compensated
with good functional and cosmetic results (Fig. 21.4d).
a
b
c
d
Fig. 21.4  Shoulder medial-adduction contracture treatment with two
pairs of adipose-scar trapezoid flaps. (a) Before the operation; axilla
has view of fold; (b) anatomy: FM surface or fossa covered with scars
causing contracture; FL surface, Cr crest of the fold; Y-radial lines of
sheets dissections, Cr fold’s crest; planning two pairs of trapezoid flaps
by the fold radial incisions; (c) 7 days after surgery; (d) excellent func-
tional and good cosmetic outcomes 1 year after reconstruction
21  Shoulder Medial Adduction Contracture: Anatomy and Treatment with Local Adipose Scar Trapezoid Flaps

201
Trapeze-Flap Plasty with Three Pairs
of Trapezoid Flaps (Fig. 21.5a–e)
In adults, if the scar fold is long, usually in cases of mod-
erate and severe contractures, the fold’s sheets are dis-
sected with radial Y-shaped incisions along all its length.
Because the fold has a semilunar shape, the radial inci-
sions convert the fold’s sheets into trapezoid flaps regard-
less of the number of incisions made (Fig.  21.5b–d).
Planning lines and incisions spread from the fold crest
to edges of the fossa or edges of muscles that form the
joint fossa (pectoralis major and latissimus dorsi muscles)
(Fig. 21.5b–d). Thus, the scars of flexion lateral surfaces
(FL) do not participate in medial contracture formation
and its treatment. After shoulder abduction, trapezoid
wounds appeared beside the trapezoid flaps (Figs. 21.2d,
f and 21.5c, d). A surface of adipose-scar flaps is usually
sufficient for scar surface deficit compensation and con-
tracture elimination (Fig. 21.2e).
In children (Fig. 21.6), the severe scar surface deficit, caus-
ing the shoulder adduction contracture, is fully compensated
and contracture is eliminated with counter-flaps’ transposition
of two pairs of trapezoid flaps. The plan for one pair of trape-
zoid flaps proved to be insufficient for full contracture release
(Fig. 21.6c). Therefore, the number of trapezoid adipose-scar
flaps increased at the time of the operation (Fig.  21.6d).
Excellent follow-up results are shown in Fig. 21.6e.
Shoulder medial adduction contracture can be combined
with the elbow edge contracture (Fig. 21.7). Both contrac-
tures are eliminated in one stage, using a specific form of
trapeze-flap plasty. Elbow contracture is removed first, then
the shoulder reconstruction becomes simpler. During the
operation, the number of adipose-scar flaps was increased to
accomplish contracture release.
a
b
c
d
e
Fig. 21.5  Medial-adduction shoulder contracture treatment with three
pairs of adipose-scar trapezoid flaps. (a) Contracture anatomy: contracted
scars cover the axillary fossa or flexion medial surface (FM) and form a
long semilunar fold, the crest (Cr) of which passes along the middle axil-
lary line; both fold’s sheets are scars and have surface deficit in length
(contracture cause) and surface surplus in width; flexion lateral (FL) sur-
face is healthy skin; “+” joint rotation axis; E joint extension surface; (b)
planning of three pairs of adipose-scar trapezoid flaps; Y-lines of scars
incisions from the fold crest to the edges of fossa or FL surface; (c) after
contracture release with a Y-shaped incision, trapeze-­shaped flaps (FP)
and wounds or scar surface deficit (Dt) appeared; (d) mobilized flaps con-
sist of the scars and superficial fat layer of axilla; (e) counter transposed
flaps covered the wound, scar surface deficit was compensated; the con-
tracture is completely eliminated (7 days after surgery, flaps are alive)
Surgical Reconstruction of Medial Shoulder Adduction Contracture with Adipose Scar Trapezoid Flaps

