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

260
a
b
c
Fig. 28.1  Anatomy of postburn dorsal interdigital contracture (syn-
dactyly). Case 1: (a) Dorsal edge interdigital scar contracture is
caused by scars covering the dorsal hand; scars smoothed commis-
sural groove and slant, formed fold along dorsal edge of interdigital
fossa; in the fold, FL—lateral (dorsal) fold’s sheet is scars; “+” sym-
bol—heads of metacarpal bone’s heads; Y-lines of contracted scars
dissection; (b) palmar side: FM the medial sheet and fossa are healthy
skin; Cr crest of the fold. Case 2: (c) After the dorsal fold’s sheet dis-
section with Y-shaped incision from the fold’s crest to the metacarpo-
phalangeal joint, a trapezoid wound appeared, which is Dt scar surface
deficit and cause of contracture; FP trapezoid flap mobilized, DW
donor wound
a
b
c
d
e
g
h
f
Fig. 28.2  Dorsal interdigital commissural contractures elimination with
trapeze-flap plasty. (a, b) Pre-surgery, planning: Y-shaped line for contrac-
ture release from the fold’s crest to the metacarpal bone heads; a line along
fold’s crest for sheets separation; two lines in the interdigital fossa are the
flap’s contours; palmar or FM fold’s sheet, fossa and 2 mm of palm are
healthy skin and included in the flap (Fp); (c) after scar sheet dissection and
finger abduction, the wound or scar surface deficit (Dt) appeared in trape-
zoid form (above the white strip; lower, donor wound (DW); FP trapezoid
adipose-cutaneous flap mobilized; Dt scar surface deficiency (cause of con-
tracture) spreads from the fold’s crest to the metacarpal bone heads; (d, e)
flap (Fp) advanced on the wound with tension and sutured with border of
scars, forming the groove and slant; donor wounds on the lateral surfaces of
proximal phalanges appeared, which were split skin grafted; (f) flap (Fp),
deficit of skin surface (Dt); flap (Fp); (g) follow-up results: contracture
fully eliminated; commissural groove, slant and fossa’s depth restored; (h)
scheme of operation
28  Postburn Dorsal and Palmar Interdigital Scar Contractures: Anatomy and Treatment

261
Scar’s Surface Deficit as the Real Cause
of Contracture
Commissural edge contracture is caused by the scar sheet
surface deficiency, which is necessary to determine as the
basis for treatment: reconstruction involves scar surface defi-
ciency compensation with a flap of a similar shape (Figs. 28.1,
28.2, and 28.3). The scar surface deficiency is measured as
follows: The lateral (dorsal) scar sheet of the fold is sepa-
rated from the medial healthy sheet with an incision along
the fold’s crest; then, the contracture is released with the scar
sheet dissection from the fold’s crest to the metacarpal bone
heads, or metacarpophalangeal joints’ rotation axis with a
Y-incision. The Y-incision (which does not go beyond the
rotation axis level) is necessary for complete wound border
divergence and contraction release. After fingers’ abduction,
the wound, as a rule, takes on a trapezoid form, reflecting the
size and form of scar surface deficiency regardless of con-
tracture severity. This fact, that scar surface deficiency (the
real cause of contracture, groove and slant deformity) has a
trapezoid form, is a key for understanding the selection pro-
cess for the flap’s form needed for adequate burned commis-
sure restoration. The form/shape of the scar surface
deficiency, which is a trapeze, is used as grounds for devel-
opment of the new approach and technique for the most
effective commissure resurfacing. Thus, it becomes clear
that the most suitable reconstructive technique for contrac-
ture release, interphalangeal groove and slant restoration,
should be based on use of the flap of a similar form (trape-
zoid) (Figs. 28.2c and 28.3c). This further explains why tri-
angular local flap plasty (Y-V plasty and Z-plasty and their
modifications) are unable to adequately compensate for scar
surface deficit, fully release contractures, and restore the
interphalangeal groove and slant.
a
b
e
f
c
d
Fig. 28.3  Technique for severe dorsal commissural contracture treatment
and result. (a) Anatomy: contracture involved most of the proximal phalan-
ges, FL—lateral sheet of the fold; “+”—metacarpal bones heads; a
Y-shaped line for contracted scars’ dissection from the fold’s crest to the
metacarpal bone heads; (b) palmar surface: line for dissection of scars
between the proximal phalanges from the fold’s crest to notch, proximal of
which the flap’s contours are outlined; (c) contracted scars dissected, FP
flap mobilized, white strip divided the wound on upper trapezoid scar sur-
face deficit (Dt), and lower donor wound (DW); (d) wounds, which
appeared after separation of the proximal phalanges, primarily closed; (e)
result (1 year after operation): contractures removed, commissural grooves,
slants and fossa’s depths fully restored; (f) scheme of reconstruction
Anatomy of Dorsal Interdigital Edge Contractures: Formation, Anatomy, and Scar Surface Deficit as Contracture Cause

262
Elimination of Interphalangeal Edge
Contractures (Syndactyly) with Trapeze-Flap
Plasty
Reconstruction consists of three parts:
(a) complete contracture release;
(b) commissure restoration with the trapezoid flap; and
(c) wounds on the medial surface of proximal phalanges are
covered using skin transplants.
The success of reconstruction depends on the optimal
donor site choice, that is, the one that would allow the neces-
sary flap size and shape with minimal deformity. Selection of
the interdigital fossa for trapezoid flap elevation is the most
important component of the new approach for commissural
contractures treatment. The techniques for dorsal and palmar
commissural contracture treatment are distinctively different.
Dorsal Edge Contracture Elimination (Figs. 28.2
and 28.3)
Planning consists of drawing four lines in each contracted
commissure: the first goes along the fold’s crest; the second is
a Y-shaped line perpendicular to the first one, passing through
the center of the interphalangeal space from the fold’s crest to
the metacarpal bone heads; the third and fourth lines outline
the trapezoid flap’s borders in interdigital fossa (Fig. 28.1c, d);
and the last lines end on the palm, 2 mm proximally to the
palmar interdigital fold’s crest (Fig. 28.1d). The width of the
flap’s end should be wider, by one-third, than the wound’s
width between the metacarpal bone heads’ level, should equal
5–7 mm, and should include a part of the fold’s crest. The
flap’s base is wider than its end according to the wound’s form.
In all cases, the flap’s width should exceed the wound by one-
third. The flap’s length is approximately 25 mm and varies (as
does the width), depending on the measurement of the hand
(adult vs. children). The length is 2–2.8 times greater than the
width (middle parts of the flap). The specifics of the flap can
be summarized as follows: the flap’s end is wide, the subcuta-
neous fat layer is included in the flap, supplying steady blood
circulation, and the flap does not undergo rotation. Therefore,
tissue necrosis and flap loss does not occur despite the flap’s
tension during its transposition on the wound; and the ratio
value (length to width) has no practical meaning or application
due to the qualities of the flap, which make it viable.
Technical Details
First, the fold’s sheets are separated with an incision along
the fold’s crest; then, with a Y-shaped incision, scars and the
subcutaneous fat layer are dissected from the fold’s crest to
the metacarpal bone heads (Figs. 28.2 and 28.3). The split
end of the Y-incision separates scars of the lateral scar sheet
of the fold from scars of the dorsal hand. After the fingers’
abduction, the trapeze-shaped wound appears (Figs.  28.2e
and 28.3c). The wound reflects the form and size of the scar
surface deficiency and suggests the flap be further raised.
According to the wound size and form (scar surface defi-
ciency), but approximately one-third wider, a trapezoid flap
is mobilized. The flap, which has a wide end and no acute
angles, includes the skin and subcutaneous fat layer of inter-
digital fossa, supplying steady blood circulation despite the
number of contractures on one hand. The flap’s base includes
the interdigital palmar fold and about 2 mm of palmar skin,
which makes the flap longer and allows for contracture
­over-­correction. After flap elevation, the interdigital
­commissure (fossa) is deepened, which shortens the wound’s
length (in anterio-posterior direction) and makes the flap
relatively longer. The raised flap shrinks and appears nar-
rower than it really is and appears to be in photos; moreover,
the flap is advanced on the wound with tension and becomes
longer and also narrower. Using two to three sutures, the
flap’s end is connected to the wound’s edge at the level of the
metacarpal bone heads and the borders of the dissected scar
sheet and flap (Fig. 28.2f, g). Thick scar edges are thinned by
an excision of inner scar layer up to 2–3 mm for better flap
adaptation. Due to the interdigital fossa deepening and flap
transposition with tension, the small donor wounds (nearly
1 cm in diameter) are formed on the lateral surface of proxi-
mal phalanges (Fig. 28.2g), which are covered with split skin
grafts (Fig. 28.2h). The transposed flap covers the wound,
compensates for scar surface deficiency, and restores inter-
digital commissure and interphalangeal groove and slant
(Fig.  28.2d–f). The scheme of the operation is shown in
Fig. 28.2h. Selection of the interdigital fossa as donor site for
trapezoid flap elevation is a second component of the new
approach and technique. The split skin transplant for proxi-
mal phalanges’ donor wound covering is harvested from the
inner shoulder’s surface; the donor wound is primarily
closed. All commissural contractures are reconstructed in
one-stage surgery. After reconstruction, the severely
deformed hand appeared normal, and restoration of commis-
sures plays an important role in this outcome.
28  Postburn Dorsal and Palmar Interdigital Scar Contractures: Anatomy and Treatment

263
Treatment of Severe Contracture Caused by
Fusion the Dorsal Surfaces of Proximal
Phalanges (Fig. 28.3)
The fused proximal phalanges are separated up to the medial
healthy sheet, where a small dimple is present (Fig. 28.3b).
Rough scars on the fingers are excised; thick scars are made
thinner by excising the inner scars’ layers, and the wound of
the proximal phalanges is primarily closed (Fig.  28.3d).
After that, the commissure is reconstructed using the tech-
nique described above. After scar sheet dissection up to
metacarpal heads with Y-shaped incision and finger abduc-
tion, the trapezoid wound appears (Fig.  28.3c), reflecting
scar surface deficiency. According to the wound’s size and
form, the adipose-cutaneous from the fossa flap is elevated.
Wounds on the dorsal end of the proximal phalanges are pri-
marily closed. The transposed flap restores form commissure
and covers part of the wound, eliminates the contracture, and
restores the interdigital fossa and interphalangeal groove and
slant (Fig. 28.3e).
Elimination of Interphalangeal Edge Contractures (Syndactyly) with Trapeze-Flap Plasty

