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

207
Surgical Technique
Contracture anatomy and anatomy of a scar surface deficit
are marked by accepted letters [1]. Planning of the operation
consists of quadrangular local scar flap design in the axillary
region, or axillary fossa projection and anterio-posterior
direction (Fig. 22.2a). Two Y-shaped lines are drawn on the
anterior and posterior shoulder joint surface from the flap
ends of the flap up to the joint rotation axis level for scar inci-
sion and contracture release by separating contracted scars
from tissues of the joint extension surface (E), by continua-
tion of incisions along the joint rotation axis level. As a
result, the end of the wounds or scar surface deficit on FL
surfaces accept an M-shape (Fig. 22.3b). The quadrangular
figure’s width is approximately 6  cm; its length is nearly
12 cm. These parameters can be changed depending on the
patient’s age and the form of the scar surface in the axillary
region. The scars and subcutaneous fat layer are dissected
according to lines (Fig. 22.2b). Simultaneously with shoul-
der abduction, the flap is mobilized from its borders by inci-
sions parallel to the trunk and inner shoulder surfaces, the
pectoralis major and latissimus dorsi flap’s edges, gradually
deepening the flap on the axillary bottom. After complete
contracture release from three joint sides and shoulder
abduction, the big wound is formed around the flap: on the
axilla, chest wall, inner shoulder surface, and on the anterior
and posterior shoulder joint surfaces (Figs. 22.2b and 22.6b–
d). The anterior flap end is sutured to an M-shaped wound
edge on the anterior joint surface; then, the posterior flap’s
end is connected to the posterior wound edge with significant
tension of the flap (Fig.  22.2c). Thus, the axilla is turned
upward to its normal level or some over-correction and is
fixed with the flap in a stable suspended position. Because of
tension, the axilla is elevated and narrowed; the flap becomes
longer, but narrower; the tissues located above the joint rota-
tion axis (E – joint extension surface) are displaced down-
ward, diminishing the distances among the wound edges in
an anterio-posterior direction; axillary fossa edges approach
each other. All these factors reduce the wound surface. The
wounds beside the lap, on the chest wall, and on the inner
shoulder surface are covered most often with skin grafts
(Figs. 22.2d, 22.3d, and 22.6d), fixed in compression condi-
tion with tie-over dressing. Results are functionally and cos-
metically good (Figs.  22.2e, f, 22.4e, 22.5c, 22.6e, and
22.7c). The scheme of the operation is shown in Fig. 22.2g.
The quadrangular adipose-scar flap has steady blood cir-
culation; therefore, its traction in the anterio-posterior direc-
tion is safe. The anatomy of the wound after flap mobilization
and descending on the axillary bottom and consecutive steps
of surgery is shown in Fig. 22.6: Dt scar surface deficit; FP
flap. The stretched flap steadily suspends the axilla at the
normal or over-corrected level and divides one large wound
into two—thoracic and shoulder—which have a solid base-
ment. These two factors ensure that the skin transplants do
not shrink (Figs. 22.2f, 22.4e and 22.5c). The steady blood
circulation allows elimination of severe contractures, where
the flap’s tension is needed.
Total shoulder adduction contracture is often combined
with breast deformity and lateral truncal contracture
(Fig. 22.4a, b). In such cases, the shoulder and truncal con-
tractures are released first, which facilitates breast recon-
struction. Figure 22.4f shows the scheme of reconstruction,
the anatomy of total shoulder contracture, and the anatomy
after surgery.
Total shoulder adduction contracture is often observed in
children, i.e., in five of eight cases (Figs. 22.3a, b, 22.4, 22.5
and 22.7). The reconstruction is performed more easily and
with greater success in pediatric patients than in adults.
In children, total shoulder adduction contracture of both
joints is a result of vast burns and scarring of the chest wall
(Fig.  22.5). After skin grafting, a flat surface can appear
between the shoulder and the chest wall (Fig.  22.5b).
Reconstruction with a quadrangular subcutaneous pedicle
flap is performed simultaneously, early, and yields perfect
outcomes (Fig. 22.6e).
This technique yields good results in small children
(Figs. 22.5, 22.6, and 22.7).
Large wound and severe scar surface deficit around the
flap can be covered with a combined method as shown in
Fig. 22.8b–d: the wound at the flaps’ ends is covered with
local tissues; the last surface of wounds is skin grafted.
Good functional and cosmetic outcomes are the results of
several factors:
(a) Contracted scars are dissected with Y-incisions and con-
tracture is released from the fold’s crests up to the joint
rotation axis anteriorly and posteriorly, and separated
from the tissue of the joint extension (E) surface.
(b) Flap mobilization from the periphery and displacement
of the flap on axillary bottom level.
(c) The axilla is stably elevated at a normal level, which pre-
vents contracture recurrence.
(d) The large wound and scar surface deficit is divided by
the flap into the shoulder and thoracic, which are sepa-
rately covered with skin transplants (Fig. 22.6).
(e) The shrinkage of skin transplants does not change the
position of the flap, which prevents contracture recurrence
and preserves normal contours of the axillary region.
Surgical Technique

208
d
a
b
c
f
g
e
Fig. 22.2  Surgical technique for total shoulder adduction scar con-
tracture elimination with quadrangular local subcutaneous pedicle
scar flap and skin grafts. (a) Pre-surgery view; contracture anatomy:
FL and FM joint surface covered by scars, axillary region descended
(has flat Q-A- flap marked); “+” joint rotation axis; planning: quad-
rangular flap in axilla; Y-lines for scars dissection from flap to “+”
axis; FP flap; (b) scars dissected according to lines, island quadran-
gular subcutaneous pedicle scars flap (FP) mobilized from the
periphery and displaced to the bottom of the axillary fossa; wound or
scar surface deficit (wound) around flap after Y-dissection of scars
trapezoid wounds appeared on FL surfaces; (c) flap’s edges con-
nected to the wound edges on joint rotation level; flap’s borders fixed
to underlying wound tissue; central axillary area is formed with the
flap (FP); flap suspends axilla at a normal level; two wounds—shoul-
der and thoracic—beside the flap, Dt scar surface deficit; (d) wounds
beside the flap skin-grafted; (e) 2 weeks after surgery: flap (FP) and
skin transplants (Tr) alive; (f) 2 years after surgery; good functional
and cosmetic outcomes; scar flap (FP) and skin transplants (Tr) well-
tolerated axillary condition, no signs of skin transplants shrinkage;
(g) scheme of operation
22  Shoulder Total Adduction Contracture After Burns: Anatomy and Treatment with Quadrangular Local Subcutaneous Pedicle Flap

209
a
b
c
d
Fig. 22.3  Results of total left shoulder adduction contracture treat-
ment in a girl with quadrangular subcutaneous pedicle flap. (a) Pre-­
surgery, flat surface (FM) in axillary fossa projection; Cr crest of the
fold; planning of operation; (b, c) operation; (d) 7 days after surgery:
contracture released, flap and transplants alive
a
b
e
f
c
d
Fig. 22.4  Results of total shoulder contracture treatment before breast
reconstruction. (a) Pre-surgery, anatomy: E joint extension surface, “+”
joint rotation axis; FL flexion lateral and FM flexion medial surfaces
displaced downward and converted in the fold; Cr crest of the fold (Fd);
planning; (b, c) reconstruction with quadrangular subcutaneous pedicle
scar flap (F); (d) central axillary zone is flap (FP), wounds beside the
flap on the shoulder and chest wall skin-grafted (Tr) without complica-
tions; (e) excellent outcome results
Surgical Technique

210
a
b
c
d
e
Fig. 22.6  Details of severe total adduction contracture elimination. (a)
Anatomy: scars covered all of the axillary region, planning of operation:
flap and lines for scars dissection on the flexion lateral surfaces; (b) quad-
rangular subcutaneous pedicle flap (FP) mobilized from the periphery
and displaced to axillary bottom; trapezoid wounds or scar surface deficit
on FL surfaces and around the flap; wound beside the flap (DT) scar sur-
face deficit, triangular (c, d) flap (FP) extended in anterio-posterior direc-
tion (F), flap’s ends connected with wound borders on joint rotation axis
level; flap stable, suspended axilla and a divided large wound on the
shoulder and thoracic, which are covered with skin transplants (T)
a
b
c
Fig. 22.5  Elimination of total shoulder adduction contractures of both
shoulders in small children (5-year-old girl), caused by immature scars
and contracted skin grafts (4 months after grafting), with local quadran-
gular adipose-scar subcutaneous pedicle flap and skin transplants. (a)
Vast deep burns; (b, c) contracture anatomy: extension, FL and FM
surfaces covered with scars; axillae descended, shoulders severely
adducted; (d) end of operation: (e) 2 years after reconstruction: excel-
lent functional and good aesthetic outcomes
22  Shoulder Total Adduction Contracture After Burns: Anatomy and Treatment with Quadrangular Local Subcutaneous Pedicle Flap

211
a
b
c
Fig. 22.7  Result of total shoulder adduction contracture treatment in
small children (5-year-old boy) with quadrangular adipose-scar subcu-
taneous pedicle flap. (a, b) Pre-surgery and planning. (c) Results,
2  years after reconstruction: excellent functional and good cosmetic
outcomes, normal development of upper extremity
a
b
c
d
Fig. 22.8  Variant of donor wound covering in case of total axillary con-
tracture treatment with a quadrangular adipose-scar subcutaneous pedicle
flap. (a) Anatomy of contracture and planning of the operation; (b) scars
of FL surfaces dissected with Y-incisions, and trapezoid wounds (D scar
deficit) appeared; flap (F) mobilized from the periphery and displaced on
the axillary bottom; (c) flap extended in anterio-­posterior direction, ends
of the flap connected with the wound borders at the joint rotation axis
level; flap axilla elevated and stably suspended. Nearly half of the donor
wound is covered with local tissues, starting from the flap’s ends; (d) the
central zone of donor wounds is covered with skin transplant located
between the extended flap and scars; no contracture recurrence. A com-
bined method of large donor wound resurfacing is anatomically justified
Surgical Technique

