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

313
Elimination of Severe Edge Knee Flexion
Contracture by Converting the Long Fold
in Trapezoid Flaps
Severe edge knee contracture is caused by wide scars that
cover the joint flexion lateral (FL) surface and neighboring
regions and form a long fold (Fig. 33.6a, b). Treatment con-
sists of conversion of the fold’s sheet and neighboring skin of
the joint FM surface on all its extents into trapezoid adipose-­
cutaneous and adipose-scar flaps. The main flap includes all
of the popliteal fossa’s adipose-cutaneous layer and covers
the joint flexion lateral surface. The flaps’ surface and neigh-
boring tissue are sufficient for complete scar surface deficit
compensation and contracture elimination (Fig. 33.6e).
a
b
d
e
c
Fig. 33.6  Treatment of severe right knee edge contracture with mul-
tiple trapezoid flaps. (a) Pre-surgery: anatomy of contracture (lateral
view): E extension surface; “+” joint rotation axis; FL joint flexion
lateral surface; Fd fold (lateral scar sheet of the fold), scar covered
the lateral surface of the right lower extremity, forming a long fold
along the popliteal fossa’s edge; scar deformity and hypotrophy of
the foot, ankle, and leg; (b) FL flexion lateral surface, FM flexion
medial surface Cr crest of the fold. Lateral sheet of the fold is scars,
medial sheet and popliteal fossa is healthy skin; C—planning of sev-
eral adipose-­cutaneous flaps from healthy tissue and adipose-scar
flaps from scar tissue for donor wounds covering; (c) after contracted
scar dissection, a trapezoid wound appeared (right of strip), a trape-
zoid adipose-­cutaneous flap elevated; during operation, additional
flaps mobilized from healthy and scar tissues; (d) 2  weeks after
reconstruction: flaps are alive, contracture is released completely by
counter transposition of the trapezoid flaps; (e) follow-up results
(2 years after surgery): complete contracture eliminated, the adipose-
cutaneous flaps became larger
Edge Contracture Elimination Techniques

314
Knee Edge Scar Flexion Contracture
Elimination by Contracted Scars Excision
and Wound Covering with Mobilized Popliteal
Adipose-Cutaneous Whole Layer
In children under 10 years of age, mild knee edge contracture
and scar deformity, caused by scars located on the lateral
knee joint, hip, and leg surfaces, can be removed by scar
excision and primary wound closure (Fig. 33.7) due to good
tissue elasticity and displacement of the adipose-cutaneous
layer. Scars are excised 5–6 cm in width, and the wound is
closed by approaching the wound edges (without mobiliza-
tion). Wound edges are connected with two or three rows of
stitches; deep tissues are approximated with non-absorbable
sutures.
Knee edge contracture release is useful in combination
with scar excision on the leg and thigh (Fig. 33.8); scar exci-
sion in the knee zone and trapeze-flap plasty is accomplished
at first; then, the scars are excised, starting from the flap, and
the wound is primarily closed step-by-step for preventing
venous congestion. The wound edges are approached with an
inner row of non-absorbable sutures.
Knee edge contracture and deformity caused by rough
scars covering the lateral surface of the knee, thigh, and leg
pose a significant cosmetic problem (Figs. 33.9, 33.10, and
33.11). Therefore, the treatment is successful if contracture
release is combined with scar excision. The wound is primar-
ily closed due to the underlying thick soft tissue layer. First,
the contracture is eliminated by scars dissection from the
fold’s crest to the joint rotation axis with a Y-shaped incision.
Then, a suitable trapezoid adipose-cutaneous flap is mobi-
lized and transposed on the trapezoid wound for scar surface
deficit compensation. Starting from the flap’s base, the scar
strip is excised proximally and distally in short steps, and the
wound is primarily closed with an inner row of non-­
absorbable stiches. Elimination of knee edge contractures
with trapeze-flap plasty and simultaneous excision of the
deforming scars on the thigh, knee, and leg restore the joint’s
function and significantly improve the appearance of all
extremities, as shown in Figs. 33.9, 33.10, and 33.11.
a
b
Fig. 33.7  Knee edge contracture in small children treated by con-
tracted scar excision and entire popliteal adipose-cutaneous layer trans-
position on the wound. (a) Pre-surgery; planning; (b) strip of scars
excised 4–6 cm in width; adipose-cutaneous layer of popliteal fossa
transposed on the wound, contracture and deforming scars eliminated
a
c
b
Fig. 33.8  (a–c) Knee edge
contracture treatment by wide
scar excision and contracture
release with popliteal
adipose-cutaneous flap
33  Knee Edge Scar Flexion Contractures: Anatomy and Treatment