264
Edge Dorsal Commissural Contracture
Elimination Is a Part of the Total Dorsal Hand
Resurfacing (Fig. 28.4)
Dorsal hand deformation with scars causes dorsal edge com-
missural contracture (Fig. 28.4a). Hand resurfacing includes
complete scars excision with the dorsal sheet of the fold, res-
toration of the first web space and interdigital commissures
with a trapezoid flap (fossa, groove and slant). After scar
excision through the intermediate layer, no bleeding occurs
because the fat tissue stays undamaged and covered with a
thin layer of mature connective tissue. Trapezoid adipose-­
cutaneous flaps are prepared from the medial fold’s sheet and
interdigital fossa (Fig. 28.4b). The flap is transposed on the
wound and its end is fixed with catgut sutures among meta-
carpal bone heads (Fig. 28.4c). The dorsal hand surface is
resurfaced with whole split skin transplants; wounds on the
inner surfaces of the proximal phalanges are covered sepa-
rately (Fig.  28.4f–j). The scheme of hand resurfacing is
shown in Fig. 28.4e.
a
e
i
j
h
b
c
d
f
g
Fig. 28.4  Commissure restoration simultaneously with total dorsal
hand resurfacing. Case 1: (a) Before operation: extreme severe defor-
mation of the dorsal hand, fingers grow together; (b) scars removed
together with the lateral sheet of the fold through the intermediate layer
without bleeding; trapezoid flap is mobilized from fossa and medial
fold’s sheet; (c) the flap’s end is fixed to tissue among the metacarpal
bone heads; (d) result of operation: contracture released, groove and
slant fully restored, dorsal hand surface resurfaced; (e) scheme of
reconstruction. Case 2: (f) pre-surgery; (g) scars excised, flap mobi-
lized, and end fixed to the wound’s tissue. Case 3: (h, i) keloid scars
covered dorsal surface of both hands; (j) dorsal surface of hands and
commissures restored, syndactyly eliminated
28  Postburn Dorsal and Palmar Interdigital Scar Contractures: Anatomy and Treatment

265
Palmar Edge Contracture Anatomy
and Treatment
Anatomy of the Palmar Edge Commissural
Contracture (Fig. 28.5)
Palmar commissural contracture is a result of hand palmar
surface burns. While the wound is healing and scarring,
the existing palmar fold spreads in a distal direction, fus-
ing the proximal phalanges and forming the palmar inter-
digital contracture. The fold consists of two sheets
(Fig.  28.5a, b): the medial sheet, which is healthy skin
that spreads on undamaged interdigital fossa, and the pal-
mar (lateral) sheet (scars spreading over the palm). The
contracture is caused by the palmar scar sheet’s surface
deficiency. After the sheets’ separation with an incision
along the fold’s crest, and scar (palmar) sheet dissection
with a Y-shaped incision to complete contracture release
and fingers abduction, the wound, as a rule, accepts a trap-
ezoid form (Fig. 28.5c).
The trapeze-shaped wound reflects the size and form of
the scar sheet deficiency. Consequently, effective contracture
elimination requires a flap with a shape similar to that of the
wound (trapezoid). Planning consists of drawing four lines:
(1) along the fold’s crest for separation of scars from healthy
skin; (2) a Y-shaped line indicating the level and form for
contracted scars’ dissection (middle length of proximal
­phalanges); and (3) two lines—the lateral contours of the
flap. Thus, the adipose-cutaneous flap includes the skin of
interdigital fossa and medial (healthy) sheet of the fold. The
base of the flap is located on the palm, laterally from the
fossa’s edge by 2–3 mm (Fig. 28.5a, b).
Surgical Details (Fig. 28.5)
The first incision separates the scar lateral (palmar) fold sheet
from the medial healthy sheet. With a perpendicular Y-shaped
incision, the contracture is released from the fold’s crest to the
metacarpal bones’ heads. (A Y-shaped incision is a necessary
component, ensuring easy scars’ edges’ divergence and com-
plete contracture release.) As a rule, a trapezoid wound is
formed after the fingers’ abduction (Fig.  28.5c, below the
white strip), reflecting the size and form of the scar surface
deficiency. According to the trapeze-shaped wound’s size, the
adipose-cutaneous flap is raised in interdigital fossa
(Fig. 28.5c, above the white strip). For neurovascular bundle
preservation, the incisions are directed parallel to the lateral
surfaces of the proximal phalanges. After the fossa’s deepen-
ing, the flap is transposed on the wound with tension, elimi-
nating contracture, and restoring the interdigital commissure
(Fig. 28.5d). The wounds located beside the flap, on the lat-
eral surfaces of proximal phalanges, are split skin-grafted. As
a result, the scar sheet surface deficiency is compensated, the
contracture is fully released, and commissural groove and
slant are fully restored (Fig. 28.5e). A scheme for this opera-
tion is shown in Fig. 28.5f. After circular hand burns, dorsal
or palmar commissural scar contractures can be combined
with the finger flexion contractures. Both contractures are
released simultaneously; the commissures are restored first.
a
b
e
f
c
d
Fig. 28.5  Palmar interdigital commissural contracture treatment. (a,
b) Anatomy: interdigital edge palmar contracture is caused by scars
covering the palm and flexion surface of fingers; scars, growing distally
among the fingers, involve the skin of the fossa and form the fold
located along the palmar fossa’s edge; palmar sheet of the fold is scars
and contracture cause; dorsal sheet and fossa are healthy skin and donor
site. Planning of operation: flap dorsal; Y-lines for contracted scars dis-
section and marked flap’s borders; (c) after scars’ dissection, the Dt—
trapezoid and donor wounds and scar surface deficit are formed (below
white strip); FP—adipose-cutaneous flap elevated; (d) transposed flap
restored bottom of fossa, wounds on proximal phalanges (scar surface
deficit) were covered and deficit compensated with skin transplants; (e)
results: contracture removed, all commissural components completely
restored; (f) scheme of the operation
Palmar Edge Contracture Anatomy and Treatment

266
Total Interdigital Contractures, Anatomy,
and Treatment
Two forms of total contractures exist: (1) Inner surfaces of
fingers are fused with scars; and (2) a flat scarred surface
formed between the fused fingers, in projection of interdigi-
tal fossa (Fig. 28.6a, b).
Interdigital fusion has a severe scar surface deficit; there-
fore, any local-flap technique is impossible to use; contrac-
ture is released with skin transplants. The flat surface in fossa
projection presents the scar surface, allowing contracture
release with the quadrangular subcutaneous pedicle flap and
skin transplant (Fig. 28.6a, b). The flap (Fig. 28.6c, d) is sep-
arated from neighboring scars and mobilized on the periph-
ery; contracted scars are dissected up to the joint rotation
axis level anteriorly and posteriorly with a Y-shaped incision;
the interdigital space is deepened, and the flap is displaced
on the commissural bottom, on the normal interdigital fos-
sa’s level (Fig. 28.6c). Then, the flap’s ends are transposed
anteriorly and posteriorly with tension and connected with
the wound’s edges (Fig. 28.6d). The flap suspends a commis-
sure steadily, and thus prevents the re-contracture. Because
the flap is placed on the fossa’s bottom, the wounds appear
on proximal phalanges, which are skin grafted.
Results of severe dorsal commissural contractures recon-
struction with trapeze-flap plasty are shown in Fig.  28.7
(three patients).
a
b
e
f
g
c
d
Fig. 28.6  Total interdigital contracture treatment with quadrangular
local subcutaneous pedicle flap. Case 1: (a, b) among proximal phalan-
ges there is a flat surface, flap marked, and Y-shaped scar dissection; (c)
FP—flap mobilized from the periphery and displaced to commissure
bottom; wounds appeared on proximal phalanges or Dt—scar surface
deficit; (d) the flap’s ends are connected with wound edges anteriorly
and posteriorly with tension; wounds on proximal phalanges are skin
grafted; (e) result. Case 2: (f) total syndactyly, planning reconstruction
with quadrangular subcutaneous pedicle flap; (g) contracture released,
fossa’s bottom and commissural slant restored; wounds on proximal
phalanges are scar surface deficit are covered with skin transplants
a
b
c
d
e
f
g
h
Fig. 28.7  Follow-up results of postburn edge dorsal commissural con-
tractures elimination with trapeze-flap plasty: (a, b) 1 year after sur-
gery; (c, d) contracture in 9-year-old child; (e, f) and (g, h) severely
deformed hand: scar surface deficit (contracture cause) compensated by
fossa’s flaps, hand dorsal surface resurfaced with skin transplants, inter-
digital fossa, interphalangeal groove, and slant restored
28  Postburn Dorsal and Palmar Interdigital Scar Contractures: Anatomy and Treatment

267
Conclusion
Dorsal and palmar edge commissural contractures are
fully eliminated using trapeze-flap plasty. A normal com-
missural groove and slant are achieved; the fossa’s depth
and width are restored. No flap loss occurred. Shrinkage
of skin transplants was insignificant and does not affect
the initial postoperative depth of interdigital fossa (does
not make it shallow). Because skin grafts are placed deep
in the fossa (beside the flap), they are barely noticeable.
The trapezoid adipose-­cutaneous flaps and skin trans-
plants do not shrink; being stretched, the flaps’ and sur-
rounding stretched skin continues to grow, restoring and
surpassing the initial flaps’ width, which prevents con-
tracture recurrence in adults and, more importantly, in
pediatric patients. Because of flap growth, the tissue
stretching normalized, as did the commissural space and
interdigital fossa’s depth. With time, the follow-up results
improve. As operation scars and grafts matured, flaps
became bigger, fully restoring interdigital fossa and com-
missural groove and slant.
Reference
1. Grishkevich VM. Postburn dorsal and palmar interdigital commis-
sural contractures: anatomy and treatment—a new approach. Adv
Biosci Biotechnol. 2013;4:518–30.
Reference

269
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Postburn Flexion Contractures
of Fingers: Anatomy and Treatment
with Trapeze-Flap Plasty
Introduction
Scar flexion medial contractures of the fingers are a signifi-
cant complication of burn injuries of the hand and a frequent
cause of patients’ disability. The restriction of finger motion
is a direct indication for performing reconstruction. The flex-
ion contracture of the fingers poses a challenge for surgeons.
The task of surgical treatment consists of complete elimina-
tion of contraction by lengthening the flexion surface of a
finger, resurfacing of the skin, and the restoration of hand
function without recurrence of contracture. Various recon-
structive techniques are used and we have tested most of
them. The results were unsatisfactory. Pursuing a more effec-
tive method for treating such contractures, a trapeze-flap
plasty method was developed, which became the preferred
reconstructive technique. This chapter describes the anatomy
and contracture cause (scar surface deficit), and techniques
for medial finger flexion contracture elimination based on
trapezoid flaps.
29