212
Conclusion
The new technique discussed here allowed elimination
of most total (severe) shoulder adduction contractures.
Quadrangular scar subcutaneous pedicle flaps had steady
blood supply; therefore, no flap loss or other serious
postoperative complications took place. Functional
long-term results were excellent. With time, the flap’s
and neighboring tissues’ tension disappears due to tissue
growth. The level of axilla is stable and normal; trans-
plants on the shoulder and chest wall gradually trans-
form into well-functioning skin. The scar flaps and skin
grafts tolerate the axillary conditions well, without mac-
erations and ulcerations. The axilla region preserves
normal form and contour. Upper extremities in children
develop normally. The method is simple, less traumatic,
safe, reliable, and allows one to avoid more complex
procedures, contracture recurrence, and repeated surgi-
cal interventions.
References
1. Grishkevich VM.  Shoulder adduction contracture after burns:
anatomy and treatment with quadrangular local scar subcutaneous
pedicle flap, a new approach. Burns. 2013;39:1423–9.
22  Shoulder Total Adduction Contracture After Burns: Anatomy and Treatment with Quadrangular Local Subcutaneous Pedicle Flap

213
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Elbow Edge Flexion Contracture:
Anatomy and Treatment with Local
Trapezoid Flaps
Introduction
Burn scars of elbow flexion lateral surfaces, growing distally,
form a fold along the elbow fossa’s edges, connecting and
approaching the shoulder and arm. Scars that undergo repeat
trauma from joint movement actively grow more aggres-
sively. The ulcers on the fold crest limit the use of the extrem-
ity because of pain. Therefore early reconstruction is needed.
Triangular local flap techniques are most often used. Our
observations showed that triangular scar flaps are short, their
ends have unstable circulation, and necrosis often occurs. The
triangular flap’s form does not match the scar surface deficit
(which is the cause of the contracture). The different qualities
of the fold’s sheets and the counter-transposed flaps do not
allow surgeons to achieve good outcomes. The resulting
incomplete contracture release leads to recurrence and
repeated reconstructions. Our experience shows that the most
effective local-flap technique to completely eliminate edge
elbow contracture is trapeze-flap plasty, based on trapezoid
elbow healthy flap and flaps prepared from the fold’s sheets.
Anatomical Features of Edge Elbow
Contractures [1]
Functional Zones and Anatomy (Fig. 23.1)
First, functionally and clinically, the surface of the elbow
joint is divided into extension (E) and flexion (F). The
dividing line passes between them through the joint rota-
tion axis (“+” symbol). The joint flexion surface is divided
with curvatures (edges of joint fossa) on two zones: flexion
lateral (FL) and flexion medial (FM). The flexion lateral
surface spreads from the edge of the cubital fossa or fold’s
crest (Cr) to the joint rotation axis. Scars grow distally and
involve skin of cubital fossa; as result, the fold is formed
along the fossa’s edge. The fold consists of a lateral scar
sheet, which is a continuation of scar of the flexion lateral
surface, and a medial sheet, which is a continuation of the
fossa’s skin. Thus, the fold is a new anatomical structure,
scar and skin surface surplus, playing an important role in
contracture elimination.
23

214
a
b
Fig. 23.1  Anatomy of postburn edge flexion left elbow contracture. (a)
The joint’s surface is divided on extension (E) and flexion (F). Curvature of
joint surface divides flexion surface into flexion lateral (FL) and flexion
medial (FM). Scars cover the flexion lateral surface of the left elbow and
wrist and form the crescent-shaped fold (Fd); ulcerous crest (Cr) of the fold
passed along the lateral edge of cubital fossa. Contracture is caused with
scars of FL surface with lateral scar sheet of the fold. (b) Flexion medial
(FM) (cubital fossa) surfaces and the medial fold’s sheet are healthy skin.
Symbol “+” is the joint rotation axis level from where the joint E surface
begins; fold (Fd); fold’s crest (Cr), ulcers in elbow and wrist zones
Edge elbow contracture has specific anatomical features
and clinical signs.
(a) Contracture is caused by scars located on the flexion lat-
eral surface and scars of the fold, spreading from the fold
crest to the joint rotation axis (Fig. 23.1a).
(b) The scars of the flexion lateral surface form the crescent
fold, which is part of the flexion lateral and medial sur-
faces and passes along the edge of the cubital fossa,
between the FL and FM surfaces (Fig. 23.1b).
(c) The fold consists of two different quality sheets: the lat-
eral sheet is scars; the medial sheet is healthy skin.
(d) The crest of the fold (Cr) is the edge of scars. All scars
from the fold crest to the joint rotation axis participate in
contracture formation and equal 6–8 cm. The fold can be
short and located in the elbow joint region, or can spread
on neighboring joints. A fold’s crest is usually rough,
thick, and often ulcerous.
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215
Scar Surface Deficit Is a Cause of Edge Elbow
Contracture (Figs. 23.2, 23.3 and 23.4)
The scar of the flexion lateral (FL) surface and scar sheet of
the fold sheet have surface deficit (Dt) in length, which is the
real cause of contracture (Fig. 23.2b). The scar surface defi-
ciency spreads down, gradually decreasing from the fold’s
crest, where it is maximal, and reaches the joint rotation axis
where it is 4 cm in length along the joint rotation axis level
(Fig.  23.2b). To choose an appropriate reconstructive tech-
nique and the shape and size for a flap, the size and form of the
scar sheet length deficit must be known. To estimate the latter,
it is first necessary to separate the scar sheet from the healthy
sheet by an incision made along the whole fold’s crest. Then,
the scar sheet should be cross-cut by a perpendicular Y-incision
from the crest of the fold all the way to the joint rotation axis.
The incision end is Y-shaped near the humerus epicondyle for
the scar’s separation from joint extension tissue (E), which
leads to better wound border divergence and contracture
release. After full elbow extension, the wound, as a rule,
accepts a trapezoid shape that equals the size and the shape of
the scar surface deficiency. The medial fold sheet and cubital
adipose-cutaneous layer were used as the donor site for tra-
peze-flap preparation and contracture elimination.
a
b
c
d
f
e
Fig. 23.2  Edge elbow contracture is caused by surface deficit of scars
located on elbow flexion lateral (FL) surface. Case 1: (a) Contracture
cause: scars on joint FL surface spread from the fold crest (Fig. 2d, UL)
to the joint rotation axis (“+”); flexion medial (FM) surface or elbow
fossa is healthy skin. Planning of operation: one-flap trapeze-flap plasty.
(b) Scars dissected with a Y-incision (Fig. 2d, UL) to the joint rotation
axis, trapezoid flap mobilized: Dt trapezoid wound appeared or real scar
surface deficit and contracture cause; flap (FP), donor wound (DW); (c)
trapezoid elbow flap (F) covered wound, and scar surface deficit com-
pensated for. Two addition trapezoid flaps planned to elevate for com-
plete contracture elimination. Case 2: (d) Anatomy and planning the
same; (e) ulcerous crest excised, trapezoid wound or scar surface deficit
appeared (Dt); trapezoid elbow flap mobilized (FP), two adipose-scar
flaps planned for donor wound covering; (f) counter-transposed flaps
scar surface deficit compensated, contracture eliminated, elbow contours
restored; 7 days after surgery: flaps are alive, complete rehabilitation
Anatomical Features of Edge Elbow Contractures

216
Edge Elbow Contractures Treatment
with Trapeze-Flap Plasty [1]
Edge Elbow Contracture Elimination with One
Adipose-Cutaneous Trapezoid Flap (Fig. 23.3)
Mild-to-moderate edge elbow contractures are removed with
one flap prepared from the healthy fold’s sheet and cubital
fossa (Fig. 23.3a). A preliminary drawing (contours) of the flap
and scar incision is performed before surgery; the flap’s shape
matches the wound but should be wider than the expected
wound by 30–40%. With the first incision, the scar sheet is
separated from the healthy sheet along the whole fold’s crest,
and the rough scars with ulcers are excised. With a perpendicu-
lar Y-shaped incision from the fold’s crest to the joint rotation
axis, the contracture is released. The incision’s end should be
Y-shaped near the humerus epicondyle for complete contrac-
ture release. As a rule, a trapeze-shaped wound is formed after
joint extension (Fig. 23.3b, c). Then, the trapezoid flap is mobi-
lized with the healthy skin and subcutaneous fat layer of the
medial sheet and all cubital fossa. The width of the flap’s end is
approximately 4–6 cm; the end of the flap includes a part of the
fold’s crest. The flap’s base is wider than the end and is located
on the contralateral edge of the cubital fossa. The flap is
advanced on the wound with tension (Fig. 23.3d). Flap tension
allows for the flap’s base approach to the scar’s sheet; the flap
displaces the lateral and back elbow skin to the anterior joint
surface, toward the wound. As a result of flap tension, the soft
tissues are squeezed, and the joint zone becomes smaller; the
donor wound is narrowed and covered with the displaced adja-
cent healthy skin. All these factors allow the flap’s end to
approach the wound’s border near the humerus epicondyle.
The scar surface deficit is compensated for, and the donor
wound is covered with healthy skin (Fig. 23.3c–e). A single
trapezoid flap is sufficient for mild edge elbow contracture
release, especially in children.
a
b
d
e
c
Fig. 23.3  Edge elbow flexion contracture elimination with one trapezoid
flap. (a) Pre-surgery, scars causing edge contracture are located on FL—
joint flexion lateral surface and fold; planning trapezoid flap in cubital fossa
and Y-line for scars dissection; (b) incisions according to lines, FL surface
separated from joint E surface and FM surface; Dt—scar surface deficit
(wound) has a trapezoid form and spreads from the fold’s crest to the joint
rotation axis; (c) FP—adipose-cutaneous flap mobilized, Dt, donor wound
(DW); (d) trapezoid flap (F) covered the wound, compensated scar sheet
surface deficit, contracture eliminated; (e) 2 weeks after reconstruction:
contracture fully eliminated, contours of elbow region restored
23  Elbow Edge Flexion Contracture: Anatomy and Treatment with Local Trapezoid Flaps