315
a
b
Fig. 33.9  Right knee edge scar contracture release with trapeze-flap
plasty and rough scar removal on leg and thigh. (a) Pre-surgery, joint
zones; E—joint extension surface; “+”—joint rotation axis; Y-line
for contracted scars incision up to joint rotation axis; FL—flexion
lateral surface covered with scars; edge of scars along the lateral
edge of fossa where the fold crest is; scars to be excised are marked;
FM—flexion medial surface is heathy skin where popliteal adipose-
cutaneous flap marked; (b) strip of deformed scars excised, con-
tracted scars dissected with a Y-incision up to the joint rotation axis,
flap mobilized and trapezoid wound (scar surface deficit) covered
with a flap; wounds beside the flap are primarily closed, starting from
the flap; flap is alive, scar surface deficit is compensated, contracture
is eliminated with one trapezoid flap, and appearance of recon-
structed zone is improved
a
b
Fig. 33.10  Removal of right knee edge contracture and hypertrophic
scars on the thigh and leg. (a) Pre-surgery, planning of contracture and
deformity elimination; (b) contracture removed with one popliteal
adipose-­cutaneous flap; large zone of scars was excised; wounds pri-
marily closed starting from the flap, simultaneously with scars
excision
a
c
b
Fig. 33.11  Removal of edge contracture and deformity of left knee,
caused with rough scars. (a) Pre-surgery, FL joint flexion lateral scar
surface; FM flexion medial surface is healthy skin; planning three-flap
trapeze-flap plasty and excision rough scars; (b) scars excised on the
leg, contracted scars dissected with a Y-incision to the joint rotation
axis, trapezoid large wound or Dt scar surface deficit appeared; FP pop-
liteal flap mobilized, and DW donor wound appeared; (c) end of opera-
tion: scar on the sigh excised, contracture released with three trapezoid
flaps; main popliteal adipose-cutaneous flap compensated scar surface
deficit, two flaps prepared from scars of joint FL surface for donor
wound covering; appearance of extremity improved and contracture
eliminated
Edge Contracture Elimination Techniques

316
Conclusion
Knee edge flexion contractures are fully eliminated with
trapeze-flap plasty without complications. Depending on
contracture severity, the different number of adipose-
cutaneous and adipose-scar trapezoid flaps is used. Main
donor site is undamaged popliteal fossa and sheets of the
fold. The adipose-­cutaneous popliteal flap surface after
surgery is significantly increased. Follow-up results are
functionally excellent; the knee joint area accepts normal
contours, and the donor site (popliteal fossa) preserves
normal form. In children, the whole popliteal adipose-
cutaneous flap transposed on the wound with tension, is
alive. Simultaneous trapeze-flap plasty with rough scar
excision and primarily wound closure in children elimi-
nates contracture and improves the appearance of the
reconstructed zone.
References
1. Grishkevich VM. Postburn knee flexions contractures: anatomy and
methods of their treatment. Trop Med Surg. 2013;1:147.
org/10.4172/2329-9088.1000147.
33  Knee Edge Scar Flexion Contractures: Anatomy and Treatment