202
a
b
c
d
e
Fig. 21.6  Severe shoulder medial adduction contracture elimination in
a 5-year-old girl. (a, b) Anatomy: contracted scars cover flexion medial
surface (FM); FL flexion lateral surface is healthy skin; “+” joint rota-
tion axis; E joint extension surface; one pair of trapezoid adipose-scar
flaps planned; (c) adipose-scar flaps are mobilized, two trapezoid
wounds appeared (strips marked) in the zone of every fold’s sheet; anat-
omy wound: DW donor wound; Dt surface deficit; Fp flap; (d) two flaps
were insufficient for complete contracture release; therefore, two addi-
tional flaps were elevated, and strips of scars excised on shoulder and
lateral trunk; (e) excellent functional and cosmetic outcomes (2 years
after surgery)
a
b
c
Fig. 21.7  Shoulder medial severe adduction contracture and elbow
edge contracture elimination simultaneously, elbow first, in a 7-year-­
old boy. (a) Functional zones in case of shoulder medial and elbow edge
contractures; (b) planning reconstruction with one pair of adipose-scar
trapezoid flaps; (c) contracture released without complication
21  Shoulder Medial Adduction Contracture: Anatomy and Treatment with Local Adipose Scar Trapezoid Flaps

203
Conclusion
In all cases, medial shoulder adduction contractures can be
fully eliminated with trapeze-flap plasty, without skin
grafting and pedicle or free flaps. After opposite transposi-
tion of one or several pairs of adipose-scar flaps, the medial
axillary line passes through the flap’s middle. Consequently,
the elongation of the maximal tension area (axillary medial
line) equals the sum of widths of all flaps minus the length
of the fold’s crest involved in plasty. Elongation reached
150–200%, which is sufficient for complete scar surface-­
deficiency compensation, contracture release (180% of
abduction), and wound covering. No flap loss or other post-
operative complications occurred. With time, the flaps’ sur-
faces became more leveled and gradually increased,
especially in pediatric patients. Therefore, no contracture
recurrence took place and re-operation was not needed.
Over time, the axillary region accepted normal contours
and form; scars in axillary fossa did not experience ulcer-
ation and did not cause any discomfort. Operation scars are
not prone to excessive growth, and stay nearly invisible.
The full range of the shoulder’s joint motion is achieved.
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(4):508–14.
2. Grishkevich VM. Postburn shoulder medial-adduction contracture:
anatomy and treatment with trapeze-flap plasty. Burns. 2013;39:
341–8.
References

205
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Shoulder Total Adduction Contracture
After Burns: Anatomy and Treatment
with Quadrangular Local Subcutaneous
Pedicle Flap
Introduction
Contracted scars and skin grafts covering the shoulder joint
flexion lateral (FL) and flexion medial (FM) surfaces cause a
total adduction contracture. Scars have severe surface deficit
(Dt), excluding use of the local flap techniques. Skin trans-
plants in the axilla shrink and contracture recurs; the big flaps
used present a traumatic and deforming procedure. To prevent
skin transplants from shrinkage and contractures from recur-
ring, we developed a new technique based on axilla suspen-
sion with scar quadrangular axillary subcutaneous pedicle
flap and skin transplants. Excellent outcomes have elevated
the level of rehabilitation of burn patients with severe shoul-
der edge adduction contractures. This surgical method and
results of its implementation are presented below.
Anatomy, Formation, and Cause of the Total
Shoulder Adduction Contracture
Total (severe) shoulder adduction contracture is caused by
contracted scars covering the joint flexion surfaces (Fig. 22.1;
FL + FM or circularly). Scars tightly surround the joint, folds
or scar surface surplus is absent. Scars can affect one or both
shoulder joints and the joints’ neighboring zones (inner shoul-
der and lateral truncal surface) and donor sites used to elevate
flaps (Fig. 22.1a–c). Vast scars have a severe scar surface defi-
cit, excluding local-flap plasty. Two anatomical total shoulder
contractures exist: (a) the axillary fossa is obliterated and dis-
placed downward, the shoulder is fused with the chest wall,
and the entire axillary region is deformed (Fig. 22.1a, b); (b) in
most patients, the scar’s surface in the projection of the axil-
22