217
a
b
c
Fig. 23.4  Three-trapeze-flap plasty for moderate edge elbow con-
tracture elimination. (a) Pre-surgery; contracture anatomy; FL—
flexion lateral surface covered with scars causing contracture;
FM—cubital fossa or flexion medial surface is healthy skin; Cr—
crest of the fold; (b) planning: main healthy adipose-cutaneous
trapezoid flap from the medial fold’s sheet and cubital fossa (FM);
two small trapezoid adipose-­scar flaps from the scar sheet (FL) for
the donor wound covering; (c) mobilized flaps (F) opposite trans-
posed, compensated scar surface deficit and complete contracture
eliminated
Moderate Elbow Contracture Treatment
with Three Trapezoid Flaps (Fig. 23.4)
If contracture and scar sheet deficiency are more severe, the
adipose-cutaneous flap, prepared from the healthy fold’s
sheet and elbow fossa, covers the central part of the wound;
the donor wounds beside the main flap are covered with the
adipose-scar trapezoid flaps prepared from a scar sheet
(three-trapeze-flap plasty). The donor wounds beside the
scars’ flaps are covered with a healthy sheet’s triangular
flaps (Fig. 23.4a–c). Scars at the fold crest often undergo
ulceration.
Edge Elbow Contractures Treatment with Trapeze-Flap Plasty

218
Treatment of Multiple Contractures
(Figs. 23.5, 23.6, 23.7 and 23.8)
Severe edge elbow and shoulder adduction contractures are
eliminated by cutting the long fold into trapezoid adipose-­
cutaneous and adipose-scar flaps (Fig.  23.5). Contracted
scars often spread over the arm and shoulder, and a long fold
is formed, which causes a contracture of the corresponding
shoulder, elbow, wrist joints, and breast (Fig. 23.4a). Edge
elbow and shoulder contractures are eliminated with a
healthy cubital fossa and axillary fossa trapezoid flaps
(Fig. 23.5b, c). The fold is converted with Y-shaped radial
incisions into a trapezoid flap (Fig. 23.4a, d). After scar sheet
dissections, the trapezoid flaps and wounds appear (Fig. 23.5c
and 23.7b), reflecting the size and form of the scar surface
deficit. Due to the surface surplus in the fold’s sheets, the
flaps’ surfaces are sufficient for full contracture elimination
and scar surface deficit compensation without skin trans-
plants and regional flaps (Fig. 23.5e, f). Treatment of elbow
and wrist contractures is shown in Figs. 23.6, 23.7 and 23.8.
Treatment of edge elbow and wrist contractures is com-
plicated by scar ulceration (Figs. 23.2 and 23.6); a painful
wound is located on the rough, thick, immature scars of the
fold’s crest. Ulcerations of the fold’s top do not change the
surgical technique: the rough scars with ulcers are excised
and the reconstruction is carried out in the usual manner,
using trapeze-flap plasty.
In all cases, using the trapeze-flap plasty technique that is
specific for treatment of edge and medial contractures, the
contractures of the edge elbow and medial wrist are
­eliminated simultaneously (Figs. 23.7 and 23.8). The surface
of axillary fossa and sheets of the fold converted in trapezoid
flaps are sufficient for scar surface deficit compensation,
complete contracture elimination, and restoration of the
upper extremity appearance without skin grafting, flaps’
necrosis, or contracture recurrence.
a
b
c
d
e
f
Fig. 23.5  Severe edge flexion elbow and shoulder adduction contrac-
tures elimination with multiple trapezoid adipose-cutaneous and
adipose-­scar flaps. (a) Before surgery: contractures caused by scars
covering the flexion lateral surface (FL); scars form the long fold (from
wrist to breast) located along the medial edge of cubital and axillary
fossa; the lateral fold’s sheet is scars and continuation of scars of FL
surface; the medial sheet and cubital and axillary fossa are healthy skin
(donor sites); (b) planning: a conversion of the fold in trapezoid flaps
with radial incisions; the main flap mobilized from cubital and axillary
fossa for elbow and axilla contracture release; (c) after contracted scars
dissections with Y-incisions from the fold’s crest to the joint rotation
axis: trapezoid scar surface deficit (Dt) or trapezoid wounds appeared
and flaps (FP) accepted trapezoid form; (d) flaps mobilized, donor
wounds (DW); (e, f) results: counter transposed trapezoid flaps compen-
sated scar surface deficit and edge elbow and shoulder contractures
eliminated without complications
23  Elbow Edge Flexion Contracture: Anatomy and Treatment with Local Trapezoid Flaps

219
a
b
c
d
Fig. 23.6  Elimination of severe edge elbow and wrist contractures
with trapezoid flaps (continuation of Fig. 23.1). (a, b) Anatomy: con-
tractures caused with scars, covering FL surface, and lateral scar fold’s
sheet; ulcers of scars over the elbow and wrist; the fold located along
lateral edge of the cubital and axillary fossa; lateral fold’s sheet (FL) is
scars; medial sheet and cubital fossa (FM) are healthy skin; crest of the
fold (Cr); trapeze-flap plasty planning with four flaps and ulcerous
deformed scars excision; main flaps are adipose-cutaneous trapezoid
cubital or FM—flexion medial surface and axillary; (c) scars with
ulcers excised, trapezoid flaps elevated: two adipose-cutaneous and two
adipose-scar; Dt scar surface deficit; FP flap, DW donor wound; (d)
2 weeks after reconstruction: flaps are alive; oppositely transposed trap-
ezoid flaps covered the wound, scar surface deficit compensated for,
and contracture completely eliminated
a
c
b
Fig. 23.7  Simultaneous elimination of edge elbow and medial wrist
contractures with trapeze-flap plasty. (a) Edge elbow contracture
caused by scars covering FL flexion lateral surface; FM flexion medial
surface or cubital fossa is healthy skin and is donor site; wrist medial
contracture caused by scars located on radial or flexion medial sur-
face; scars formed the long fold, which is surface surplus scar and
skin. Specific planning of edge elbow and medial wrist contractures
release; (b) after dissection of scar with Y-incision, large trapezoid
wound or scar surface deficit appeared, which are real causes of con-
tracture; (c) skin of cubital fossa and scars causing contractures con-
verted by radial Y-incision in the flaps, counter transposed and
eliminated both contractures
Edge Elbow Contractures Treatment with Trapeze-Flap Plasty

220
a
b
c
i
d
e
f
g
h
Fig. 23.8  Severe edge flexion elbow contracture elimination with multi-
ple trapezoid flaps. (a, b) Anatomy: scars covered flexion lateral surface
(FL) of the elbow and wrist, formed a wide and long fold, and caused both
joints edge contractures. Standard contracture marked, FL lateral surface
is scars, medial (FM) surface is skin; both fold sheets are surface surplus
scars and skin. (c) Planning: typical three-flap plasty. Scars dissected with
a Y-incision, Dt large trapezoid wound or scar surface deficit appeared; FP
cubital trapezoid flap mobilized, DW donor wound. (d–f) Operation:
elbow and wrist contracture eliminated with local tissues. (g, h) Three
months after surgery: good functional and cosmetic outcomes without
skin grafts and regional flaps. (i) Variants of trapeze-flap plasty (without
skin grafting): one-, three-, and multiple-­flap techniques (scheme)
23  Elbow Edge Flexion Contracture: Anatomy and Treatment with Local Trapezoid Flaps

221
Conclusion
Scar edge flexion elbow contractures are eliminated with
trapezoid flaps without skin grafting, regional pedicle, or
free flaps. The adipose-cutaneous and adipose-scar trap-
ezoid flaps are large, with a wide end, without acute
angles, contain a full subcutaneous fat layer, and do not
undergo rotation. Therefore, the flaps have a steady blood
circulation, and flap advancement with tension is not
dangerous. Flap loss does not occur. In the 3 months after
reconstruction, stretching of the skin and mild venous
congestion disappear, and the contours of the elbow are
restored as a result of healthy skin growth. Follow-up
functional results are good: the full range of flexion and
extension in operated elbow joints was observed. No re-
contracture takes place and no reoperation is needed.
The stretching healthy skin of the trapezoid flap, located
among the scars, and the stretching skin of the adjacent
regions, continues to grow until the skin tension disap-
pears completely. Therefore, the results improve with
time. In children, the healthy skin grows more inten-
sively, preventing contracture recurrence and providing
favorable conditions for normal development of the
whole limb. The cubital fossa (donor site) preserves nor-
mal skin and contours.
References
1. Grishkevich VM.  Trapeze-flap plasty: an effective technique for
postburn edge elbow contracture elimination. Should Elb. 2010;2(4):
273–80.
References

223
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

The Postburn Elbow Medial Flexion
Scar Contracture Treatment
with Trapeze-­Flap Plasty
Introduction
Medial contractures are not well studied and we did not find
literature devoted to this theme. Therefore, all that is pre-
sented below is new. Joint elbow flexion medial contracture
is a result of burn and scars of the elbow flexion medial (FM)
surface (cubital fossa). Scars restrict extension and impair
upper extremity function. Attempts to extend the joint tear
scars, fissures appear, and ulcerations are seen more fre-
quently than in other joint contractures. Pain during exten-
sion impairs all upper extremity function. Medial elbow
flexion contracture should therefore be released early. We
studied and treated patients with medial elbow contrac-
tures—anatomy and clinical signs—and compared the effi-
cacy of triangular-flap techniques with trapeze-flap plasty.
We ascertained that the most effective method for medial
contractures is trapeze-flap plasty based on adipose-scars
trapezoid flaps.
Joint Elbow Functional Zones and Anatomy
of Elbow Medial Flexion Contracture
Functional Zones and Anatomy (Fig. 24.1)
The elbow joint surface is functionally divided into extension
(E) and flexion (F) surfaces. The flexion surface has two cur-
vatures formed by the edges of cubital fossa, which divides
the flexion surface into two zones: the joint flexion lateral sur-
face from the cubital fossa’s edge to the joint rotation axis.
The space between the fossa edges is the flexion medial (FM)
surface (Fig. 24.1). Medial elbow contracture is caused by
scars located on the FM surface. Scars covering the FM sur-
face of the joint, shoulder, and arm undergo contraction and
continue to grow. Scars grow, and contraction elevates scars
over the cubital fossa and forms a fold along the medial line
of the FM surface. Scars approximate forearm to shoulder
and cause elbow FM contracture. Attempts to extend the
24