270
Anatomical Features of Medial Finger
Flexion Contractures
Finger flexion contractures are caused by scars located on
the entire finger’s flexion surface, which forms the fold, the
crest (Cr) of which is located along the medial line of the
flexion surface of the fingers. The fold has a semilunar
(crescent) shape. Both fold sheets are scars. The scar fold is
located against one interphalangeal (IP) joint, mostly the
proximal IP (PIP) joint, or it occupies both IP joints and all
flexion surfaces (Fig.  29.1a, b). Scar sheets of the fold
spread from the fold’s crest up to the joint rotation axis
level. The crest of the fold corresponds to the medial line of
the finger flexion surface (medial contracture). The widest
part of the fold is usually situated against the PIP joint or
the middle phalange. The fold’s sheets have a scar surface
deficit in length, which causes the contracture; however, a
scar surface surplus in width allows contracture elimination
with local flaps. The more the fold’s protrusion, the more
skin surface surplus there is in the sheets. Very often, finger
scar contractures are combined with palm and thumb con-
tractures, that is, volar syndactyly; more rarely they are
combined with boutonniere deformity and articular
­structure injuries.
a
b
d
e
c
Fig. 29.1  Postburn finger flexion contracture anatomy and elimination
with trapeze-flap plasty. (a) Before reconstruction: crescent-shaped
fold along medial line finger’s flexion surface, both fold sheets are scars
and spread from the fold crest to the interphalangeal joints axis (medial
contracture); (b) FM flexion medial surface; Cr crest of the fold; plan-
ning: radial Y-lines mark the flap contours along all sheets from the
fold’s Cr to joint rotation axis level; (c) after radial incisions and finger
extension, the flaps (FP) and wounds (Dt surface deficit) accepted trap-
ezoid shape (trapeze-shaped surface deficit in length); (d) trapezoid
flaps mobilized with split subcutaneous fat layer and finger’s flexion
surface delivered from scars; after finger extension, the tendon sheets
did not expose, fat layer preserved their integrity; (e) opposite trans-
posed flaps covered joint FM surface, small wounds at proximal and
distant phalanges covered with full-thickness skin transplants; thumb
adduction contracture eliminated simultaneously with trapeze-flap
plasty
29  Postburn Flexion Contractures of Fingers: Anatomy and Treatment with Trapeze-Flap Plasty

271
Scar of Finger Flexion Surface Deficit
as the Real Cause of Contracture
The flexion surface of fingers is small and has a round form;
therefore, the entire flexion surface belongs to the flexion
medial (FM) surface and thus causes contracture of the
“medial” type (Fig.  29.1a). During wound healing, con-
tracted scars are elevated over the finger flexion surface and
a fold forms, the crest of which passes along the medial line
of the flexion surface. Therefore, both sheets of the fold are
scars, and both spread from the fold crest to the axis of IP
joints, have a surface deficit in length (contracture cause) and
a surface surplus in width, allowing contracture elimination
with local flaps (Fig. 29.1). For adequate contracture elimi-
nation it is necessary to know the size and form of the sur-
face deficiency in the fold sheets, because the contracture
elimination is based on the compensation of scar surface
deficit by flaps of a similar form and size (Fig. 29.1). To esti-
mate the scar deficit it is first necessary to separate fold
sheets with incision along the fold crest and cross-cut the
scar sheets from the crest of the fold all the way to the joint
rotation axis. For complete release of the scar’s tension, the
ends of incisions should be Y-shaped, which separates the
contracted scars of the joint’s flexion surface (FM) from the
scars of the joint’s extension surface (E). As a rule, after the
joint is extended and the wound’s edges diverge, a
­trapeze-­shaped wound is formed, or a scar surface deficit
(Dt), despite the quantity of incisions made, reflecting a real
cause of contracture (Fig. 29.1b–d). Consequently, to ade-
quately eliminate the contracture and cover the wound, the
local flaps of the same trapezoid shape must be applied.
Because the flap has a semilunar form, radial incisions of the
fold convert the fold’s sheets into trapezoid flaps
(Fig. 29.1b–e).
Scar of Finger Flexion Surface Deficit as the Real Cause of Contracture

272
Principles of the Surgical Technique
(Figs. 29.1, 29.2, 29.3 and 29.4) [1]
Flap Planning (Fig. 29.1a–c)
Scar flexion contracture elimination of all fingers is a single-­
stage procedure. The main planning goal is to convert both
sheets from the crest of the fold to the joint axis level into
trapeze-shaped flaps. The first line is drawn along the fold’s
crest; then, several radial lines are drawn along the fold’s
extension; these radial lines spread from the fold’s crest to
the joint axis level. The end points of the perpendicular inci-
sions must be Y-shaped (2–3 mm, 60°). The distance between
the radial lines, if measured at the fold’s crest, equals
1–1.5 cm (the width of the flaps’ ends). The base of the cen-
tral pair of the trapezoid figures should be located on the
lateral surfaces of the PIP joint (Fig. 29.1b).
Flap Mobilization (Figs. 29.2c and 29.4b)
As a rule, the flaps should be mobilized on the finger that is
in the flexion position. The finger is fixed with sutures.
According to the marked lines, the sheets are separated along
the fold’s crest and are then cross-cut by radial incisions. The
flaps are mobilized from their end to the base, from the fold
crest to the joint axis level. Because of flap mobilization, the
contracted finger’s flexion surface should be delivered from
the scars up to the joint axis level. Depending on the fold
length, one or several pairs of flaps are mobilized, com-
pletely transforming the fold sheets including all extents into
adipose-scar trapezoid flaps (Fig. 29.1). The shorter the fold,
the fewer the pairs of flaps that may be formed. The end
points of the perpendicular incisions must be Y-shaped
(2–3 mm, 60°). The distance between the radial lines, if mea-
sured at the fold’s crest, equals 1–1.5 cm (the width of the
flaps’ ends). Since the fold is of a crescent form, trapeze-­
shaped figures are formed. The fold itself is thus transformed
into one or several pairs of these trapezoid figures. The base
of the central pair of the trapezoid figures should be located
on the lateral surfaces of the PIP joint (Fig. 29.1b).
Finger Extension
The mobilized flaps are fixed by sutures and pulled apart to
the sides. The napkin is placed on the finger’s wound. Both
of the surgeon’s thumbs are placed on the wound flexion sur-
face, and the other surgeon’s fingers apply pressure to the
back surface of the patient’s finger. Using moderate-to-­
severe pressure, the finger is gradually completely extended.
Due to pressure upon the wound, the fat layer remains solid
and the tendon sheet covered, not exposed or injured
(Fig. 29.1d). According to the author’s experience, such a
finger extension technique plays an essential role in success-
ful finger reconstruction.
Flap Transposition and Wound Covering
(Figs. 29.3b and 29.4c)
Once the complete contracture release is achieved, wound
coverage is carried out on a fully extended finger. The oppo-
sitely located mobilized adipose-scar flaps are transposed
toward one another with a mild tension that is harmless due
to good blood circulation. The end of one flap reaches the
opposite flap’s base. First, the oppositely transposed flaps
cover the PIP joint flexion zone. The last flaps are then
counter-­transposed, fully or partially covering the wound
surface. Because of the flaps’ tension, the opposite flaps’
bases approach, the skin of the back finger is displaced on
the finger lateral surfaces, the wound is narrowed, and its
surface is diminished. The finger’s soft tissues are squeezed,
and the finger becomes thinner.
29  Postburn Flexion Contractures of Fingers: Anatomy and Treatment with Trapeze-Flap Plasty

273
a
c
b
Fig. 29.3  Moderate PIP
joints flexion contracture
elimination with trapezoid
adipose-scar flaps. (a)
Planning: radial Y-lines for
contracted scars dissection
from the fold’s crest to the
joint rotation axis; first pair of
flaps is prepared against the
PIP joint’s rotation axis level;
(b) reconstruction with one
pair (fourth and fifth fingers)
and two pairs (second and
third fingers) of adipose scar
trapezoid flaps; (c) one, two,
and three pairs of trapeze-flap
plasty variants without skin
grafting (scheme)
a
b
d
e
c
Fig. 29.2  The PIP joint scar contracture (mild-to-moderate) of two fin-
gers eliminated with two pairs of adipose-scar trapezoid flaps without
skin grafting. (a) Anatomy: FM flexion medial surface from the crest (Cr)
to the joint rotation axis (“+”); E extension surface; (b) trapeze-­flap plasty
planning (F): the radial line spread from the semilunar fold crest to the
joint rotation axis level; (c) two pairs of trapezoid flaps were mobilized;
(d) contracture was eliminated with counter-transposition of trapezoid
adipose-scar flaps (F), palmar contracture was released and wound skin
grafted (7 days after surgery); (e) results (2 months after reconstruction.);
flaps are alive, both fingers’ contractures are eliminated fully
Principles of the Surgical Technique

274
a
b
c
d
e
f
g
h
Fig. 29.4  Elimination of severe finger flexion contractures with a com-
bined method. Case 1: (a) Preoperative view, severe contractures; two
pairs of trapezoid flaps planning; (b) adipose-scar flaps (F) mobilized;
Dt surface deficit, DW donor wound; (c) flaps covered wound; except
distal phalanges and base of proximal phalanges, where skin transplant
used. Case 2: (d) Pre-surgery: short folds; only one pair of trapezoid
flaps; Dt surface deficit; (f) wounds skin grafted, contracture elimi-
nated, and fingers can be prepared; (e) transposed flaps (FP) covered
flexion PIP joint zones, wounds next to the flaps are fully straightened
(10 days after surgery): flaps and transplants are alive; (g) 2 weeks after
reconstruction, there are no complications; (h) three variants of finger
flexion contractures elimination (scheme)
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275
Surgical Technique [1]
Mild-To-Moderate Contracture Elimination
with Trapezoid Flaps Per Se (Figs. 29.2 and 29.3)
Contracture usually involves the PIP joints; therefore, the
scar crescent fold is short and moderately expressed. The
peculiarities and details of flap planning and finger wound
coverage depend on many factors. Mild or moderate contrac-
ture is released with trapeze-flap plasty: an incision is made
along the fold’s crest; then the sheets are dissected with
radial Y-incisions perpendicular to the fold’s crest toward the
joint rotation axis level, and a pair of trapezoid flaps and
wounds appear. The main pair of flaps form against the PIP
joint and cover it. If all of the scar surface deficit was not
compensated, additional flaps are mobilized until complete
and unrestricted finger extension is possible. In most cases,
the surface surplus of the sheets is sufficient for the scar’s
surface deficit compensation and contracture elimination
(Figs.  29.2d, e and 29.3b, c). Trapeze-flap plasty variants
without skin grafting are shown in Fig. 29.3c.
Surgical Technique