317
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Knee Medial Scar Flexion Contractures
After Burns: Anatomy and Treatment
Introduction
Knee medial contractures form after burns of the knee poste-
rior surface (flexion medial [FM]). The anatomy and treat-
ment of this contracture type is not explored and highlighted
in the literature. When wounds from burns are healing, scars
form a fold that covers the entire popliteal fossa. In the fold’s
sheets is a surface deficit in length (contracture cause) and a
scar surface surplus in width, allowing medial contracture
elimination with local adipose-scar trapezoid flaps. Fold
sheets have a surface deficit in length of a trapezoidal form,
which is the real cause of contracture. These trapezoid obser-
vations enabled us to develop a technique to convert fold
sheets into trapezoid flaps and to eliminate contracture with
a local trapezoid flap. Rough, ulcerous scars should be
excised and wound skin grafted.
Functional Zones and Anatomy of Knee Joint
Flexion Medial Contracture (Fig. 34.1)
Scars that cause knee medial flexion contracture cover the
joint’s FM flexion medial surface or popliteal fossa; the flex-
ion lateral (FL) surface stays undamaged (Fig  34.1b, c).
Scars in the popliteal area form a crescent fold (Fd), the crest
of which is located along the medial line of popliteal fossa;
both sheets of the fold are scarred (FM) and spread from the
fold’s ulcerous crest to the popliteal fossa’s edges (FL)
(Fig. 34.1b, c).
These three anatomical features determine the name for
this type: medial. Both scar sheets of the fold have a surface
deficiency in length (cause of a contracture) and surface sur-
plus in width, which allows treatment of the contracture with
local flaps. The fold can be small and short or may spread to
the thigh and leg. Thus, flexion contracture of the knee joint
has specific anatomical features and signs, shown in
Fig. 34.1. Contracture is caused by a scar surface deficit in
length, the maximal tension is along the fold’s crest; there-
fore, ulcers at first appeared along the fold’s crest.
34

318
a
b
c
Fig. 34.1  Knee joint’s functional zones and medial scar contracture
anatomy. (a) Left knee: the flexion medial (FM) surface (popliteal
fossa) is covered with scars that formed the fold, ulcerous crest (Cr) of
the fold passed along the medial fossa line. (b, c) The fold (Fd) has a
semilunar form, both sheets of the fold are scars and spread from the
fold crest to the edges of the popliteal fossa or flexion lateral surface
(FL); the flexion lateral surface does not participate in contracture for-
mation; symbol “+”—joint rotation axis; E—joint extension surface
34  Knee Medial Scar Flexion Contractures After Burns: Anatomy and Treatment

319
Scar Surface Deficit Is the Cause of the Knee
Medial Contracture (Fig. 34.2)
The sheets of the fold are scars and have a surface deficit in
length, causing joint flexion contracture; maximal tension
(deficit) is at the crest of fold and spreads to the edges of
popliteal fossa. In addition, the fold sheets are new anatomi-
cal structures, a surface surplus that allows the contracture to
be eliminated with local tissue (Figs. 34.2 and 34.3). The
scar surface deficit or contracture cause is estimated in the
following way (Fig. 34.2a–c): The fold sheets are divided
with an incision along the fold’s crest; contracture is released
by a perpendicular Y-shaped incision from the fold crest to
the popliteal fossa edges; the split end of the incision sepa-
a
b
c
d
Fig. 34.2  Scar surface deficit in sheets of the fold and flaps has a
trapezoid form. (a) Before operation: long ulcerous (UL) fold, plan-
ning: three pairs of trapezoid flaps marked. (b) After sheet separation
and cross-cut with Y-shaped incisions, flaps and wounds (distance
among the flaps) accepted trapezoid form; (c) counter flap’s transposi-
tion compensated scar surface deficit and complete contracture elimi-
nated; (d) follow-up results: contracture released, knee appearance
normalized
a
b
d
e
c
Fig. 34.3  Knee severe medial contracture treatment with trapeze-flap
plasty (accepted abbreviation used). (a, b) Before operation, planning
by radial Y-incision; (c) semilunar fold is dissected by radial incisions,
which formed adipose-scar trapezoid flaps mobilized, scar surface defi-
cit (Dt) in both fold’s sheets (the space among trapezoid flaps) has trap-
ezoid form; (d) counter-transposed flap (F) covered most flexion
surface, residual wound/deficit (Dt); (e) 10  days after surgery: flaps
(Fp) and transplants (Tt) are alive and contracture release is complete
Scar Surface Deficit Is the Cause of the Knee Medial Contracture