224
a
b
Fig. 24.1  Anatomy of the elbow medial flexion contracture. (a, b) The
joint surface is functionally divided into extension (E) and flexion (F).
Flexion surface curvatures, caused by the edge of cubital fossa, divides
flexion surface on flexion lateral (FL) and flexion medial (FM). Medial
elbow contracture is caused by scars located on the flexion medial sur-
face (FM), and the scars form a fold (Fd). The fold has semilunar form
and its crest (Cr) passes along the medial line of the joint flexion sur-
face; both sheets of the fold (Fd) are scars; in the fold’s sheets there is
surface surplus in width and deficit in length in the sheets (contracture
cause). Maximum tension occurs at the crest of the fold (Cr) and
decreasingly extends to the flexion lateral surface (FL) or edges of
elbow fossa
elbow stimulate the scar’s growth, making the fold wider and
longer (Fig. 24.1). The fold consists of two scar sheets that
spread from the fold crest to the fossa edges. The fold has a
semilunar form and is located on a middle flexion surface of
the joint (FM); both sheets of the fold are scars. The sheets of
the fold have surface surplus in width and a deficit in length
(contracture cause). The fold is a new anatomical structure,
with scar surface surplus allowing contracture elimination
with local flaps. Maximum tension occurs at the crest of the
fold (Cr) and decreasingly extends to the flexion lateral sur-
face (FL) or edges of the cubital fossa.
Medial elbow contracture is characterized by three spe-
cific features (Fig. 24.1):
(a) The contracted scars are located on the joint flexion
medial (FM) surface and form the fold.
(b) The fold is located in the center of the scar medial sur-
face; the fold’s crest passes along medial line of the joint
flexion surface.
(c) Both sheets of the semilunar fold are scars.
24  The Postburn Elbow Medial Flexion Scar Contracture Treatment with Trapeze-Flap Plasty

225
Scar Surface Deficit as the Real Cause
of Contracture (Fig. 24.2)
The maximum tension of scars covering the elbow FM sur-
face occurs at the top of the fold (Cr) and is equal in both
sheets. The tension of the sheets (scar surface deficit), sub-
siding, reaches the edges of cubital fossa, and, going side-
ways, forms a trapezoid scar surface deficit, which is the real
cause of contracture, and is equal in both sheets (Fig. 24.2c).
To choose an appropriate plasty method and flap shape,
one must know the size and the form of the scar surface
deficiency. To estimate the latter, it is first necessary to
cross-cut the scars with radial Y-incisions from the fold’s
crest all the way to the edges of fossa. To complete releasing
of the scar tension, the end of the incision should be Y-split
to separate the scars of the FM surface from skin of the FL
surfaces. As a rule, a trapeze-shaped wound was formed
despite how many incisions were made (Fig. 24.2c, d). The
best way to convert the fold’s sheets into trapezoid flaps and
fully release the contracture is to separate the fold’s sheets
by incision along the crest of the fold and cross-section of
sheets with radial Y-incisions (Fig. 24.2b). Incisions with
bifurcate ends (Y-shaped) separate scars of the FM surface
from tissues of the FL surfaces, which allows unrestricted
wound edges divergence. This is necessary for a full con-
tracture release. Because of the semilunar shape of the fold
and the radial direction of the incisions, trapeze-shaped
flaps are formed and Y-incisions form trapeze-shaped
wounds (Fig. 24.2c). In most cases the excess of the scar
surface is sufficient to make up for the deficiency of length
(Fig. 24.2e, f). The scheme of plasty with trapezoid flaps is
shown in Fig. 24.2g.
a
b
g
c
d
e
f
Fig. 24.2  Scar surface deficit is the flexion medial contracture cause.
(a, b) Anatomy of elbow medial contracture and planning of scar sur-
face deficit to define and trapeze-flap plasty, the radial Y-lines/incisions
of semilunar fold up to edges of the fossa make trapeze-shaped figures/
flaps; (c) fold cross-cuttings with Y-shaped incisions, elbow joint
extended, the trapeze-shaped wound (scar surface deficit—Dt) and
flaps (FP); (d) mobilized three pairs of adipose-scar flaps; (e, f) oppo-
site flap transposition covered the wound, scar surface deficit was com-
pensated, and full contracture was eliminated (5 and 14  days after
surgery); (g) scheme of the trapeze-flap plasty treatment of elbow
medial contracture
Joint Elbow Functional Zones and Anatomy of Elbow Medial Flexion Contracture

226
Surgical Techniques [1]
Anatomy and Features of Trapeze-Flap Plasty
(Figs. 24.1, 24.2, 24.3, 24.4, 24.5, and 24.6)
Scars on the joint elbow flexion medial (FM) surface takes the
form of the semilunar fold (FD). The scar sheets spread from
the fold’s crest to the edges of the elbow fossa or the joint flex-
ion lateral (FL) surfaces. The scars of the FM surface (sheets)
are tightly connected to the tissues of both FL surfaces.
Therefore, for a full contracture release and effective use of the
scar surface surplus, the sheets should be separated between
themselves first, and every sheet partly separated from the tissue
neighboring joint zones (FL). In this example, scars sheets are
partly separated by Y-incisions from tissue of both flexion lat-
eral (FL) surfaces. This is a common principle of operation for
scar contractures having folds and surface surplus: the fold’s
sheets are separated with an incision along the fold’s crest; scars
are partly separated from the neighboring joint zone with a
Y-incision, which at the same time radially dissects contracted
scars. The planning of surgery (incisions) is shown in Fig. 24.2b.
The distance (length) between cross-cuttings is 3–5 cm, which
forms the width of the flaps’ ends. The width of the flap’s base
reaches 6–8 cm. An all fat layer is included within the flap; a
deep fascia remains in situ (Fig. 24.2d). The length of the scar-
adipose flaps varies. It equals the distance from the crest fold to
the level of the edge of cubital fossa or joint FL surface. Both
sheets are converted to flaps all along their length (Fig. 24.2d).
The quantity of the flaps depends on the fold’s length. Adipose-
scar trapezoid opposite the flaps are transposed toward one
another with moderate tension. The end of the flap reaches the
base of the opposite flap (Fig. 24.2e). Thus, the shortage in the
scar’s length is compensated for by the surplus in the width
(Fig. 24.2f). All mild, moderate, and most severe contractures
can be released completely with trapeze-flap plasty. The scheme
of the operation is shown in Fig. 24.2g. Depending on the fold’s
length and the severity of contracture, reconstruction is per-
formed with one or several pairs of trapezoid flaps per se, or in
combination with skin grafts. Usually, the fold including its full
extent is transformed in the flaps. Therefore, the surgical tech-
nique has several peculiarities:
1. Reconstruction with one pair of the flaps (Fig. 24.3): The
technique is effective if contracture is mild and the fold
is short.
2. In the case of more severe contracture, the full extent of
the fold is converted in trapezoid adipose scar flaps, suit-
able for complete scar surface deficit compensation,
wound covering, and contracture elimination (Fig. 24.2).
3. The formation of severe contracture is accompanied by a
relative decrease of the surface surplus of the fold’s sheet,
and, therefore, the surface of several pairs of flaps
(Fig. 24.4a–d) becomes insufficient for complete wound
closure with flaps; the remaining small wound among the
flaps had to be skin-grafted (Fig. 24.4e, f).
4. In some cases, the fold is poorly expressed (Fig. 24.5a,
b), and trapezoid adipose-scar flaps are short and do not
reach the opposite edge of the wound (Fig. 24.5c, d).
After counter flap transposition, small wounds remained
uncovered, located ahead of the flaps’ ends, which are
covered with skin transplants (Fig. 24.5e). This com-
bined technique does not decrease the quality of out-
comes. As a rule, the contractures were eliminated
completely. After surgery, a common gutter splint was
used and no special immobilization after surgery was
required.
5. The crest of the fold can be subject to ulceration (Fig. 24.6a,
b). In such cases, rough scars with ulcers are excised and a
pair of the adipose-scar trapezoid flaps is prepared from
the fold’s sheets, which are counter-­transposed; wounds
beside the flaps are primarily closed (Fig. 24.6c–e).
The mild-to-moderate elbow medial scar flexion contrac-
ture is caused by a slightly expressed scar surface deficit.
Therefore, the contracture is usually eliminated with one pair
of adipose-scar trapezoid flaps (Fig. 24.3).
Severe Elbow Medial Contracture Treatment
Caused by a Long Fold (Fig. 24.4)
The sheets of such folds have a severe scar surface deficit, which
is eliminated with several pairs of adipose-scar trapezoid flaps
alone or in combination with skin transplants (Fig. 24.4). The
formation of severe contracture is accompanied by a relative
decrease in the surface surplus of the fold’s sheet, and, therefore,
the surface of several pairs of flaps (Fig.  24.4a–d) becomes
insufficient for complete wound closure with flaps; the remain-
ing small wound among the flaps was skin-grafted (Fig. 24.4f).
Trapeze-Flap Plasty in a Case of Insufficient
Width of Scar Fold (Fig. 24.5)
Scanty fold protrusion narrows the fold’s sheets and shortens
the trapezoid flaps (Fig. 24.5a, b). After mobilization, trape-
zoid flaps were counter transposed, but the flaps were too short
and could not reach the base of the opposite flap (Fig. 24.5d).
Such a condition does not contraindicate trapeze-­flap plasty.
Small wounds at the flap’s end are skin grafted (Fig. 24.5c, d).
Such a technique does not lower the quality of outcomes
(Fig. 24.5e). As a rule, the contractures were eliminated com-
pletely. After surgery, a usual gutter splint was used, and no
special immobilization after surgery was required.
The crest of the fold can be subject to ulceration
(Fig. 24.6a, b). In such cases, rough scars with ulcers are
excised and a pair of the adipose-scar trapezoid flaps is pre-
pared from the scar fold sheets, which are counter-­transposed,
restoring the cubital fossa (Fig. 24.6c, d). Wounds beside the
flaps are primarily closed (Fig. 24.6e).
24  The Postburn Elbow Medial Flexion Scar Contracture Treatment with Trapeze-Flap Plasty