276
Severe Finger Flexion Contracture
Elimination (Fig. 29.4)
In severe contractures, the scar fold can be long (Fig. 29.1a)
or short (Fig. 29.4a); the full length of the fold’s sheets is
then converted into trapezoid flaps and transposed to the base
of the opposite flap. If the scar surface deficit in the fold’s
sheet is severe and the fold is short, the reconstruction is per-
formed with the use of a combined method: counter-­
transposed flaps cover the PIP or both finger’s joint zone, and
the small wounds beside the counter-transposed flaps are
covered with full-thickness skin grafts (Fig.  29.4b–g).
Variants of the combined technique are shown in Fig. 29.4g.
If, after surgery, fingers are resistant to full extension, or fin-
gers have a tendency toward flexion, para-osseous, para-­
articular K-wire, or 18-gauge syringe needles can be used for
finger extension. This allows the joint to be fixed in an
extended position for several weeks. There is no need for
intra-articular K-wire or syringe needle insertion. After the
reconstruction of every finger, a small bolster is put on the
full-thickness skin transplant without any special fixation;
the bolster, as well as all finger surfaces, is covered with a
napkin and fixed by circular compression dressing. The fin-
ger tip’s color serves as an indicator of blood circulation.
Severe finger flexion contracture is often combined with
thumb medial contracture in the thenar zone (Fig. 29.5). If
fingers have a short fold, only one pair of flaps is prepared,
which cover the PIP joint surface (Fig. 29.5a, b). Wounds
beside the transposed flaps are skin-grafted. Thumb contrac-
ture is usually of the medial type and eliminated with
counter-­transposition of trapezoid flaps (Fig.  29.5); palm
contractures are eliminated simultaneously. After an ade-
quate contracture release, usual splinting during the first
2 weeks and for 1–2 months at night is enough to prevent
recurrence of flexion contracture.
a
d
b
c
Fig. 29.5  Severely burned fingers, including the thumb, had medial flex-
ion contractures caused by a short scar fold and treated by one pair of
trapezoid flaps which covered the PIP joint. (a) Pre-surgery view, ankylo-
ses of the second finger PIP joint; planning; (b) short fold allows prepara-
tion of only one pair of trapezoid flaps for PIP joint covering; FP flap, Dt
surface deficit; DW (first finger) donor wound; (c) flaps covered PIP joint
surface, wounds beside flaps on fourth and fifth fingers are skin-grafted;
thumb contracture released with one pair of trapezoid flaps; palm wound
is skin-grafted; (d) three variants of severe finger flexion contractures
elimination with trapezoid flap and skin transplants
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277
Surgical Tactics for Multi-Component Hand
Flexion Contracture Elimination
Deep burns of the hand volar surface result in a multicompo-
nent contracture, which includes the flexion contracture of
fingers and palm, thumb adduction, and volar syndactyly
(Figs. 29.6a and 29.7a, b). All contractures of the hand flex-
ion surface are eliminated in a single-stage procedure that
follows this sequence: the adduction of the thumb, flexion
contractures of the metacarpophalangeal joints, palmar syn-
dactyly, flexion contractures of the fingers, and contracture
of the palm. Each contracture is removed with a special
reconstructive technique. The medial scar flexion contrac-
tures of fingers are eliminated with the trapeze-flap plasty
alone or in combination with skin grafting (also before the
postburn boutonniere deformity elimination).
The treatment of severe hand/fingers flexion contractures in
children is shown in Fig. 29.7a–g. Severe fingers flexion con-
tracture is reconstructed using a combined method. Contracture
of free fingers is eliminated first; the fingers’ fusing with the
palm is a result of loss of skin on the finger’s flexion surface.
After the fingers’ separation from the palm and palm contrac-
ture release, the flexion surface of the fingers and palm are cov-
ered with full thickness or thick split skin transplants (Fig. 29.6
and 29.7e). Due to the trapezoid flap’s form and good blood
supply, small scar trapezoid flaps do not undergo necrosis; the
flaps and skin transplants grow proportionally with hand devel-
opment, and finger flexion re-­contracture is prevented.
a
b
c
d
e
f
Fig. 29.6  Method and results of combined reconstruction (trapeze-flap
plasty and skin grafting) of the fingers and palm skin grafting. (a) Pre-­
operation: severe flexion contractures of fingers and palms of both
hands; (b) end of right hand reconstruction; (c) 4 months after surgery;
(d) 3 years after one-staged multiple contracture elimination. (e) Left
hand: 2 weeks after surgery; (f) follow-up result
Surgical Tactics for Multi-Component Hand Flexion Contracture Elimination

278
a
b
e
f
g
c
dd
Fig. 29.7  Reconstruction of the severe flexion multiple contracture of
right hand in a 6-year-old girl with a combined method (trapeze-flap
plasty and skin grafting). (a, b) Severe flexion contracture of the entire
hand palmar surface, fusion of the second and third fingers with the
palm, medial contracture and trapeze-flap plasty planning of fourth and
fifth fingers, hand hypotrophy, trapeze-flap plasty planning, F trapezoid
flaps; Cr crest of the fold; (c) medial contracture of fourth and fifth
fingers released with local trapezoid flaps; (d) second and third fingers
separated from the palm, contracted scars excised on fingers and palm,
palmar syndactyly removed with trapezoid flaps taken from interdigital
fossa; (e) wound covered with a full-thickness skin transplant; (f, g)
results (3 months and 1 year after surgery): finger’s flexion and exten-
sion as well as anatomy and function of the hand restored; fingers grow,
skin transplant looks like normal skin
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279
Total Fingers Flexion Contracture: Anatomy
and Treatment
Anatomy (Fig. 29.8)
Circular deep burns of the hand result in total finger contrac-
ture development. Scars are usually thin and can be easily
torn; they tightly surround the finger without a fold, soft tis-
sues are hypotrophic, and the finger’s tendon extension appa-
ratus and articular solid structures are damaged (Fig. 29.8a).
The range of motion of interphalangeal joints is severely
restricted or absent. Such severe flexion contracture impairs
the function of the entire hand and leads to disability. The
surgical goal is directed at scar contracture release and
straightening of the fingers to achieve a functionally useful
condition, and elimination of the scar component of the flex-
ion of the entire hand.
a
b
d
e
c
Fig. 29.8  Treatment of total severe finger scar flexion contractures
combined with boutonniere deformity and soft tissue hypotrophy.
(a) Pre-surgery view; (b) scar dissected with a transverse double-Y-
shaped incision at the middle flexion surface zone of the proximal
and middle phalanges. Scars with a thin fat layer are mobilized
proximally and distally; scars covering interphalangeal joints stay in
situ. Then, the fingers are extended, creating pressure on the wounds.
Newly appeared wounds are skin-grafted; F flap; Dt scar surface
deficit; (c) full thickness skin transplants alive; F flaps; (d, e) scar
component of contracture eliminated; finger’s incomplete extension
because of tendon extensor apparatus injured (boutonniere
deformity)
Total Fingers Flexion Contracture: Anatomy and Treatment

280
Surgical Technique (Figs. 29.8 and 29.9)
The contracted scars on the finger flexion surface are dis-
sected transversely in each phalange, not injuring the fat
layer, with a Y-shaped double-split incision on the joint rota-
tion axis level. The scars are mobilized with the thin fat layer
in the direction of the interphalangeal joints; about 1 cm of
scars in the projection of the joint remains in situ. Then, the
fingers are extended, not injuring the fat layer, as described
above. Because the wounds’ edges diverge, the wounds
appear in the middle of phalanges, and the tendons are not
exposed (Figs. 29.8b and 29.9b). The wounds are covered
with full-thickness skin transplants and the fingers are immo-
bilized in a new extension position. This technique signifi-
cantly improves functional possibilities of the hand
(Fig. 29.9d) and allows for tendon extensor apparatus repair
(boutonniere deformity) and soft tissue restoration with the
groin flap (see Chap. 30).
a
b
c
d
Fig. 29.9  Technique of total
finger flexion scar contracture
treatment. (a) Pre-operative
view: severe flexion
contracture of the fingers,
hypotrophy of soft tissues; (b)
contracted scars dissected in
the middle surface of all
phalanges with double end
Y-shaped incision, adipose-­
scar layer of finger’s flexion
surface mobilized in the
direction of interphalangeal
joints, where scars remain in
situ; fingers extended by
surgeon’s finger pressure on
contracted finger’s flexion
surface; planning of
treatment, medial thumb
contracture with one pair of
adipose-scar trapezoid flaps;
F flap; (c, d) wounds covered
with full-thickness skin
transplants; all fingers
straightened, skin transplants
alive without visible
retraction; F flaps
29  Postburn Flexion Contractures of Fingers: Anatomy and Treatment with Trapeze-Flap Plasty

281
a
b
c
d
Fig. 29.10  Flexion contracture anatomy peculiarities of the fifth fin-
ger. (a, b) Fifth finger is more severely damaged than other fingers; the
lateral ulnar surface of the fifth finger is more severely injured than the
flexion medial; the fold of the fifth finger is displaced to ulnar edge of
flexion medial surface (the fold of other fingers is located along the
middle line of the flexion medial surface); (c) reconstruction of two to
four fingers’ technique as in the case of medial contracture treatment
(with a pair of local trapezoid flaps); (d) the fifth finger is reconstructed
with a technique developed for edge contractures: the main flap from
the medial fold’s sheet and flexion medial surface, and two trapezoid
flaps from the scar lateral (ulnar) sheet and FL surface for the donor
wound
Anatomical Features and Treatment
of the Fifth and First Finger Flexion
Contractures
Anatomy of the Edge of the Fifth Finger
Flexion Contracture (Fig. 29.10)
In most cases, like the other fingers, the fifth finger flexion
contracture is medial (Fig.  29.10a, b shows the third and
fourth fingers). However, the fifth finger differs from other
fingers because it is opened, and its flexion lateral (ulnar)
surface is not protected by a neighboring finger (Figs. 29.1
and 29.10). Therefore, fifth fingers are injured more severely
than other fingers; the open lateral flexion surface of the fifth
finger is more severely damaged than its medial flexion lat-
eral surface. As a result, the fold is located not along the
middle line of the flexion medial surface (sign of medial con-
tracture), but passes along the ulnar (lateral) edge of the flex-
ion medial surface (Figs. 29.10a and 29.11b, c), and forms an
edge flexion contracture. The lateral fold’s sheet is scars; the
medial sheet and medial flexion surface can be healthy or
less damaged skin than the lateral sheet. These anatomical
features form the edge contracture, and do not occur in other
fingers.
Fifth Finger Medial Type Contracture
Treatment (Figs. 29.3 and 29.4)
The fifth finger’s flexion contracture is most often recon-
structed in a manner similar to reconstruction of the medial
contractures of other fingers. Contracture is caused with the
fold located along the medial line of the flexion medial sur-
face. Both fold sheets are scars and spread laterally to the
interphalangeal joint’s rotation axis. Reconstruction is per-
formed using the trapeze-flap plasty; the fold’s sheets are
converted into adipose-cars flaps, one or two pairs alone or in
combination with skin transplants. First, PIP joint is covered
with the flaps (Figs. 29.3, 29.4, 29.5, and 29.8).
Anatomical Features and Treatment of the Fifth and First Finger Flexion Contractures