320
rates scars of the fold’s sheets from the tissue of both flexion
lateral surfaces; therefore, the wound edges of dissected
scars diverge freely, allowing full release of contracture.
After joint extension, as a rule, the trapezoid wound appears
in both scar sheets, which is widest at the fold crest and
spreads, subsiding, to the popliteal fossa edges where the
wound’s end is 4–5  cm wide (Fig.  34.2b). Consequently,
adequate contracture treatment of knee medial contracture
can be performed by means of surface deficiency compensa-
tion with the trapezoid flaps (Fig. 34.2b–d).
Scars in the popliteal area undergo severe tension while
the patient is walking; therefore, the scars tear first in the
maximal tension zone (fold crest), and scars in the popliteal
area often become pathological—rough, thick, red,
keloid—and unfit for plasty (Fig. 34.4). Because of tension,
scars tear, a small wound gradually converts to a chronic
ulcer, and the normal scars become pathological, and
should be excised.
a
b
c
Fig. 34.4  Knee medial contracture treatment by wide flat (without
fold) pathological scars excision through the intermediate layer without
bleeding and skin grafting. (a) Pre-operation: rough ulcerous scars cov-
ering the popliteal area; (b) scars excised through the intermediate
layer, no bleeding, the fat layer uninjured; (c) the wound is covered with
split skin grafts, contracture released, transplants are alive
34  Knee Medial Scar Flexion Contractures After Burns: Anatomy and Treatment

321
Knee Medial Contracture Elimination
Techniques [1]
Reconstruction with Trapeze-Flap Plasty
(Figs. 34.2 and 34.3)
Two procedures have been used. If scars of the fold are pli-
able and thin, the fold sheets’ scars are used for plasty. The
goal is to fully convert the fold’s sheets in the flaps (Fig. 34.2a).
The ulcerous fold’s crest is excised, and the fold’s sheets are
divided along the entire fold’s crest. As the fold has a crescent
form, the Y-shaped incisions from the fold’s crest to the pop-
liteal fossa’s edges convert the sheets in the flaps which, as a
rule, take on a trapezoid form; after knee extension, the
wounds also take on a trapezoid form (Fig. 34.2a).
The flap’s end is nearly 5 cm in width and includes part of
the fold’s crest; the flap base corresponds to the popliteal
fossa’s edge. Scars and full subcutaneous fat layers are
included in the mobilized flap, with a steady blood supply.
Flaps are counter-transposed with tension. The flap’s ends
approach the opposite flap’s base (Fig. 34.2b). Depending on
contracture severity and fold length, one or several pairs of
the flaps are elevated until contracture can be fully released
and the wound covered with flaps. In the case of severe con-
tracture, the fold is expressed insufficiently, and the flaps
cover the central knee flexion zone; residual wounds were
skin-grafted (Fig.  34.3). The rate of lengthening always
exceeds 100% (the sum of all flaps in their middle width
minus the length of the crest involved in plasty).
Knee Medial Contracture Elimination Techniques