227
a
b
d
e
f
c
Fig. 24.4  Severe medial elbow contractures elimination using several
pairs of trapezoid flaps and skin transplants. (a–d) Pre-surgery view,
anatomy: E, FL, FM, Cr, “+”—deformed joint’s surfaces; wide and
long semilunar fold, four pairs of flaps marked, the Y-lines spread to the
joint fossa’s edges to the flexion lateral (FM) surface; (e) mobilized
adipose-scar flaps; (f) wound covered with opposite flaps transposition,
a small wound skin grafted (7 days after operation), complete elbow
extension, flaps alive
a
b
Fig. 24.3  The mild-to-moderate medial elbow contracture treatment
with one pair of adipose-scar trapezoid flaps. (a) Pre-surgery; anatomy
contracture: joint’s surfaces: FM, FL, E, and “+” (fold crest); operation
planning: one pair of adipose-scar trapezoid flaps in the zone of the
flexion medial surface, strip of scars to be excised; (b) mobilized
adipose-­scar flaps counter-transposed, wound covered, and contracture
eliminated; 7 days after surgery: contracture released, flaps alive; scars
on the shoulder excised
Surgical Techniques

228
a
b
c
e
d
Fig. 24.5  Medial elbow contracture treatment in a case of narrow
fold with short trapezoid adipose-scar flaps. (a, b) Pre-operation,
joint functional zones and contracture anatomy: FL the flexion lateral
surface and FM flexion medial surface are scars; Cr crest of the fold,
both sheets of the fold are scars; “+” joint rotation axis. Planning:
three pairs of trapezoid flaps marked in elbow (FM) zone and three
flaps in the axilla for edge anterior shoulder adduction contracture
treatment; (c) short flaps (FP) mobilized; the space between flaps
equal to scar surface deficit (Dt) in size and form; shoulder edge con-
tracture eliminated; (d) counter-­transposed short flaps did not achieve
basement of opposite flaps; therefore, small wounds at the flap’s end
(arrows) were covered with skin transplant. (e) Results: contracture
fully eliminated, flaps and skin transplants alive (2  weeks after
surgery)
a
b
c
e
d
Fig. 24.6  Treatment of medial elbow contracture, complicated by
ulcerous condition of fold’s crest, using trapeze-flap plasty. (a, b) Pre-­
surgery; anatomy of elbow medial contracture with fold’s crest ulcer-
ation: FM the flexion medial surface has big fold; Cr crest of the fold
with ulcer, two adipose-scar trapezoid flaps marked, all FM surface of
elbow included in the one pair of flaps, ulcerous crest marked and exci-
sion; (c) rough scars with ulcer excised; two trapezoid adipose-scar
flaps mobilized; (d) flaps counter-transposed. (e) Seven days after sur-
gery: flaps alive, donor wounds beside the flaps primarily closed.
Contracture completely released, elbow region looks well
24  The Postburn Elbow Medial Flexion Scar Contracture Treatment with Trapeze-Flap Plasty

229
Consequences Following the Opposite
Transposition of Flaps
This method of plasty involves several constituents:
(a) A flap that stretches throughout the opposite transposition
brings the bases of the opposite flaps together. Thus, the
edges of the wound and tissue of joint flexion lateral (FL)
surfaces are displaced on FM surface being shifted by the
flap’s traction. The wound, therefore, becomes narrower.
(b) The skin of the joint flexion lateral surfaces (FL) is dis-
placed forward, reaching over the flexion medial (FM)
surface and partially covering the wound. ­Simultaneously,
the skin of the joint’s extension (E) surface is displaced
to the lateral surface of the joint (FL).
(c) Soft tissues undergo compression due to the stretching
of the flaps. The area where the joint is positioned, the
adjacent zones of the arm and the shoulder, become thin-
ner. Thus, the surface of the flaps and the lateral and
back surface of skin increases relative to the decreased
wound. This allows transmitting the end flaps to the base
of the opposite flaps, covering the wound, and omitting
the skin-grafting procedure. Due to the transposition of
the flaps, the length of the medial flexion surface
increases. Consequently, the sheets of the fold, the skin
of lateral and extension surfaces of the joint, and adja-
cent zones of the arm and shoulder, all participate in the
trapeze-flap plasty, making it especially effective.
Conclusion
Trapezoid flaps have a wide end and base and do not
undergo rotation; they include the complete underlying
fat layer and therefore are not subject to necrosis.
Because of these features, the stretching of flaps does
not pose a danger. Due to these features, flap loss, con-
tracture recurrence, and repeated surgery do not occur.
The soft tissues, which underwent compression, serve
as expanders, prompting the healthy skin and scar flaps
to grow. In approximately 2–3 months, the skin tension
and compression disappear due to the growth of
undamaged skin. One may very rarely encounter the
superficial necrosis of the flaps’ ends. No edematous
problems or compromises in venous return have been
observed if all the fatty tissues are included in flaps.
The wounds were healed under dressing without fur-
ther complications. The full range of the joint’s flexion
and extension has been noted in all patients. Due to the
flaps’ stretching, scars become more even. The borders
(edges) of the flaps are unnoticeable. The features of
the trapeze-flap plasty guarantee excellent functional
and good cosmetic results.
Reference
1. Grishkevich VM.  The post-burn elbow medial flexion scar con-
tracture treatment with trapeze-flap plasty. Burns. 2009;35:
280–7.
Reference

231
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Total Elbow Flexion Contracture
Treatment
Introduction
Total elbow contracture is a result of vast burns and scars cov-
ering the entire flexion (two lateral and medial) surfaces.
Scars often injure the extremity circularly and involve the
wrist and hand. Scars tightly surround the joint and neighbor-
ing regions without a fold. For the most part the scars are
rough, thick, solid, red, and painful. Such contractures cannot
be treated with local tissues. A regional flap can cover only
the joint zone; normal skin between the scars is cosmetically
unacceptable. However, functional and cosmetic effects can
be achieved by vast mature scar excision through intermedi-
ate layer and wound resurfacing with whole skin transplants.
Anatomy
After severe vast circular burns of the upper extremity,
scars cover the elbow joint and neighboring segments of
the limb and wrist circularly (Fig. 25.1) or surround both
joints’ flexion medial (FM) and flexion lateral (FL) surfaces
(Fig. 25.2a, b) without a fold formation. Because no excess
tissue exists, this contracture cannot be reconstructed with
local flaps. All attempts to extend the elbow make the scars
more disfigured—rough, thick, ulcerated, firm, and thus not
suitable for plasty (Figs. 25.1, 25.2 and 25.3). Therefore, in
addition to functional disorders, limb disfigurements bother
the patients as well.
25
Fig. 25.1  Total elbow, wrist, and hand contractures caused with circu-
lar immature scars without folds

232
a
b
c
d
Fig. 25.2  Total elbow contracture caused with local rough ulcerous
scars. (a, b) Pre-surgery view; elbow joint’s functional surfaces: E
extension; “+” symbol joint rotation axis; FL flexion lateral surface;
FM flexion medial surface; Cr crest of the fold; boundaries of scars
excision (solid line); (c) 2 weeks after vast excision of scars through
intermediate layer and skin-grafting, transverse placed whole skin
transplants look good; (d) 2.5 months after surgery: good functional
and cosmetic outcomes
a
b
Fig. 25.3  Total elbow, wrist, and dorsal hand contractures and defor-
mity treatment with mature scars excision through intermediate layer
and the wound cover with whole skin transplants. (a) Pre-surgery view.
(b) Operation: scars fully excised through an intermediate layer with
minimal bleeding, wound covered with whole skin transplants, placed
transverse; duplication of transplants’ edges and fixed among them-
selves and wound tissue with metallic staples
25  Total Elbow Flexion Contracture Treatment

233
Surgical Treatment
When planning treatment, two factors, function and cos-
metic appearance, should be considered. The reconstruc-
tion of the contracture consists of excision of vast rough
scars by removing a long strip, nearly 3  cm in width,
through an intermediate layer, which is formed from the
inner scar’s layer and has poor vascularity. The wound is
covered with split whole skin transplants placed trans-
versely (Figs. 25.2c, 25.3b, and 25.4b); edge transplants
are duplicated and transplants are fixed through them to
wound tissue with U-stiches (Fig. 25.3a, b). Pedicle and
free flaps are used only if the joint zone is injured with the
soft tissue defect, since the flap’s skin resembles the patch.
Because the elbow joint’s position at rest is an exten-
sion, the skin graft easily responds to stretching, using
a regular gutter splint. With time, the transplants become
normal skin, and there is no threat of re-­contracture. The
wider the scars that are excised, the better the outcomes
(Fig. 25.4a, b).
a
b
Fig. 25.4  Result of total elbow and wrist contracture treatment with scar excision through intermediate layer and skin grafting. (a) Before opera-
tion: severe contractures caused circular keloid scars; (b) 10 days after surgery: transplants alive, contractures released
Surgical Treatment

234
Conclusion
Total elbow contracture occurs as a result of vast burns
that also injure the neighboring zones, joints, and hand.
The formed scars are rough and thick; thus, they impair
upper limb function and create a severe cosmetic defect.
Severe scar surface deficits exclude contracture release
with local tissues. Reconstruction, therefore, is aimed at
function restoration and maximal removal of the cosmetic
defect. The procedure is done by excision of contracted
deformed scars through the intermediate layer and wound
covering with split whole skin transplants taken from the
lateral surface of the hip joint. Scar excision without
injuring the fat layer prevents shrinkage of the skin trans-
plants. Wider scars are removed, and better outcomes are
achieved.
Suggested Reading
1. Yudenich VV, Grishkevich VM.  Deformity and contractures
of elbow joint. In: Yudenich VV, Grishkevich VM, editors.
Guidance of rehabilitation of burned. Moscow: Medicina; 1986.
p. 232–46.
25  Total Elbow Flexion Contracture Treatment