282
Elimination of Edge Contracture of the Fifth
Finger with Three Trapezoid Flaps
Depending on the contracture severity and scar sheet’s sur-
face surplus, the contracture is removed with local trapezoid
flaps (three-flap plasty) (Figs. 29.11 and 29.12). The adipose
cutaneous flap is prepared from the medial healthy sheet and
the finger’s flexion medial surface, which covers the PIP
joint; small donor wounds beside the main flap are covered
with adipose-scar flaps prepared from the scar’s lateral fold
sheet.
The severe edge scar contracture of the fifth finger is
eliminated with a combined technique: one trapezoid flap is
elevated from the medial fold’s sheet and it covers the PIP
joint; the wounds beside the flap are skin-grafted
(Fig. 29.13).
a
b
c
d
e
f
Fig. 29.12  Technical details of edge fifth finger flexion contracture
with three local trapezoid flaps. Case 1: (a) pre-surgery view, planning:
main adipose-cutaneous flap from FM surface and medial fold sheet;
two adipose-scar flaps from FL surface and lateral scar sheet for donor
wound covering; (b, c) flap mobilization; (d) contracture released, scar
surface deficit compensated with counter transposed adipose cutaneous
and adipose-scar flaps. Case 2: (e, f) severe edge contracture, soft tis-
sues hypotrophy; contracture released with three local trapezoid flaps
a
b
Fig. 29.13  Severe fifth finger
contractures reconstructed
with one trapezoid flap and
skin transplants. (a) Planning
trapeze-flap plasty of PIP
joint edge contracture; (b)
trapezoid flap from flexion
medial surface covered wound
over the PIP joint; wounds
beside the flap are
skin-grafted
a
b
c
d
Fig. 29.11  Scar edge flexion contracture of the fifth finger: anatomy
and reconstruction with three trapezoid flaps. (a) Fifth finger edge
flexion contracture in case of hand dorsal burns. (b, c) Anatomy: E
joint extension surface; “+” joint rotation axis; Cr crest of the fold;
FM flexion medial surface; scars cover the flexion lateral surface
(FL) of the fifth finger and form a fold crest (Cr) passing along the
flexion lateral and flexion medial surfaces; lateral fold’s sheet is scar
and part of the FL surface; medial sheet and flexion medial (FM)
surface is healthy skin (signs of edge contracture); reconstruction
planned with three trapezoid flaps: main adipose cutaneous trape-
zoid flap—healthy skin and two adipose-scar trapezoid flaps from
scar sheet and FL surface; Y-line for contracted scars dissection
from fold crest to the PIP joint rotation axis; (d) contracture removed
with local trapezoid flaps
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283
Treatment of Medial Contractures of Fifth
Finger and Ulnar Hand, Caused with Long Fold
(Fig. 29.14)
Burns of the ulnar surface of the hand’s edge can form a long
fold and medial contractures of the fifth finger and ulnar
hand border (Fig.  29.14a). Fingers and hand zones were
reconstructed separately. The active zone of the metacarpo-
phalangeal joint remained in situ (Fig. 29.14b–d).
a
b
c
d
Fig. 29.14  Treatment medial
scar contracture caused with
long fold involving the ulnar
edge of the hand and fifth
finger. (a–d) Release of the
contracture of hand and the
finger performed separately
with two pairs of adipose-scar
trapezoid flaps
Anatomical Features and Treatment of the Fifth and First Finger Flexion Contractures

284
First Finger Flexion Contracture
Medial contracture of the thumb in the thenar zone is
caused by scars that form the fold passing along the
medial line of flexion surface or closer to the lateral flex-
ion surface (Figs.  29.15, 29.16, and 29.17). Both fold
sheets are scars; therefore, contracture is of the medial
type. Elimination of the contractures involves the conver-
sion of the fold’s sheets into trapezoid adipose-scar flap
and their counter-transposition.
The treatment of severe contracture requires a combined tech-
nique: one pair of adipose-scar trapezoid flaps cover the wound
against the interphalangeal joint; wounds beside the counter
transposed flaps are skin grafted (Fig. 29.16). The first finger is
fixed in extension position with a syringe needle para-articularly
(Fig. 29.16c). (FM joint flexion medial surface and trapezoid flap
planning; E joint extension surface; “+” joint rotation axis.)
A well-expressed long fold is converted into adipose-­
scars trapezoid flaps on all its extension, and flaps are
counter-­transposed (Fig. 29.17).
a
b
c
Fig. 29.17  Medial scar contracture of thumb treatment with two pairs
of adipose-cutaneous trapezoid flaps. (a) Scars dissected with radial
incisions; trapezoid scar surface deficit and flaps (FP), scar surface defi-
cit (Dt) or contracture cause; (b, c) flaps mobilized and counter-­
transposed. Contracture released with local tissue
a
b
c
Fig. 29.16  Treatment of severe medial contracture of the thumb with a
combined technique. (a) Pre-surgery; (b) planning plasty with one pair of
adipose-scar trapezoid flaps; FM flexion medial surface, trapezoid flap;
(c) counter-transposed flaps covered interphalangeal joint, wounds beside
the flaps resurfaced with full-thickness skin transplants. Interphalangeal
joint fixed in extension position with two needles para-articularly
a
b
Fig. 29.15  First finger metacarpophalangeal joint medial scar contrac-
ture removal with one pair of adipose scar trapezoid flaps. (a) Pre-­
surgery, planning of reconstruction with one pair of flaps; (b)
counter-transposed flaps released the contracture of metacarpophalan-
geal joint; simultaneously, adduction contracture of the fifth finger is
eliminated by a similar technique
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285
Conclusion
Scars, causing contracture, cover the entire finger flexion
surface, and form the fold, both sheets of which are scar
(medial contracture). The contracted fold’s sheets spread
from the fold crest to the joint rotation axis, causing
medial flexion contracture of one PIP joint or the entire
finger. The fold’s sheets have a surface deficit in length,
trapezoid form (contracture cause), and surplus in width.
Scar sheets are dissected by Y-incisions, the flexion
surface is freed from scars by extension under the sur-
geon’s finger pressure. Trapezoid flaps cover the PIP joint
first. Wounds between flaps are covered with full-thick-
ness skin grafts. Fingers extension position stays up to
skin graft stabilization. Follow-up results depend on the
condition of the fingers. Use of an external device for PIP
joint extension combined with mobilization until fully
unrestricted passive movements in the joint are restored is
absolutely necessary before extensor tendons plasty.
Reference
1. Grishkevich VM. Flexion contractures of fingers: contracture elimi-
nation with trapeze-flap plasty. Burns. 2011;37:126–33.
Reference

287
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Surgical Treatment of Postburn
Boutonniere Deformity
Introduction
Deep burns of the dorsal hand can injure tendon extension
apparatus over the proximal interphalangeal (PIP) joint. The
defect of the central slip and retinaculum cause displacement
of the lateral bands below the joint rotation axis. As a result,
the finger (PIP joint) is flexed up to 90° and the extremity
becomes disabled. The literature is limited regarding con-
tracture anatomy and evaluation of the efficiency of the
existing treatment methods. The problem becomes great if
the PIP joint loses its passive extension, if there was intraar-
ticular damage, if the dorsal hand lost soft tissue, and if thin
scars were connected with osseous phalanges. Existing pub-
lications do not have answers for these problems. In our
institute there were numerous possibilities to explore the
anatomy of the contracture, to test methods of tendon plasty,
and to develop techniques of passive PIP movement restora-
tion and tendon plasty and techniques of adipose-cutaneous
layer restoration. Good results have been achieved. All these
aspects are presented in this chapter.
Anatomy of Postburn Boutonniere
Deformity [1, 2]
All fingers are fixed 90° at the PIP joints without active
extension (Fig. 30.1a). The passive movements of the PIP
joints are sharply restricted (less than 45°). Many patients
have a soft-tissue defect of the dorsum of the hand, and joint
capsule and cartilage of phalanges are often injured. We have
found that postburn boutonniere deformity has diverse forms.
Anatomical Features (Figs. 30.1 and 30.2)
Postburn boutonniere deformities are divided into two groups:
(a) Those with soft tissue preserved on the dorsal surface of
the fingers and hand where the scars are not tightly con-
nected with the bones and joint cartilages of the PIP joint
(Fig. 30.1b, c).
(b) Those with a soft tissue defect and damaged PIP joint cap-
sule (Figs. 30.1a and 30.2d). The scars are thin, not folded,
and strongly (tightly) connected with the bones and carti-
lages of the PIP joint. As a result of that, when a finger is
passively extended, a transverse scar depression appears over
the PIP joint. (Figs. 30.2b and 30.3a). Because the central
slip and retinaculum of the extensor, apparatus are damaged
over the PIP joint (Fig. 30.2c), the lateral bands are displaced
to palmar, below the PIP joint rotation axis (Fig. 30.2c–e).
Functional Features (Figs. 30.1, 30.2 and 30.3)
Functionally, the patients are also divided into two groups:
(a) Those in whom the range of passive movements of the
PIP joint is normal or more than 45°, and who were able
to achieve a complete unbending of the PIP joint and
80–90° of range of passive movement.
30

288
a
b
c
Fig. 30.1  Anatomy of boutonniere deformity. (a) View of hands after deep burns; (b) soft tissue of fingers and over the PIP joint preserved; mod-
erate finger’s flexion; (c) PIP joint capsule preserved; central slip’s defect, lateral bands displaced below the PIP joint rotation axis
a
b
Fig. 30.2  Anatomy of
boutonniere deformity. (a)
Severe PIP joint flexed, soft
tissue of fingers hypotrophy,
scars thin; (b) joint capsule of
PIP joint, phalanges cartilage
and suspension apparatus
injured
a
b
d
e
c
Fig. 30.3  Clinical signs of severe PIP joint injury. (a) Transverse scar
depression appears above manually extended PIP joint (b) while
under distraction with apparatus, a depression appears above PIP
joints; (c, d) displacement of the lateral bands below the PIP joint
rotation axis; (e) scheme of the lateral bands displacement below the
joint rotation axis
(b) Those with passive movement of the PIP joints of less
than 45° and in whom it is necessary to use a distraction
apparatus before tendon plasty.
Postburn boutonniere deformity is often aggravated by
contractures of the other hand joints: Syndactyly, extension
contracture of the carpophalangeal joints, flexed contracture
of the fingers caused by the scars located on the palmar sur-
face, and damage of the PIP joints.
These anatomical and functional peculiarities are crucial
to therapeutic tactics and the sequence and volume of surgi-
cal interventions. The tendon plasty of the extensor appara-
tus of the joints is successful if the combined contractures of
the hand joints are eliminated by initial surgery, passive PIP
joint movements are restored to 80–90°, and, along with the
tendon plasty, the defect of the soft tissue on the dorsum of
the fingers and on the hand as a whole is eliminated with a
groin flap.
30  Surgical Treatment of Postburn Boutonniere Deformity

289
Preliminary Distraction and Passive
Movement Restoration of the PIP Joints
The essence of these operations consists of efforts to: (1)
Restore passive movement in the PIP joints before the ten-
don plasty; (2) eliminate flexion contracture caused by the
scar on the palmar surface of the fingers with trapeze-shaped
flaps; and (3) reconstruction of the extensor tendons. If pas-
sive movement in the PIP joint is severely restricted after
contracture release (less than 45 °), then it is caused by cap-
sular damage and joint cartilage changes, and is an indica-
tion for the distraction apparatus use. One such device
consists of two arcs with cuts at the ends connected with two
bars (Fig. 30.4a); the screw units connect the apparatus com-
ponents and make it possible to move the distal arc, creating
distraction. Apparatus application is shown in Fig. 30.4b. By
releasing the units, the distal arc is freed from the bars to
enable the patient to practice passive movements on his or
her own as part of distraction (Fig.  30.5a–c). It takes
4–6 weeks to achieve full extension of the finger, and it takes
yet another month to continue the passive movement train-
ing. Only then is tendon plasty performed.
a
b
Fig. 30.4  (a) The distraction
apparatus and (b) its
utilization
a
b
c
d
Fig. 30.5  Restoration of PIP
joints’ passive movements.
(a) Apparatus on fingers; (b)
distance between phalanges,
forming the PIP joint,
increased (in comparison with
second finger); (c, d)
periodically distraction is
released and finger
movements continued
manually after that, the
distraction is continued until
the passive movements of PIP
joints become easy and full
range
Preliminary Distraction and Passive Movement Restoration of the PIP Joints