322
Wide Pathologic Scars Excision and Skin
Grafting (Figs. 34.4, 34.5, and 34.6)
Scars covering the popliteal area were often pathologic
(rough, thick, solid, and ulcerous) which impossible to con-
vert in the flaps. Such matured scars are excised through the
intermediate layer, which is formed during maturation of the
scars’ inner surface and has a scanty number of vessels. Only
after the scars’ excision can the knee be extended, with cau-
tion. To prevent tearing of the fatty layers, the surgeon lays
his or her palm on the wound, creating pressure during knee
extension. The split transplants, placed on such a wound’s
transverse surface, grew well; their shrinkage is minimal and
contractures are eliminated completely.
Knee medial scar flexion contractures of both joints are
eliminated simultaneously. Rough and ulcerous scars are
excised through the intermediate layer in rhombus form
(Fig. 34.5a, b) or butterfly (Fig. 34.4), and wounds are skin-­
grafted. If scars in one popliteal zone are not pathologic,
trapeze-flap plasty is indicated (Fig. 34.5d, right knee).
a
b
c
d
Fig. 34.5  Case 1: Ulcerous pathologic scars caused knee medial con-
tracture; (a) before surgery: rough scars, ulcer along the crest of the
fold; planning of scars excision in the rhomboid form; (b) contracted
scars excised on both knee and wound skin grafted (10 days after sur-
gery); skin transplants look well. Case 2: (c, d) Contracture of left knee
caused by rough ulcerous scars and treated with skin grafting; right
knee contracture caused by scar fold eliminated simultaneously with
one pair of adipose-scar trapezoid flaps; good follow-up results
a
b
c
Fig. 34.6  Follow-up result of
the knee medial contracture
treatment with scar excision
and skin grafting. (a) Before
surgery: pathologic ulcerous
scars in the popliteal zone; (b)
scars excised through an
intermediate layer without fat
tissue injury and bleeding; the
wound is skin-grafted; (c)
2 years after reconstruction:
contracture released in full,
no shrinkage of skin
transplants, no re-contracture
and ulceration
34  Knee Medial Scar Flexion Contractures After Burns: Anatomy and Treatment

323
Conclusion
After trapeze-flap plasty, no scar flap loss was observed;
good follow-up results were achieved. After excision of
scars, skin transplants cover large wounds without com-
plication and are functioning well during all phases of
observation,
without
signs
of
ulceration
and
re-contracture.
References
1. Grishkevich VM. Postburn knee flexions contractures: anatomy and
methods of their treatment. Trop Med Surg. 2013;1:147.
References

325
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Total Knee Flexion Contracture After
Burns: Anatomy and Treatment
Introduction
Circular burns and scars of the lower extremity constrict soft
tissues of the knee joint and the distal segment of the lower
extremity, severely restricting joint motion and causing tis-
sue hypotrophy. Scars in the popliteal zone suffer from
intense tension during walking, resulting in tears and pro-
gressing to nonhealing ulcers. If the passive range of motion
in the knee is preserved, then scars can be excised through
the intermediate layer and the wound covered with skin graft.
In cases of intra-articular restriction of complete extension,
scar excision and grafting are combined with the use of an
orthopedic external fixation/traction device.
Contracture Anatomy
After vast and deep burns, scars tightly constrict the knee,
creating severe scar surface deficit without a scar fold
(Fig. 35.1). Reconstruction with local flaps is not possible.
These anatomical criteria are characteristic of total con-
tracture. As a result of severe tension on scars of the poste-
rior knee surface when the joint is extended, scars
progressively degenerate to thick, firm, rough pathologic
scars, prone to necrosis and ulceration. Along with the
severe scar contracture, deep burns may injure the articular
structures, adding to the contracture’s severity and making
it difficult to treat.
35

326
a
b
c
d
e
Fig. 35.1  Severe right knee scar flexion contracture with large ulcer
and soft tissue hypotrophy. The entire affected extremity surface was
treated by excision of all pathologic scars and skin grafting. (a, b) Pre-­
surgery view. (c) Pathologic scars with ulcer excised in one block,
exposed nerves and vessels covered with fat tissue transposition; (d)
large wound covered with whole skin split transplants (2 weeks after
plasty, transplants alive); (e) 2 months after reconstruction: knee con-
tracture is fully released, compensatory ankle contracture is dimin-
ished, skin transplants look good, and the leg has become thicker
35  Total Knee Flexion Contracture After Burns: Anatomy and Treatment