235
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Wrist Scar Contracture, Hand Deviation:
Anatomy and Treatment with 
Trapeze-­Flap Plasty
Introduction
Hand burns can be complicated by scar contracture of the
radial or ulnar wrist and hand border. The contracture
restricts mobility of the hand. Multiple techniques are cur-
rently used to release scar tension. We have tested most of
these techniques in our practice, and the results have been
unsatisfactory. The use of local triangular pointed flaps posed
obvious limitations. A literature review confirmed that the
management of hand border/wrist contractures has not been
sufficiently studied. This chapter describes the anatomical
features of scar border contractures of the wrist and presents
an effective method for contracture elimination with the use
of trapeze-flap plasty.
Medial Ulnar and Radial Wrist Scar
Contracture and Hand Deviation
Anatomy of Wrist Scar Contracture and
Hand Deviation (Figs. 26.1 and 26.2)
Three types of wrist scar contractures occur: medial (most
often), edge, and total. Medial contractures are a result of
burns of the ulnar (Fig. 26.1) or radial (Figs. 26.2, 26.3 and
26.4) wrist border. Edge wrist contracture forms scars cov-
ering the dorsal or palmar wrist surfaces (Fig.  26.5). In
cases of medial contractures, scars form the crescent fold
along the wrist’s border, causing radial or ulnar hand devia-
tion. Both sheets are scars. Scars located on the dorsal and
palmar wrist surfaces also form a crescent fold along the
wrist border, but only one sheet consists of scars; the other
sheet and adjacent wrist surface are healthy skin (Fig. 26.5a,
b). The fold and neighboring scars have surface deficit in
length, which is the cause of the contracture; both sheets of
26

236
a
b
c
e
f
g
h
d
Fig. 26.1  Right wrist ulnar medial contracture and hand deviation:
anatomy and treatment with trapeze flap plasty. Case 1: (a) Contracture
caused by scars covered the ulnar flexion medial (FM) surface of wrist
and the ulnar border of the hand; scars formed a semilunar fold, the
crest (Cr) of which passes along the central zone; contracted scars have
a surface deficit in length that causes the contracture. Both sheets of the
fold are scars and have a surface surplus in width; (b, c) flap (FP) plan-
ning by radial Y-lines for converting flexion medial (FM) surface and
sheets of the crescent fold into trapezoid flaps; (d) after fold incisions
and hand straightening: the trapezoid wounds or scar surface deficit
(Dt) of FM surface and flaps appeared that accepted trapezoid form
(trapeze-shaped scar sheet deficit in length); (e) adipose-scar flaps
mobilized; (f) trapezoid flaps counter transposed and fully contracture
released; (g) contracture and deviation of hand eliminated in full; no
flap loss, plasty zone lengthened by more than 100% (2 weeks after
reconstruction). Case 2: (h), Ulnar left wrist medial contracture elimi-
nated with two pairs of adipose-scar trapezoid flaps (5  days after
surgery)
a
b
Fig. 26.2  Medial mild-to-moderate wrist contracture elimination
with two opposite-located adipose-scar trapezoid flaps. (a) Pre-
surgery view, the scar fold is located along the radial side of the wrist;
both sheets of the fold (joint flexion medial surface—FM) are scars;
planning contracted scars dissection for flaps formation (Y-lines); (b)
mobilized adipose-scar trapezoid flaps counter transposed, scar sur-
face deficit compensated, and contracture eliminated (10 days after
surgery)
the fold are new anatomical structures—scar and skin sur-
face surplus, allowing elimination of both types of wrist
contracture—medial and edge—with local flaps. The flaps
are absent in total contractures, making any local-flap tech-
nique application impossible.
The scar surface deficit is the contracture cause, and the
goal of the treatment is scar surface deficit compensation.
Therefore, the first step of surgery is to determine the scars’
surface deficit form, size, and location; then, an adequate flap
planning for scar surface deficit compensation and contrac-
ture elimination takes place.
Scar surface deficit definition: The fold’s sheets are sepa-
rated with an incision along the fold’s crest (Cr); the fold/
contracted scars are dissected with radial/perpendicular
Y-incisions. After hand straightening, the wound accepts, as
a rule, a trapezoid form of wound or scar surface deficit (Dt)
(Fig. 26.1d). Since the fold has a semilunar (crescent) shape,
the radial lines and Y-incisions transform the sheets into
trapeze-­shaped flaps (FP) (Fig. 26.1d, e). This means that
contracture treatment is concluded in scar surface deficit
compensation with trapezoid flaps, which can be prepared
from the fold’s sheet (Fig. 26.1c, d). In cases of edge contrac-
ture, a Y-incision dissects contracted scars on the dorsal or
palmar wrist surface (Fig. 26.5). A trapezoid wound appears.
The plan for scar surface deficit compensation and contrac-
ture elimination is shown in Fig. 26.5c. The larger the fold,
the greater the surface surplus in the sheets, which is used for
medial and edge wrist contractures elimination.
26  Wrist Scar Contracture, Hand Deviation: Anatomy and Treatment with Trapeze-Flap Plasty

237
a
b
c
d
g
e
f
Fig. 26.3  Medial radial wrist treatment with two pairs of trapezoid
flaps and edge elbow contracture elimination with trapeze-flap plasty.
(a) Pre-surgery: severe medial contracture of the wrist, thumb, and
hand deviation caused by scars covering flexion medial surface (FM);
Cr crest of the fold; (b) planning two pairs of adipose-scar trapezoid
flaps; (c) flaps mobilized; surface deficit (Dt) is equal to the space
between the two mobilized flaps, has a trapezoid form, and is the real
cause of the contracture; (d) flaps transposed one toward the other;
(e) 2 weeks after reconstruction: no flap loss, no contracture; thumb,
hand, and wrist accepted normal outlines. Case 2. Medial radial right
wrist contracture elimination with two pairs of trapezoid adipose-
scar flaps. (f) Planning of operation; (g) result (5 days after surgery).
Deformed contracted scars on left wrist excised and wound primarily
closed
a
b
d
e
c
Fig. 26.4  Severe radial medial wrist contracture treatment caused imma-
ture ulcerous scars. (a) Pre-surgery: contracture caused by rough, thick,
and ulcerous scars covered wrist radial flexion medial surface (FM). Scars
formed a long and wide fold; Cr crest of the fold; (b, c) wrist’s dorsal and
palmar surfaces; marked scars to be excised and two trapezoid flaps; (d)
scars excised and pair of adipose-scar trapezoid flaps mobilized; (e) flaps
counter transposed and covered the wound of wrist joint, the wound beside
the flaps primarily closed; contracture released (end of operation)
Medial Ulnar and Radial Wrist Scar Contracture and Hand Deviation

238
a
b
c
d
Fig. 26.5  Edge wrist contracture anatomy and elimination with trape-
zoid flap. (a, b) Pre-operation: contracture caused by the scars covering
the dorsal surface of the wrist, hand, and arm; scars formed a long and
wide fold, crest of the fold (Cr); the dorsa flexion lateral surface (FL),
including the dorsal fold sheet, is scars; the palmar or flexion medial
(FM) joint surface and palmar fold’s sheet is healthy skin; (c) planning
trapeze-flap plasty: Y-line for FL—scars on flexion lateral surface dis-
section; trapezoid flap planned on flexion medial surface (FM) or wrist
palmar healthy tissues. (d) Contracture eliminated with one adipose-­
cutaneous trapezoid flap, normal joint’s form and function
26  Wrist Scar Contracture, Hand Deviation: Anatomy and Treatment with Trapeze-Flap Plasty

239
Surgical Techniques for Medial Wrist
Contracture (Hand Deviation) Elimination
The fold’s presence and the surface’s surplus in scar sheets
allow reconstruction using local tissue flaps (Figs. 26.1, 26.2,
26.3 and 26.4) [1]. The planning consists of the following: a
line along the fold’s crest and several radial or perpendicular
Y-lines, which are the edges of trapezoid flaps. In all cases the
fold has a semilunar/crescent form and, therefore, the radial
line marks trapezoid figures. Scar surface deficit is maximal at
the fold’s crest and then subsides, eliminating the sheet’s sur-
face deficiency (real contracture cause) in length, the deficiency
has a trapezoid form (Fig.  26.1d). Depending on the fold’s
length, one or several pairs of trapezoid flaps are planned. The
flap’s end is located at the top (crest) of the fold; the flap’s base
is situated on the back and palmar wrist surfaces. The optimal
distance between radial lines at the fold’s top equals 3 cm; this
distance matches the width of the flap’s end. The flap’s base is
wider than the top because of the semilunar shape of the fold.
The sheets of the fold are first separated by one incision
along the fold’s crest. Following the contoured lines, the
radial Y-incisions convert both semilunar sheets into trapeze-­
shaped flaps. The scar and fat layer incisions are extended
toward the back and the palmar surface of the wrist until the
scar tension is fully released and the hand and the fifth finger
and the thumb reach a normal position. The incision’s ends
are split (Y-incision) to completely eliminate the scar tension
and divergence of wound borders (Fig. 26.3). The flaps are
mobilized with the full fat layer (trapezoid adipose-scar
flaps) and transposed toward each other with tension applica-
tion until the flap end reaches the base of the opposing flap
(Fig. 26.2f). Because of the tension, the bases of the opposite
flaps come closer; the skin of the back and palmar surfaces of
the wrist are displaced, partially covering the wound. The
soft tissues are squeezed because of existing flap tension. As
a result, the wound becomes narrower; the surface of the
wound is decreased significantly, which enables the surgeon
to close the wound with the opposite flap’s transposition.
Because of the counter transposition of the flaps, the flaps’
middles correspond to the central wrist border line or the
zone of maximal tension. This means that the plasty zone
doubles, at least, in length. This allows full contracture elim-
ination with only flaps; neither skin-grafting nor pedicle
flaps are needed. The gain rate equals the sum of all flaps’
width in their middle, minus the length of the fold’s crest
involved in plasty.
Medial wrist contractures are eliminated with one
(Fig. 26.2a, b), two (Fig. 26.3b, c), or three pairs (Fig. 26.1)
of adipose scar trapezoid flaps, depending on contracture
severity, fold length, and neighboring joints involved.
Ulcerous scars of medial contractures on the fold’s crest
are excised, and reconstruction is carried out with counter
transposition of the adipose scar trapezoid flaps (Fig. 26.4).
Edge Wrist Scar Contracture
Reconstruction of Edge Wrist Contracture
(Fig. 26.5)
The reconstruction is accomplished with the technique used
for the edge contracture release of the other location. The
sheets are divided, the contracture is released with a
Y-incision of the scar sheet, and the trapezoid wound (scar
surface deficit) that appears is covered with the adipose-­
cutaneous trapezoid flap prepared from the healthy skin of
the sheet and wrist per se, or in combination with adipose-­
scar trapezoid flaps taken from the fold’s scar sheets
(Fig. 26.5c, d).
Edge Wrist Scar Contracture