290
The First Stage of Tendon Extension
Apparatus Restoration
Tendon transplant preparation (Fig. 30.6): Our method allows
both the return of the lateral bands to their position—above the
PIP joint rotation axis—and restoration of continuity of the cen-
tral slip. We apply a 12-cm-long tendon transplant of the pal-
maris longus muscle and the flexor carpi radialis muscle
(Fig. 30.6a–c).
Lateral bands and central slip mobilization (Fig. 30.7):
With an incision along the central line of the fingers’ dorsum,
the extensor apparatus is opened (Fig. 30.7a, b). The lateral
bands are fixed with threads (Fig. 30.7b), the retinaculum is
isolated and dissected (Fig. 30.7c); lateral bands displace the
upper joint rotation axis (Fig. 30.7d); and the stump of the
central slip is separated from the scars, the defect of which
amounts to 2–3 cm (Fig. 30.7e).
a
b
c
d
Fig. 30.6  Tendon transplants
preparation. (a) Palmaris
longus and flexor carpi
radialis muscles exposed; (b)
tendon of palmaris longus is
split on two transplants; (c)
one transplant is separated
from carpi radialis muscle;
(d) three transplants, nearly
12 cm each, ready for use
a
b
d
e
c
Fig. 30.7  Mobilization of lateral bands and stump of central slip. (a)
Before operation: boutonniere deformity of the second, fourth, and fifth
fingers of the left hand; (b) PIP joint’s tendon structures opened, lateral
bands taken on threads; (c) lateral band mobilization and elevation by
retinaculum dissection; (d) central slip’s stump mobilization; (e) lateral
bands elevated by upper joint rotation axis
30  Surgical Treatment of Postburn Boutonniere Deformity

291
Our Technique of Tendon Extension
Apparatus Restoration (Figs. 30.8, 30.9, 30.10,
30.11, 30.12, 30.13 and 30.14) [1]
The eight-shaped tendon plasty of the lateral bends is carried
out in line with Peacock’s method, but one end of the trans-
plant is left 3–4 cm longer than the other tendon’s end. The
crossing of the ends over the middle phalanges is done as
shown in Fig. 30.8a. The shorter end is sutured to the lateral
bands and the triangular ligament over the distal (nail)
­phalanges (Fig. 30.8b). The longer end is rotated proximally
and is sutured to the central slip stump over the proximal
phalange (Fig. 30.8c). The finger is fully unbent during the
plasty and 1 month after the operation. The tendons in all
intersections are connected using absorbable threads and are
covered by groin flap. Simultaneously, tendon plasty is
applied to all the damaged fingers, from the second to the
fifth on one hand. After that, the local scars cover transplants
or the whole wound is covered with a groin flap (Figs. 30.8d
and 30.9b–d). The scheme of our tendon plasty technique is
shown in Fig. 30.8e. Results are seen in Fig. 30.8f, g.
At the second stage, 3–4 weeks later, the stem of the flap
is intersected, the fingers are separated by pairs, and so is the
flap; interdigital commissure is restored with trapezoid
adipose-­cutaneous flap prepared from the interdigital fossa
(Fig. 30.12b). At the third stage (Fig. 30.9f) after another
3–4 weeks, the rest of the fingers are separated, interphalan-
geal commissures are formed with a trapezoid flap prepared
from the interdigital fossa’s skin, and small wounds on the
lateral surfaces of proximal phalanges are skin-grafted.
The surplus of subcutaneous fat is excised. One month
after the operation, active PIP joint movements are allowed,
followed 3 months later by light physical exercises, and stan-
dard physical exercises in 6  months’ time. Results of the
operation are seen in Fig. 30.9f, g.
If soft tissue on the fingers’ dorsal surface has been pre-
served, the wound of every finger is covered (after tendon
plasty) with local adipose-scar flaps (Fig. 30.10).
Boutonniere deformity of the fifth finger is a challenge for
surgeons. Reconstruction is often finished by PIP joint
artrodesis or amputation. Using the new technique presented
here, the fifth finger’s extension apparatus and its function
can be restored completely or significantly improved, and the
finger can be saved (Fig. 30.11).
Results of a severely injured dorsal hand reconstruction
are shown in Figs. 30.12, 30.13 and 30.14.
a
b
c
d
f
g
e
Fig. 30.8  Our tendon plasty technique. (a) Lateral bands elevated with
Peacock’s technique; (b) after ends crossing over nail phalange, the short
end is sutured with triangular ligaments; (c) the long stump is directed
proximally and connected with central slip; (d) flap borders of neighbor-
ing fingers are sutured together, and large wounds are covered with a
groin flap; (e, f) 10 months after surgery; (g) scheme of operation
Our Technique of Tendon Extension Apparatus Restoration

292
a
b
e
f
g
c
d
Fig. 30.9  Surgical treatment of boutonniere deformity of the left hand
with the syndactyly and soft-tissue defect (the third stage). (a) Before
the operation (left hand): boutonniere deformity of the second, fourth,
and fifth fingers; (b) boundaries of scars excision and groin flap; (c)
after tendon plasty of the second, fourth, and fifth fingers is performed,
the fingers are sutured together and scars are removed. (c, d) Second
stage: wound covered with the groin flap; (e) fingers separated by pairs
(second stage). (f, g) Third stage: the fingers are separated and commis-
sures restored (2 years after operation)
a
b
c
d
Fig. 30.10  Results of
surgical treatment of postburn
boutonniere deformity and
dorsal syndactyly; tendon
transplants covered with local
flaps. Case 1: (a, b) right
hand, second, third, and
fourth fingers, using the local
scar flaps for the wound and
tendon transplant covering
and trapezoid flaps of
interdigital fossa for dorsal
syndactyly elimination. Case
2: (c, d) second and fourth
fingers’ extension apparatus
restored (3 weeks after
reconstruction)
30  Surgical Treatment of Postburn Boutonniere Deformity

293
a
b
c
d
Fig. 30.11  Severe
boutonniere deformity of fifth
finger treated (authors’
technique) and tendon
transplants coverage with
local adipose-scar flaps. (a)
Pre-surgery view; first, the
hand dorsal surface was
resurfaced, including the fifth
finger, with skin transplants;
(b) tendon transplant covered
with local adipose-scar flaps
(7 days after surgery), flaps
alive; (c, d) 1 year after
reconstruction, complete PIP
joint’s function restored.
a
b
d
e
c
Fig. 30.12  Results of boutonniere deformity surgical treatment. (a)
Before the operation, right hand, tendon contractures of the second
through fifth fingers and dorsal hand soft-tissue defect; damaged PIP
joint capsules, and restricted movements (less than 45°). (b) Passive
PIP joint movements restored with distractors; tendon extensor appa-
ratus restored with original technique, dorsal hand and connected fin-
gers covered with groin flap. Next stages of reconstruction: the hand
is separated from the trunk, the fingers are separated by pairs, and the
interdigital commissure is restored with the fossa’s trapezoid flap;
(c–e) 2 years after reconstruction: good active movements in interpha-
langeal joints are restored and soft tissue defect of dorsal hand is
eliminated
Our Technique of Tendon Extension Apparatus Restoration

294
a
b
Fig. 30.13  (a, b) Severe
multiple boutonniere
deformity elimination with
the PIP joints distraction,
authors’ tendon plasty
technique, and soft-tissue
defect restoration with the
groin flap
a
b
Fig. 30.14  (a, b) Elimination
of severe multiple boutonniere
deformity with PIP joint
distraction, the authors’
tendon plasty technique, and
soft-tissue defect restoration
with the groin flap
30  Surgical Treatment of Postburn Boutonniere Deformity

295
Conclusion
Boutonniere deformity treatment with our technique is
indicated for all four fingers and for all grades of contrac-
ture severity and soft tissue defects on the dorsal hand.
Finger distraction, tendon plasty, and soft tissue on dor-
sum hand restoration achieve good function and cosmetic
outcomes. Both arthrodesis and amputation of the bou-
tonniere deformed fingers should be avoided.
References
1. Grishkevich V. Postburn boutonniere deformity surgical treatment.
Washington, DC: Plastic Surgical Forum; 1992. p. 81–2.
2. Grishkevich VM. Surgical treatment of postburn boutonniere defor-
mity. Plast Reconstr Surg. 1996;97:126–32.
References

297
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Burned Perineum: Anatomy of Medial
Contracture and Reconstruction
with Trapezoid Adipose-Scar Flaps
Introduction
Deep burns of the perineum result in contractures that
restrict smooth motion and make personal hygiene difficult.
Two basic contracture types exist: (1) medial, in which
scars form the fold of the perineum; and (2) total, charac-
terized by perineum obliteration. The inelastic scar fold
causing tightness and restricting movement is more easily
observed with abducted thighs. The transverse scar fold
forms below or above the genitals. Scar folds, protruding
distally, obliterate the perineum. Scars of the perineum
make walking and personal hygiene difficult and this indi-
cates surgery. Total contracture, or perineum obliteration,
does not have a transverse fold. The fold is scar surface
surplus, allowing medial contracture elimination with local
trapezoid flaps.
Anatomy of Perineal Medial Contracture
Anatomy
Postburn scars of the perineum grow distally and form a fold
on the surfaces of the inner thighs (Figs. 31.1 and 31.2). The
fold, growing transversely below or above genitalia, prohib-
its abduction of the the thighs and walking. The fold is a new
anatomic structure, with scar surface surplus determining
possibilities for the use of local-flap techniques. The length
and the width of the fold vary from case to case and depend
on many factors (contracture severity, burn treatment meth-
ods, age, etc.). Both sheets of the fold are scars (the main
sign of medial contracture). Scar surface surplus is usually
sufficient for contracture elimination with the local flaps of
the fold sheets having surface deficit in length.
31
Fig. 31.1  Anatomy of medial perineal contracture. Moderate contrac-
ture of the perineum caused by a crescent scar fold located below geni-
talia; SC scars; Cr crest of the fold, both sheets (FM) of the fold are
scars, which have a scar surface deficit in the length (contracture cause)
and surface surplus in width allowing contracture treatment with local
tissue