327
Total Knee Contracture Treatment
The operation consists of excision of pathologic and ulcer-
ated scars in the popliteal area and lateral joint surfaces.
Manual knee extension is combined with pressure on the
wound by the surgeon’s palm to prevent tearing of fat tissue
and exposure of solid structures. If total contracture is com-
plicated by ulcers (Figs. 35.1a and 35.2a), pathologic scars
are excised in one block; the exposed blood vessels and
nerves (Figs. 35.1b and 35.2c) are covered with the local fat
tissue transposition; the wound is covered with skin trans-
plants (Figs.  35.1c–e and 35.2c, d). Only mature scars
undergo excision when the inner layer of the scars is con-
verted into pliable connective tissue without numerous cap-
illaries found in immature scars. Such scars are easier to
remove without bleeding in one segment through the inter-
mediate layer. Skin transplants placed on such wounds
grow well onto underlying tissue without forming hemato-
mas or necrosis.
Successful reconstruction is achieved if all pathologic
scars are fully excised. After surgery, the operated extrem-
ity becomes thicker and skin transplants look well without
ulceration. For treatment of the articular knee contracture,
an orthopedic external traction device is applied (Fig. 35.3).
After surgery, the usual gutter splint is applied for
3–5 weeks.
a
b
c
d
Fig. 35.2  Severe total knee contracture with lympho-venous insuffi-
ciency treatment with wide excision of ulcerous scars and skin grafting.
(a) Pre-operative view; scar with pathologic ulcers covering all the pop-
liteal zone; the distal segment of the damaged leg is much thicker than
the healthy side. (b) Scars excised through intermediate layer, no bleed-
ing, the fat layer is not injured, covered with a thin layer of connective
tissue; an exposed nerve is covered with local fat tissue. (c, d) The
wound is covered with whole split skin transplants; 6 months after
reconstruction: good functional and cosmetic results
a
b
c
Fig. 35.3  Severe total knee contracture caused by contracted scars and
injured solid articular structures, which is treated using an external trac-
tion device and skin transplant. (a) Pre-surgery: severe contracture,
atrophic soft tissue; (b) contracted scars in popliteal fossa excised and
wound skin grafted, distractor applied; (c) flexion contracture compen-
sated and knee joint straightened
Total Knee Contracture Treatment

328
Conclusion
Total knee contracture is successfully eliminated by
wide excision of all pathologic, ulcerous scars and
skin grafting. An external traction device should be
used if the joint cannot be extended fully after all con-
tracted scars are excised or if contracture is caused by
injury of the joint itself and its support structures. The
skin transplants, covering a large wound, turn into a
well-functioning skin; therefore, wide scar excision
and skin grafting significantly improves the overall
extremity appearance.
Suggested Reading
1. Grishkevich VM. Postburn knee flexions contractures: anatomy and
methods of their treatment. Trop Med Surg. 2013;1:147.
35  Total Knee Flexion Contracture After Burns: Anatomy and Treatment

329
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Ankle Edge Dorsiflexion Scar
Contractures: Anatomy and Treatment
with Trapeze-Flap Plasty
Introduction
Postburn ankle scar contractures cause functional limitations
of affected extremities and create a serious cosmetic defect;
patients cannot use normal footwear and therefore need sur-
gical reconstruction. The anatomical features of ankle dorsi-
flexion contractures and their treatment have been covered in
the literature far less than those of other joint contractures,
and their treatment is still a challenge for many surgeons.
Our comparative data show that the anatomically substanti-
ated technique is trapeze-flap plasty, which yields excellent
outcomes because the local trapezoid flaps cover the scar
surface deficit (cause of contracture).
Anatomy of Edge Ankle Dorsiflexion Scar
Contracture
The ankle joint’s surface is divided functionally into a flex-
ion (F) surface and an extension (E) surface. A line passes
between them through the malleolar apex or joint rotation
axis (“+”) (Fig. 36.1). The flexion anterior surface is divided
into flexion lateral (FL) and flexion medial (FM) surfaces; a
boundary passes along the curvature of the flexion surface
(Fig. 36.1). During wound healing, the crescent fold forms
along the edge anterior and the lateral ankle surface
(Fig. 36.1b). Scars cover the FL surface and form the lateral
fold’s sheet; the medial fold’s sheet is healthy skin that
spreads on the FM surface. The crest of the fold (Cr) is the
edge of scars (these anatomical features reflect the name for
this type, edge) (Fig. 36.1b).
36