240
Total Wrist Scar Contractures
Anatomy and Reconstruction (Figs. 26.6 and 26.7)
Vast and deep burns of the upper limb result in the formation
of circular scars that tightly surround the wrist joint without
fold and scar surface surplus. With time, the scars can
become rough, thick, and painful, causing disability.
Restriction of motion of the hand and the scars’ deformity of
the upper limb indicate the need for reconstruction after scar
maturation. If the scars are cosmetically acceptable, the con-
tracture is released with an incision only (Fig. 26.6); rough
keloid scars should be widely excised (Fig. 26.7). In both
cases, the wound is resurfaced with whole split skin trans-
plants. Because the wrist at rest is in a straight position, the
shrinkage of the skin grafts is minimal and the results, both
functional and cosmetic, are good. After the reconstruction,
a common gutter splint supports the hand in a straightened
position; it is used for 2–4 weeks. Skin transplants are trans-
formed in normal skin functionally and cosmetically.
a
b
c
d
Fig. 26.6  Severe wrist
flexion contracture treatment
by contracted scars dissection
in different directions and
skin grafting. (a) Pre-surgery;
(b) scars dissected and
contracture released; the
wound is scar surface deficit;
(c) the wound is covered with
skin transplant; (d) follow-up
result: good functional and
cosmetic outcomes
26  Wrist Scar Contracture, Hand Deviation: Anatomy and Treatment with Trapeze-Flap Plasty

241
a
b
c
d
e
f
Fig. 26.7  Both wrist contractures caused by circular keloid scars and
eliminated with scar excision through intermediate scar layer and skin
grafting. (a–c) Before surgery, left wrist: rough thick keloid scars, cir-
cularly surrounding wrists and hands, removed; wrist and hand restored,
1  year after surgery; (fifth finger’s PIP joint damaged). (d–f) Right
hand: scars excised through intermediate layer, interdigital commis-
sures and first web spaces and commissural fossa restored with adipose-­
cutaneous trapezoid flaps taken from interdigital fossa; wounds of the
wrist and hands resurfaced with whole skin transplants (10 days after
surgery)
Total Wrist Scar Contractures

242
Conclusion
Using trapeze-flap plasty, the medial and edge wrist scar
contractures caused by a scar’s fold located on the ulnar
and radial borders of the wrist are eliminated completely.
The trapezoid wounds appear after contracted scars are
dissected with Y-incisions; wounds are fully closed, and
the scar surface deficit is compensated by the counter
transposition of trapezoid flaps prepared from the fold’s
sheets and neighboring healthy skin (edge contracture).
The adipose-scar flaps have stable blood circulation,
which prevents tissue necrosis and other postoperative
complications; the flap’s surface does not decrease, and
no contracture recurs. Total wrist contracture is released
with two methods: Contracture release with scars’ inci-
sions and skin grafting (Fig. 26.6); but wide rough scar
excision through intermediate layer and wound resurfac-
ing with wide split skin transplants, placed transversely
(Fig. 26.7), is cosmetically acceptable.
Reference
1. Grishkevich VM. Postburn hand border contractures and eliminat-
ing them with trapeze-flap plasty. J Burn Care Res. 2010;31:286–91.
26  Wrist Scar Contracture, Hand Deviation: Anatomy and Treatment with Trapeze-Flap Plasty

243
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

First Web Space Postburn Scar
Contractures: Anatomy and Elimination
with Local Trapezoid Flaps
Introduction
First web space contractures commonly occur in dorsal, pal-
mar, and total hand burns and can significantly affect overall
hand function because thumb abduction and opposition are
either impaired or lost. The functional deficiencies include
loss of grasp and loss of key pinch. A first web space adduc-
tion contracture justifies surgical intervention. Despite the
abundance of surgical methods, the problem of reconstruc-
tion of the first web space has not been solved. No compara-
tive studies have reviewed the effectiveness of various
methods of reconstruction. Based on our personal clinical
observations, we identified the three basic anatomical types
of thumb adduction contractures and developed methods of
reconstruction for each type. With the use of these plasty
methods, all web space scar contractures can be eliminated
completely and definitively.
Basic Types of Thumb Adduction
Contractures
The three anatomical types of web space contractures can be
categorized as edge (dorsal and palmar), medial, and total
contracture.
Edge adduction contractures often develop in patients
who have sustained either dorsal (Fig. 27.1a) or palmar hand
burns (Fig. 27.1b). A crescent-shaped fold forms along the
dorsal or palmar edge of the web space dip. The lateral sheet
(in relation to web space dip) of the fold is scarred; the
medial sheet and web space are healthy skin. The contracture
is caused only by the scar’s sheet because of a scar surface
deficit in length that is present between the first and second
metacarpals and the second metacarpal and the proximal
phalange of the thumb. The scar sheet surface deficiency
spreads from the fold’s crest to the trapeziometacarpal joint
level. The scar sheet length deficiency has a trapezoid shape
(Fig.  27.2b, c). The scar sheets have a surface surplus in
width. The presence of the fold allows contracture elimina-
tion using local flaps (Figs. 27.2d–f and 27.3a–c).
Medial adduction contracture develops in patients who
have sustained burns of the first web space fossa (Fig. 27.1c).
As a result, a crescent fold is formed at the medial part (cen-
ter) of the web space, bringing the thumb and the second
metacarpal together. Both sheets of the fold are scars with a
surface deficiency in length and surface surplus in width.
The scar sheet surface deficiency spreads from the fold’s top
to the trapeziometacarpal joint level. The scar sheet length
deficiency has a trapezoid shape and has a surface surplus in
its width. The presence of the fold allows contracture to be
eliminated by using local flaps.
Total thumb adduction contracture (Fig. 27.1d) is always
severe and develops in cases of extensive deep hand burns.
The scars brings the thumb and the second metacarpal
together and replace the web space. The web space is either
eliminated completely or is very shallow. The fold is not
formed. Besides the thumb adduction, the first web space,
27

244
as a rule, is shallow and deformed in all contracture types,
mostly in medial and total contractures. Therefore, the web
space resurfacing can be achieved by compensating the
scar deficiency and restoring the web space depth and con-
tour. It is necessary to consider that the thumb assumes the
adduction contracture position when at rest. Therefore, the
first web space is prone to re-contracture after skin
grafting.
a
b
c
d
Fig. 27.1  Three basic types
of web space (thumb)
contractures: (a, dorsal) and
(b, palmar) edge contractures
caused by semilunar fold in
which one sheet (FL) is
scarred, and the other (FM) is
healthy skin; (c) medial
contracture caused by FM
scar’s fold in which both
sheets are scars; (d) total
adduction contracture without
a fold. Different local flap
plasty methods are planned:
trapezoid flap for edge and
medial contracture, subdermal
pedicle flap for total web
space contracture
27  First Web Space Postburn Scar Contractures: Anatomy and Elimination with Local Trapezoid Flaps

245
a
b
c
d
e
f
g
Fig. 27.2  Edge adduction contracture of first finger elimination with
three-flap trapeze-flap plasty. (a) Edge dorsal adduction contracture,
FL—scar fold’s sheet and flexion lateral surface; planning operation
with one trapezoid flap, Y-line for scars dissection; Cr—crest of the
fold; (b) contracture released, trapezoid wound or scar surface deficit
(Dt) appeared (upper of white strip); one flap (Fp) was insufficient for
scar surface deficit compensation; (c, d) two additional adipose-scar
trapezoid flaps elevated from the scar sheet; (e) three trapezoid flaps
mobilized; (f) 10  days after surgery, flaps are alive, contracture is
released; (g) 3 years after surgery; (h) trapeze-flap plasty variants for
dorsal edge web space contractures (scheme): (ha) one-trapeze-flap
plasty; (hb) three-trapeze-flap plasty; (hc, hd) combined trapeze-flap
plasty (one flap and skin grafts)
27  Basic Types of Thumb Adduction Contractures

246
h
Fig 27.2  (continued)
27  First Web Space Postburn Scar Contractures: Anatomy and Elimination with Local Trapezoid Flaps

247
a
c
b
Fig. 27.3  Palmar edge adduction contracture treatment with trapezoid
flaps. (a) Before operation, planning three-flap plasty; contracture anat-
omy: FL scar flexion lateral surface and fold’s sheet; FM flexion medial
surface fold’s sheet is healthy skin; Cr crest of the fold; Y-line for con-
tracted scars dissection; (b) scars sheet dissected with the Y-shaped
radial incisions, large trapezoid wound or Dt—scar surface deficit and
contracture cause appeared; Fp—main flap from FM surface is healthy
skin; additional flaps planned; (c) eight trapezoid adipose-cutaneous
and adipose-scar flaps mobilized, counter transposed and contracture
released in full (10 days after reconstruction); (d) variants of trapeze-­
flap plasty for palmar edge contracture treatment (scheme): (da, db)
one- and multiple-flap plasty; (dc, dd) combined techniques
27  Basic Types of Thumb Adduction Contractures

248
d
Fig 27.3  (continued)
27  First Web Space Postburn Scar Contractures: Anatomy and Elimination with Local Trapezoid Flaps