298
Scar Surface Deficit as Contracture Cause
Together with increasing surface (surplus) in width, scar
contraction continues. This causes shortening of the length
of the scar surface, which in turn causes surface deficit in
length between the inner surfaces of the thighs. As a result of
scar contraction, the width of the scars between the thighs
increases. This means that contracture treatment should be
accomplished by scar release and scar surface deficit com-
pensation. The scar fold has surface deficit in length (con-
tracture cause) and surface surplus in width (Figs. 31.1 and
31.2). The deficit in surface length causes contracture. To
plan and prepare the adipose-scar flaps effectively, it is
important to know the form, size, and distribution of this
deficit. The deficit can be determined using the following
method: First, the incision passes along the fold crest (Cr)
and separates the sheets. The sheets are then cross-cut with a
Y-incision until complete scar tension release is achieved
(Figs. 31.3a, b and 31.4b, c). For the best divergence of the
a
b
c
d
Fig. 31.3  Elimination of moderate medial contracture of the perineum
with two pairs of trapezoid adipose-scar flaps. (a) Anatomy of medial
contracture of perineum: Contracture caused with scars which form a
fold below genitalia: both sheets of which are scars (FM) Cr crest of
the fold below genitalia. (b) Two pairs of adipose-scar trapezoid flaps
(Fp) planned, one pair on the thigh away from the center of the
perineum; radial lines for trapezoid flap formation; (c) wound anatomy:
Fp flap; DW donor wound; Dt deficit of contracted scars surface; adi-
pose-scar trapezoid flaps mobilized (Fp); scar surface deficit (Dt) has
trapezoid form; (d) counter-transposed flaps; (Fp) flap scar surface defi-
cit compensated and contracture eliminated
Fig. 31.2  Medial contracture is caused by the crescent scar fold
located above genitalia; FM scar sheets of the fold; Cr crest of the fold
31  Burned Perineum: Anatomy of Medial Contracture and Reconstruction with Trapezoid Adipose-Scar Flaps

299
wound edges, the ends of the Y-incision are lengthened. The
thighs move further apart, the edges of the wounds widen,
and the tension disappears. The lowered perineum returns to
its normal position. Thus, as a rule, irrespective of the num-
ber of cross-incisions, trapezoid-shaped wounds and
adipose-­scar trapezoid flaps are formed on the inner thighs in
the area of each dissected sheet. This suggests that the best
reconstructive perineum procedure is the one that uses the
flaps that match the form (shape) of the wound, and the pro-
cedure is to be called the trapezoid-flap plasty method.
a
b
c
d
Fig. 31.4  Elimination of moderate-to-severe perineum contracture
with four pairs of trapezoid flaps. (a) Pre-operative view: crescent scar
fold is located below genitalia; (b) surgery planning: radial lines on
medial thighs for converting sheets into trapezoid flaps; B—FM—flex-
ion medial surface, scar sheet of the fold; Cr—crest of the fold; incision
along the fold crest and radial Y-cross-incisions of the fold; mobilized
four pairs of trapezoid adipose-scar flaps; (c) flaps mobilized, space
between the flaps (FP) is trapezoid scar surface deficit (Dt); (d) wound
covered, scar surface deficit compensated and contracture eliminated
by counter-­transposition of the trapezoid flaps; 1 week after surgery
Anatomy of Perineal Medial Contracture

300
Elimination of Perineal Medial Contractures
with Trapeze-Flap Plasty [1]
Specific surgical features depend on contracture severity and
the location of the transverse fold (i.e., below or above
genitalia).
Elimination of Mild-to-Moderate Contracture
with Two Pairs of Adipose-Scar Trapezoid Flaps
(Fig. 31.3)
Planning consists of drawing the lines of radial cross-­incisions
of the fold on both inner thighs and the longitudinal line on
the crest of the fold (Fig. 31.3a). The middle portion of the
contracture on the perineum itself and the pubic zone are not
included in plasty. The interval between cross-­incisions is
about 4 cm, and it determines the width of the flap points. The
base of each flap is 1.5 times wider than its ends.
The first incision on top of the fold on both thighs sepa-
rates one sheet from another. Then, the radial cross-incisions
are performed, which form flaps. The wider the fold, the lon-
ger the flaps. The longer the fold, the more flap pairs are
prepared. For the best divergence of the wound edges and
contracture release, the ends of each radial incision are
Y-shaped. Better results are achieved if contracture is
released with some over-correction. After trapezoid adipose-­
scar flaps mobilization, two trapezoid wounds appear,
reflecting the form and size of the scar tissue deficit, which is
the true cause of the contracture (Figs.  31.3b and 31.4d).
Both sheets of the fold are scar surface surplus, allowing
contracture treatment with local tissue.
Then, applying moderate tension, mobilized adipose-scar
flaps are transposed toward each other so the apex of one flap
reaches the base of the opposite flap, covering the narrowed
wound (Fig. 31.3c). The tension of the adipose-scar flap is harm-
less, as flap scars are not distensible and the circulation in the
underlying blood vessels of the hypodermic layer is preserved.
Perineum Reconstruction with Four Pairs
of Trapezoid Adipose-Scar Flaps (Fig. 31.4)
Planning and flap mobilization are typical (Fig.  31.4b).
Moderate-to-severe contracture is caused by the presence of
a longer semilunar fold, with a more excessive scar surface
deficit (Fig. 31.4c). Scar sheets of the fold on all its borders
are converted into adipose-scar trapezoid flaps, two or three
pairs on each thigh. The central perineal zone is not included
in plasty (Fig. 31.4c). Mobilized flaps and wounds accept the
trapezoid form (Fig.  31.4c). The surfaces of counter-­
transposed flaps are sufficient for scar surface deficit com-
pensation
and
complete
elimination
of
contracture
(Fig. 31.4d).
31  Burned Perineum: Anatomy of Medial Contracture and Reconstruction with Trapezoid Adipose-Scar Flaps

301
a
b
Fig. 31.5  Surgical treatment of the perineum contracture caused by scars
covering a wide region and forming a semilunar fold located above geni-
talia. (a) Anatomy of contracture: FM flexion medial surfaces; FP flaps;
Cr crest of the fold; pre-operative view: crescent scar fold is located on the
front of genitalia; planning: radial Y-lines for contracture release; both
sheets of the fold are scars, converted into trapezoid flaps with radial inci-
sions of the fold; (b) results (5 days after surgery): contracture completely
eliminated with counter-transposed adipose-scar trapezoid flaps
Treatment of the Medial Perineal Contracture
Caused by the Fold Located Above Genitalia
(Fig. 31.5)
Scars covering the perineum and abdomen wall can form a
fold located above the genitalia. Reconstruction is per-
formed using trapezoid-flap plasty. Several pairs of flaps
are planned on each thigh; the central part of the fold
remains in situ (Fig. 31.5a) and disappears after contrac-
ture release. Mobilized adipose-scar flaps are oppositely
transposed and compensate for the scar surface deficit,
fully cover the wound, eliminate the contracture, and sig-
nificantly improve the appearance of the deformed area
(Fig. 31.5b).
Elimination of Perineal Medial Contractures with Trapezoid-Flap Plasty

302
Conclusion
Counter-transposition of trapezoid adipose-scar flaps
achieves full elimination of the perineal contracture. The
fold in the middle of the perineum and above the genital
area and abduction contracture disappears without inter-
vention on the perineum itself and the pubic zone. Because
of the transposition of the flaps, the zone of maximum
tension, i.e., the top of the contracture fold, is elongated
by 2–3 times. It is equal to the sum of widths of the mid-
dle part of all flaps minus the sum of widths of the points
of the flaps of one sheet of a fold. The flaps have no sharp
angles, their apices and bases are wide, and they do not
undergo rotation. The mobilized adipose-scar flaps are
easily transposed to the opposite side of the wound. Well-
preserved blood circulation prevents complications (total
or partial flap loss), and the flap surface does not contract;
therefore, contracture does not recur.
References
1. Grishkevich VM. Burned perineum reconstruction: a new approach.
J Burn Care Res. 2009;30(4):620.
31  Burned Perineum: Anatomy of Medial Contracture and Reconstruction with Trapezoid Adipose-Scar Flaps

303
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Postburn Perineum Obliteration:
Elimination of Perineal, Inguinal,
and Perianal Contractures
with the Groin Flap
Anatomy of Total Perineum Contracture
Deep burns of the perineum result in perineal obliteration,
severe hip adduction contracture, and perineum deformation,
which restrict the hip’s normal motion. These burns also
make personal hygiene difficult (Fig. 32.1). Perineum oblit-
eration (also called total perineal contracture) is often com-
bined with genitalia injury and inguinal and perianal
contractures. Elimination of such a complex perineal con-
tracture is a challenge for surgeons.
Total perineal contracture (perineal obliteration) forms
without a fold; therefore, the local flap technique cannot be
used. The common reconstructive method consists of scar
dissection on the thigh and skin grafting. Because thighs are
positioned in adduction when at rest, skin transplants in the
perineal region usually shrink, and contracture recurs.
Perineal contracture is released using Z-plasty. However, the
perineal obliteration, inguinal, and anal orifice contractures
can be more successfully eliminated with a pedicle groin flap
(Fig. 32.2).
32
Fig. 32.1  Perineum obliteration or total perineal contracture
Fig. 32.2  Groin flap planning

304
Surgical Technique of Total Perineum
Contracture Treatment
The groin flap boundaries are shown in Fig. 32.3 [1]. One-­
third of the flap’s width is located below the inguinal liga-
ment; two-thirds of the width is located above the inguinal
ligament. The flap’s base is located 4 cm laterally from the
femoral artery. The flap extends beyond the anterosuperior
iliac spine. Such groin flap design, with the flap’s length of
20 cm and width of 10 cm, does not pose danger. The flap’s
length equals the distance from the flap’s base to the rear
border of the perineal contracted scars, which needs to be
released. The flap’s width or surface is sufficient to compen-
sate for the perineal scar deficit.
First, the groin flap is elevated, including the skin and full
subcutaneous fat layer, with fascia superficial and superficial
circumflex iliac vessels. The donor wound is primarily closed.
The flap has a steady axial blood circulation. For adequate
perineum reconstruction, it is necessary to prepare a wide groin
flap. In such cases, it is appropriate to cover a part of the donor
wound with a superficial inferior epigastric artery flap that has
a common base with the groin flap (bilobe flap, Fig. 32.3). The
donor wound of the epigastric flap is primarily closed. On clo-
sure of both donor wounds, the scars are dissected along the
inguinal fold and medial perineal line. The scars around the
anal orifice are excised; the rectum is mobilized at a 3-cm
extension. After the thighs’ abduction and complete contrac-
ture release, the groin flap is placed over the wound. The cen-
tral flap zone is fixed with sutures to fascia along the inguinal
fold and the middle of the perineum. The rectum end, fixed
with sutures, is led through the flap’s end orifice and sutured
with the flap skin. The flap borders are sutured with the scar
wound borders. The under-flap space is drained. A silicone
tube (three small tubes in this case, Fig. 32.3d, e) is covered
with antibiotic gauze and inserted in the rectum for 3–5 days. A
good result is shown in Fig. 32.3f–h.
In case of perineal and bilateral inguinal fold obliteration,
two bilobe flaps are used (Fig. 32.4). The “dog-ear” usually
appears near the flap’s base and is removed several months
later. The “dog-ear” has a surface surplus that is used for
adjacent
deformed
region
correction
or
genitalia
reconstruction.
a
e
f
i
j
k
g
h
b
c
d
Fig. 32.3  Perineal, inguinal, and anal contracture reconstruction with
bilobe groin flap. (a, b) Pre-surgery perineum obliteration (view poste-
rior and anterior); (c) bilobe (groin and hypogastric) flap planning; (d,
e) end of surgery: groin flap covered inguinal, perineal, and anal
regions, three silicone tubes inserted in rectum; epigastric inferior
donor wound primarily closed, part of groin flap donor wound covered
with epigastric inferior flap, “dog-ear” at flap base; (f) 3 weeks after
operation; (g–i) 5 years after reconstruction: all three contractures (per-
ineal, inguinal, and anal) eliminated in full; (j) view of donor site; (k)
perineum reconstruction with groin flap (scheme)
32  Postburn Perineum Obliteration: Elimination of Perineal, Inguinal, and Perianal Contractures with the Groin Flap