330
a
b
Fig. 36.1  Ankle joint functional surfaces. (a) Healthy ankle: joint sur-
face of the healthy ankle is divided into flexion (F) and extension (E);
the dividing border between them passes through the malleolar apex
(“+”). The flexion surface of the healthy ankle joint is divided into flex-
ion anterior/medial (FM) and flexion lateral (FL), located among joint
flexion anterior/medial (FM) and joint extension/posterior (E) surface.
Curvature between FM and FL is less well expressed than in other large
joints. (b) Anatomy of edge scar contracture: (1) scars cover FL sur-
face; (2) scars form the fold along edge of FL surface; (3) Different
quality of fold sheets: lateral is scars,part of scars of FL surface; medial
is healthy skin and part of FM surface; (4) crest of the fold (Cr) is edge
of scars
36  Ankle Edge Dorsiflexion Scar Contractures: Anatomy and Treatment with Trapeze-Flap Plasty

331
Scar Surface Deficit Is the Real Contracture
Cause [2]
Contracture is caused by scars that cover the joint flexion
lateral surface (FL) and form the fold, the scar sheet of
which participates in contracture formation. Scars have a
surface deficit in length (Fig.  36.2), maximal along the
fold’s crest. The scar surface deficit spreads to the joint rota-
tion axis where it has a lineal meaning, nearly 3–4 cm in
width (Fig. 36.2b), which causes the contracture. The fold is
a new anatomical structure, with a surface surplus of scars
and healthy skin, and allows scar surface deficit compensa-
tion with local tissue. The scars have surface deficiency in
length and form (reason for contracture) is determined by a
first step because reconstruction is aimed at compensating
for the deficiency with one or more adequate flaps. The form
and size of the scar surface deficiency is estimated using the
following steps: The sheets are divided with an incision
along the fold’s crest, and a Y-shaped incision perpendicular
to the crest dissects the scar sheet from the fold’s crest to the
malleolus, where the incision is split at 45°. After ankle
dorsi-extension, the wound, as a rule, accepts a trapezoid
form, reflecting the form and size of scar surface deficiency,
which is maximal at the fold’s crest and spreads, subsiding
to the ankle joint rotation axis (Fig.  36.2); the trapezoid
flap’s form is necessary for deficiency compensation and
contracture elimination becomes obvious.
a
b
Fig. 36.2  Anatomy and
contracture cause/scar surface
deficit of the left ankle edge
contracture. (a) Right ankle:
scars cover the joint flexion
lateral (FL) surface; the
flexion medial surface is
healthy skin. A fold is formed
between the flexion lateral
and flexion medial surfaces.
The fold consists of two
sheets: the lateral fold’s sheet
(FL) is scars; the medial sheet
and adjacent flexion medial
(FM) surface are healthy skin;
the crest (Cr) of the fold lies
between them, where the edge
of scars is; (b) after scar sheet
dissection with a Y-shaped
incision and contracture
release, the wound (Dt—scar
sheet surface deficit) accepts
trapezoid form (to the right of
the white strip), which is the
real cause of the contracture).
Trapezoid flap (FP) mobilized
Scar Surface Deficit Is the Real Contracture Cause