249
Three Technique Types of Adduction
Contractures Elimination [1]
Edge Contractures Management (Figs. 27.2
and 27.3)
Mild-to-moderate edge contracture is eliminated with three
trapezoid flaps. The method consists of the compensation
of trapeze-shaped scar sheet surface deficit by an adipose-­
cutaneous trapezoid flap, prepared from the healthy
­contralateral fold sheet and web space tissues. With the
incision along the fold’s crest the sheets are separated. The
scar sheets and the fat layer are dissected perpendicularly
with a Y-incision from the top of the fold to the level of the
trapeziometacarpal joint on the hand’s dorsal or palmar
surface. The end of the incision is split (Y-shaped) to
achieve a better divergence of the wound borders. The
thumb and the first metacarpal are fully abducted. As a rule,
a trapeze-shaped wound is formed (Figs. 27.2a and 27.3b).
A similar trapezoid adipose-cutaneous flap, wider than the
wound by 20–50%, is prepared from the medial sheet and
web space tissues. The flap is transposed on a wound with
tension; due to flap traction, the palm skin is displaced and
covers part of the donor wound. Small donor wounds of
one or both sides of the main transposed flap are covered
with trapezoid adipose-scar flaps that are prepared from the
scar sheet (Fig. 27.2c–e). The palmar edge thumb adduc-
tion contracture is eliminated by the same trapeze-flap
plasty. The adipose cutaneous trapezoid flap is elevated
from the healthy skin of the medial sheet and web space/
fossa (Fig.  27.3). The flap is transposed on the trapeze-
shaped wound in the zone of scar sheet dissection; there-
fore, the scar sheet deficit is compensated for and the
contracture is fully eliminated. The donor wound is cov-
ered with healthy skin displaced from the hand’s dorsum
surface, or with small adipose-scar trapezoid flaps prepared
from the scar sheet (Fig. 27.3a–c). The edge contracture is
released with some over-correction.
27  Three Technique Types of Adduction Contractures Elimination

250
Medial Contracture Management (Figs. 27.4
and 27.5)
The fold’s scar sheets are separated by an incision along the
fold’s crest. The fold sheets are transformed into flaps by
radial Y-incisions on all their extents, forming trapezoid
wounds. Because the fold has a crescent shape, the flaps
accept a trapezoid shape as well (Fig. 27.4a, b). The flaps are
elevated with the fat layer. When the contracture is mild and
the fold is short, only one pair of flaps is mobilized. If the
adduction contracture and scar surface deficit are severe and
the fold is long, several flap pairs are elevated. The base of
the central pair of flaps is located near the trapeziometacar-
pal joint level, creating over-correction. Then, the thumb and
first metacarpal are abducted to the normal position. The web
space deepens due to the dissection of soft tissues, and, if
necessary, the fascia of the adductor and first dorsal interos-
seous muscles are also dissected. The oppositely located
flaps are transposed toward each another with moderate ten-
sion (Fig. 27.4c). The central pair is transposed first. As a
result, the web space accepts a normal depth and contours. In
cases of severe contractures and scar surface deficit, the fold
is short, and only one pair of flaps can be elevated. With the
counter flaps transposition, the central part of the web space
is formed (Fig. 27.5a–c). The remaining small wounds are to
be skin-grafted. Counter transposed adipose-scar trapezoid
flaps with tension make deeper and suspend first web space
with over correction, preserve skin transplants from shrink-
age and contracture recurrence.
a
c
b
Fig. 27.4  Medial adduction contracture elimination with trapeze-flap
plasty. (a) Scars at first web space, the fold formed, both fold’s sheets
are scars. Two pairs of trapezoid adipose-scar flap planned from fold’s
sheets and flexion medial surface (FM); crest of the fold (Cr); (b) fold
with Y-incisions dissected, trapezoid flaps and wounds appeared; flaps
mobilized; (c) counter transposed flaps scar surface deficit compen-
sated and contracture eliminated; (d) variants of contracture release
with flaps per se (da, db) and in combination with skin grafts (scheme)
27  First Web Space Postburn Scar Contractures: Anatomy and Elimination with Local Trapezoid Flaps

251
d
Fig 27.4  (continued)
27  Three Technique Types of Adduction Contractures Elimination

252
a
c
b
Fig. 27.5  Severe medial adduction contracture release with trapezoid
flaps and skin grafts. (a) Contracture caused with scars covered all first
FM surface or web space; scars formed a fold in the central zone; both
fold’s sheets are scars. One pair of trapezoid flaps (FP) planned; (b)
trapezoid adipose-scar flaps mobilized; large wound appeared, which
consists of two parts (between strips) according to two sheets of the
fold; half of the wound consists of scar surface deficit (Dt) and donor
wound (DW); scar surface deficit equals surface of all wound minus
surface of both flaps; (c) counter-transposed flaps formed at the bottom
of the web space, compensated part of scar surface deficit; wounds
beside the flaps present the real contracture cause and are covered with
a skin transplant; (d) scheme of medial mild-to-severe adduction con-
tractures elimination with flaps (da, db) and in combination with skin
transplants (dc, dd)
27  First Web Space Postburn Scar Contractures: Anatomy and Elimination with Local Trapezoid Flaps

253
d
Fig 27.5  (continued)
27  Three Technique Types of Adduction Contractures Elimination

254
Total Thumb Adduction Contracture
Elimination (Figs. 27.6 and 27.7)
Reconstruction consists of the web space contracture
release and the bottom depth formation with the local quad-
rangular scar subcutaneous pedicle flap (Fig.  27.6). The
contracture is eliminated with the incision of scars around
the flap, and dorsal and palmar web space surface up to the
trapeziometacarpal joint level. The flap is displaced over
the web space bottom (Fig. 27.6b, c). After the thumb and
first metacarpal abduction, the flap’s ends are connected to
the wound edges on the dorsal and palmar surfaces of the
hand. The flap suspends the web space level in a normal
position, preventing contracture recurrence. The wounds on
both sides of the flap are skin-grafted. Suspending the first
web space in a normal level flap also prevents shrinkage of
skin transplants. No special splinting is required.
Reconstruction with quadrangular flap and skin grafts
allows for restoration of very severe thumb adduction in
children (Fig. 27.7).
a
b
d
e
c
Fig. 27.6  Total first web space contracture treatment with quadrangu-
lar scar subcutaneous pedicle flap and skin grafts. (a) Planning; (b) flap
(FP) isolated from neighboring scars with incision, flap’s borders mobi-
lized from periphery and subcutaneous pedicle flap (FP) displaced at
commissure bottom; (c) ends of the flap sutured with wound’s edges
anteriorly and posteriorly with tension; wounds beside the flap (FP) is
Dt or D—scar surface deficit and cause of the contracture; (d) wounds
covered with skin transplants; (e) scheme of the operation
a
b
d
e
c
Fig. 27.7  Severe total first web adduction contracture treatment with
scar quadrangular subcutaneous pedicle flap and skin grafts. (a, b) Pre-­
operative view; (c) prepared subcutaneous pedicle flap (FP) displaced
at commissural bottom, wound around the flap is Dt—scar surface defi-
cit and contracture cause; (d) ends of the flap sutured with scar edges
with tension; (c) wounds skin grafted, first web space restored
27  First Web Space Postburn Scar Contractures: Anatomy and Elimination with Local Trapezoid Flaps

255
Fig. 27.8  First web space contracture release as part of hand dorsum
resurfacing. (a) Pre-surgery: scars deformity of dorsal left hand, edge
dorsal syndactyly and first web space adduction contracture; (b) scars
excised through intermediate layer without bleeding, trapezoid flap
mobilized from first web space; (c) flap’s end fixated to dorsal hand
tissue with catgut threads; (d, e) 10  days and 1  year after surgery,
respectively; (f, g) scheme of reconstruction
a
b
d
e
c
f
g
Dorsal Edge Thumb Adduction Contracture
Treatment Is Part of Dorsal Hand Surface
Resurfacing (Fig. 27.8)
A dorsal hand surface deformity is usually associated with
the edge of the thumb adduction contracture, caused by the
fold in which the lateral/dorsal sheet is scar tissue and the
medial sheet and fossa are healthy skin. Reconstruction in
such cases consists of a wide scar excision, including the first
web lateral/dorsal scar sheet of the fold. The dorsal edge of
the web space is restored with the trapezoid adipose-­cutaneous
flap prepared from the healthy medial fold sheet and the first
web fossa (Fig. 27.8a, b). The flap’s end is fixed to wound
tissues with 2–3 catgut sutures. The flap restores the depth of
the first web space, web space contours, and prevents skin
transplants shrinkage and re-contracture after skin grafting.
Follow-up results of the first web space reconstruction
with trapeze-flap plasty is shown in Fig. 27.9.
27  Three Technique Types of Adduction Contractures Elimination

256
c
a
b
d
Fig. 27.9  Follow-up results
of severe adduction
contractures elimination with
trapezoid flaps in combination
with skin grafts. (a, b) Case 1.
(c, d) Case 2
27  First Web Space Postburn Scar Contractures: Anatomy and Elimination with Local Trapezoid Flaps

257
Conclusion
Good results were achieved, as a rule: a full range of
thumb abduction and its movements, and complete and
definitive restoration of the web space. No re-operation
was needed for any cases. The trapeze-flap plasty
increases the length of the fold’s top zone from 100 to
200%. Severe contractures, particularly total contrac-
tures, can be caused by injuries of the fascia that sur-
round adduction and dorsal interosseous muscles, the
first metacarpophalangeal joint, and the trapeziometacar-
pal joint. Even though the adduction was not completely
liquidated during surgery, only contracted sheets of mus-
cles need to be dissected. Daily living exercises accom-
plish full hand rehabilitation. No flap loss or other
post-operative complications occur with the use of this
technique. The flap’s fixation to the depth of the web
space with moderate tension for three weeks. Adipose-
scar flaps and skin transplants did not shrink, their sur-
face did not decrease, and everyday labor and pressure
were well tolerated.
Reference
1. Grishkevich VM. First web space post-burn contracture types: con-
tracture elimination methods. Burns. 2011;37:338–47.
Reference