305
a
d
b
c
Fig. 32.4  Obliterated
perineum and bilateral
inguinal contracture
elimination with two bilobe
(groin and inferior epigastric)
flaps. (a) Pre-surgery; (b)
boundaries of two bilobe flaps
depicted; (c) 2 weeks after
reconstruction: inguinal and
perineal contractures
eliminated, next treatment
stage directed to genitalia
reconstruction; (d) scheme
plasty with two bilobe flaps
Surgical Technique of Total Perineum Contracture Treatment

306
Conclusion
Perineal, inguinal, and perianal contractures are elimi-
nated using the groin flap. Groin flaps are alive; there is
no tissue necrosis, flap loss, or other postoperative com-
plications. The flaps do not shrink, their surface does not
decrease, there is no contracture recurrence, and the flap’s
skin preserves its quality (elasticity, color, and texture).
The full thigh abduction (approximately 80°) and hip
joints’ range of motion are achieved. The level flap sur-
face and full hip motion allow for easy personal hygiene.
The anal orifice opened freely during defecation. There
was no skin inflammation around the anus. The donor
place deformity is esthetically acceptable. In children, the
groin flap continues to grow; this prevents contracture
recurrence.
References
1. Grishkevich VM. Postburn perineal obliteration: elimination of per-
ineal, inguinal, and perianal contractures with the groin flap. J Burn
Care Res. 2010;31:786–90.
32  Postburn Perineum Obliteration: Elimination of Perineal, Inguinal, and Perianal Contractures with the Groin Flap

307
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Knee Edge Scar Flexion Contractures:
Anatomy and Treatment
Introduction
Specific anatomical features of knee flexion contractures are
the result of burns located on the flexion lateral (FL) joint
surface (medial or lateral), flexion medial (FM) surface (pop-
liteal area), or all three surfaces (both lateral and medial)
together. Corresponding with scar location, three anatomical
contracture types form: edge (lateral and medial), medial,
and total. An edge contracture has a fold that is a surface
surplus of scars and skin. The cause of the contracture is a
scar surface deficit of a trapezoidal form. We proved that the
best-matched flap is trapezoid-shaped and taken from the
popliteal fossa. The tissue surplus is sufficient for complete
contracture using trapeze-flap plasty without skin grafts and
triangular flaps.
Functional Zones of the Knee Joint Surface
Before surgery, the knee joint surface is divided into a flex-
ion surface (F) and extension surface (E); the line between
them passes along the joint rotation axis level (“+”)
(Fig.  33.1). The joint’s flexion surface is divided by the
joint’s surface curvature (edge of popliteal fossa) into the FL
flexion lateral and FM flexion medial surface. Burns and
scars, injuring the lateral knee flexion surface (FL), cause the
edge flexion contracture; scars located on the FM surface
(popliteal fossa) cause a knee medial flexion contracture.
33

308
a
b
d
e
c
Fig. 33.1  Function zones of
the knee joint’s surface. Case
1: (a, b) knee joint zone
functionally is divided into
flexion (F) and extension (E)
surfaces; the boundary
between them is the joint
rotation axis (“+”); the flexion
surface is divided by
curvature on flexion lateral
(FL) and flexion medial (FM,
popliteal fossa); the line
between them and the crest of
the fold passes along the edge
of popliteal fossa. Case 2:
anatomy of severe knee edge
flexion contracture (right
knee). (c): Lateral view: E
extension surface; “+” joint
rotation axis; FL flexion
lateral surface of joint and all
extremity lateral surface
covered with rough scars,
hypotrophy of leg and foot
and deformation; big fold
(Fd), lateral sheet which is
made up of scars and
continuation of the FL
surface; (d) posterior view:
crest (Cr) of the fold passes
along the lateral edge of the
popliteal fossa; FL flexion
lateral and FM flexion medial
surfaces and Fd fold; flexion
medial surface (FM) and
medial sheet of the fold are
healthy skin. (e) Medial view:
flexion medial (FM), FL
surfaces and lateral sheet of
the fold are healthy skin
33  Knee Edge Scar Flexion Contractures: Anatomy and Treatment

309
Formation and Anatomy of Knee Edge
Flexion Contracture
Knee edge flexion contracture has four specific anatomical
features and clinical signs (Fig. 33.1c, d):
(a) Burns and scars causing knee edge contracture are
located on the joint flexion lateral (FL) surface.
(b) Contracted scars of the FL surface grow distally,
approaching the thigh and the leg, involve healthy skin
of the popliteal fossa, and thus form a crescent fold along
the popliteal fossa edge.
(c) The fold consists of scars on the lateral sheet (continua-
tion of scars of the joint FL surface), and the medial
sheet that is healthy skin and part of the FM surface.
(d) The fold’s crest (Cr) is the edge of the scars.
These four anatomical features determined the name of
this type: edge. Both sheets of the fold are new anatomical
structures, and the surface surplus of scars and skin, the tis-
sue of which is used with FM tissue (popliteal fossa) for
knee edge flexion contracture elimination with local trape-
zoid flaps.
The fold’s length and its protrusion vary from case to
case, depending on the contracture severity. Contracted
scars spread from the fold’s crest to the joint rotation axis;
scars located in the two segments (thigh and leg), forming
the joint flexion contracture, have the scar surface deficit,
which is the real cause of the contracture (Figs.  33.2c,
33.3b, and 33.4c).
a
b
c
d
Fig. 33.2  Scar surface deficit is the cause of the contracture. (a, b)
Contracture caused by the scar on the joint flexion lateral (FL) surface;
scars spread to the joint rotation axis (“+”); E—joint extension surface
does not participate in contracture formation; small fold and lateral
sheet of the fold; FM—popliteal fossa is healthy skin and the donor site;
planning reconstruction with one popliteal trapezoid flap; (c) contracted
scars dissected with a Y-incision from the fold crest to the joint rotation
axis, a trapezoid wound appeared, reflecting Dt scar surface deficit; F
trapezoid knee flap; E extension surface; “+” joint rotation axis; FL
flexion lateral surface; FP flap; (d) for complete contracture release, a
trapezoid adipose-cutaneous flap is mobilized in popliteal fossa and
scar surface deficit is compensated (one-flap-trapeze-plasty)
Formation and Anatomy of Knee Edge Flexion Contracture

310
a
b
c
d
Fig. 33.4  Knee edge contracture treatment in case of scar ulceration.
(a, b) Pre-surgery: ulcerous scars along fold’s crest; FL flexion lateral,
FM flexion medial surface; E extension surface; “+” joint rotation axis;
planning trapezoid flap and incision of scars; (c) scar excised, a
Y-shaped scar incision; a trapezoid wound/deficit (D) appeared; donor
wound (DW); trapezoid adipose-cutaneous flap (FP) mobilized; (d)
contracture eliminated by scar surface deficit compensation with one
adipose-cutaneous trapezoid flap, donor wounds primarily closed
a
b
d
f
e
c
Fig. 33.3  Mild-to-moderate knee edge contracture treatment with one
adipose-cutaneous trapezoid flap. Case 1: (a) pre-surgery: contracture
anatomy and scar surface deficit: scars on FL flexion lateral surface;
FM popliteal fossa or flexion medial surface (donor site) is healthy skin;
FP flap planning; E joint extension surface, “+” joint rotation axis; (b)
after FL contracted scars dissection with a Y-shaped incision, a trape-
zoid wound (Dt scar surface deficit) appeared; Fp flap mobilized; (c, d)
flap compensated scar surface deficit and contracture released. Case 2:
(e, f) edge knee contracture elimination with an adipose-cutaneous flap;
strip of scars excised
33  Knee Edge Scar Flexion Contractures: Anatomy and Treatment

311
Scar Surface Deficit as Edge Contracture
Cause
The knee edge contracture is caused only by the scar of the
FL surface and scar sheet of the fold in which there is a sur-
face deficit in length between the thigh and leg, which
spreads from the fold’s crest to the joint rotation axis
(Fig. 33.2). The form and size of the scar’s surface deficiency
(the reason for contracture) must be determined first. The
form and size of the scar surface deficiency is estimated
using the following steps: According to lines, the scar sheet
is separated from healthy skin of the FM surface with an
incision along the fold’s crest; then, with a perpendicular
incision, scars are dissected with a Y-incision from the fold’s
crest to the joint’s rotation axis level, where the incision’s
end is split 45°, forming a 90°angle. Split incision separates
contracted scars of the FL surface from the joint extension
tissue—(E). After joint extension, a trapezoid wound
appears, which reflects, as rule, the real scar surface defi-
ciency. The wound shape suggests that a flap should have a
trapezoid form. Both sheets have a surface surplus in width,
which allows preparation of a trapezoid flap from the healthy
sheet and popliteal fossa (Fig. 33.2c).
Edge Contracture Elimination Techniques [1]
Reconstruction of Mild-To-Moderate
Contracture with One Trapezoid Flap
Planning consists of drawing several lines: one along the fold
crest separating scars from healthy skin; a Y-shaped perpen-
dicular line for scars dissection, with a split end of 45° neces-
sary for complete contracture release and full scar divergence
without incision prolongation beyond the joint rotation axis.
Two lines below the crest line mark the boundaries of the flap
(Fig. 33.3a). The first incision separates the scar sheet from
the healthy skin; then, the scar’s subcutaneous fat layer is dis-
sected with a Y-incision from the fold crest up to the joint
rotation axis. According to the wound size and form, but 30%
wider, the adipose-cutaneous flap is mobilized in the popliteal
area up to the opposite popliteal fossa’s edge, including the
medial fold’s sheet and all subcutaneous fat layers. The
wound’s end flap’s end is nearly 5 cm in length and includes
part of the fold’s crest; the flap’s length equals a distance
among the popliteal fossa’s edges (8–10 cm). The flap’s end
can be incised nearly 2 cm in depth for connecting with the
same form “M” of the wound’s edge (Fig. 33.3c). The flap is
transposed on the wound with tension until the flap’s end
achieves a wound’s end; the angles of the scar sheet cover the
wound beside the flap (Figs. 33.2d and 33.3c, f).
One-Flap Plasty in Case of Fold’s Crest Scars
Ulceration
The scars in the popliteal area often undergo ulceration at the
fold’s crest (Fig. 33.4). Ulcerous scars are excised first; then,
contracted scars are dissected with a Y-shaped incision;
according to the trapezoid wound that appears, a flap is
mobilized then covers the wound; scar surface deficit is com-
pensated, and contracture is fully released (Fig. 33.4b–d).
Edge Contracture Elimination Techniques