332
b
c
a
d
Fig. 36.3  Mild-to-moderate ankle edge and toe contracture elimina-
tion with one adipose-cutaneous trapezoid flap. Case 1: (a) contracture
caused with scars located on the lateral joint surface, the scars form a
crescent-shaped fold; the medial fold sheet and anterior ankle surface
are healthy skin; (b) flap mobilized on ankle anterior surface and (c)
compensated scar surface deficit and contracture eliminated; 5  days
after surgery, the flap is alive. Case 2: (d–f) edge ankle contracture is
eliminated with one trapezoid adipose cutaneous flap (SC scars; FL
flexion lateral surface). Case 3: (g) edge contracture released with one
trapezoid flap and strip scars excised on the lag. Simultaneously
removed contractures of toes; (h) scheme of ankle edge contracture
elimination with one adipose-cutaneous trapezoid flap
Treatment of Edge Ankle Dorsiflexion
Contractures with Trapezoid Flaps
Anatomical features of edge contractures (severity, fold
length, and protrusion) lead to the use different variants of
trapeze-flap plasty [1].
One-Trapeze-Flap Technique
The mild-to-moderate edge ankle contracture is removed
with one flap, prepared from the medial healthy fold sheet
and skin of the ankle anterior surface. The planning
(Fig. 36.3a, d) consists of several lines: The line along the
fold’s crest; a perpendicular line on the scar’s sheet with a
Y-shaped end at the head of the malleolus; and two lines
marking the flap’s borders in ankle joint projection. With the
first incision along the fold’s crest, the sheets are separated.
The Y-shaped incision then dissects the scar sheet to the
malleolus (scars and subcutaneous fat layer). After full
ankle extension, a trapezoid wound is formed (Figs. 36.2b
and 36.3b). According to the wound’s form and size, the
adipose-­cutaneous trapezoid flap is elevated. The end of the
flap is 4 cm wide; the flap’s length is about 5–6 cm. The flap
is transposed on the wound with moderate tension
(Fig. 36.3c, f, g). The tension of the flap causes the flap’s
base to approach the scars, and neighboring skin of the
opposite side of the ankle is displaced to the anterior ankle
surface, covering the narrowed donor wound. Due to flap
tension and neighboring tissue displacement, it was feasible
to transpose the flap’s end to the malleolus and the angle of
the scar sheet to the flap’s base, thus covering the donor
wound, compensating for the scar deficit, and eliminating
the contracture in full. Rough scars are excised simultane-
ously on the leg and the wound is primarily closed
(Fig. 36.3b, c, f, g). Extension contracture of the fifth toe
was simultaneously removed with trapeze-flap plasty
(Fig. 36.3e, f).
36  Ankle Edge Dorsiflexion Scar Contractures: Anatomy and Treatment with Trapeze-Flap Plasty

333
e
f
g
h
Fig. 36.3  (continued)
Treatment of Edge Ankle Dorsiflexion Contractures with Trapezoid Flaps

334
Treatment of Moderate Edge Ankle
Contracture with Three Trapezoid Flaps
(Fig. 36.4)
In cases of moderate contracture, the scar sheet surface defi-
ciency is more severe; thus, the surface of one flap is not suffi-
cient and the angles of scar sheets could not reach the flap’s base
and donor wound cover beside the flap’s borders. In such cases,
three flaps are planned (Fig. 36.4a, b). The main adipose-cuta-
neous flap formed the ankle central flexion area; both trapezoid
adipose-scar flaps are raised from the scar’s sheet for donor
wound covering at both sides of the main flap (Fig. 36.4c). The
size of the adipose-scar flaps depends on the size of the wounds
beside the adipose-cutaneous flap but is always smaller than the
main flap. The full subcutaneous fat layer is included in all flaps.
The scheme of the operation is presented in Fig. 36.4d.
a
d
b
c
Fig. 36.4  Moderate-to-severe ankle flexion contracture elimination
with three trapezoid flaps. (a) Pre-operative view: contracture caused
by scars (SC) located on lateral joint surface (FL), joint anterior surface
or flexion medial (FM) is healthy skin (SK); Cr—rough scars; (b) three-­
flap plasty planning: main adipose-cutaneous flap (FP) on anterior
ankle surface (FM) and two small flaps from scar sheet (FL) for donor
wound covering beside the main flap; planning; (c) 7 days after opera-
tion: contracture is released, scar sheet’s surface deficit is compensated,
flaps are alive, ankle contours are restored; (d) scheme of three-flap
trapeze-flap plasty
36  Ankle Edge Dorsiflexion Scar Contractures: Anatomy and Treatment with Trapeze-Flap Plasty

335
Treatment of Severe Edge Both-Ankle
Contractures with One Trapezoid Flap and Skin
Grafts
Widespread, deep burns cause rough deformity and defect
of the soft tissue of the ankle joint region and foot and leg.
An extensive area of scarring and a deficit of undamaged
skin make reconstruction challenging (Fig. 36.5a). Burns of
the ankle lateral flexion surface leave healthy skin on the
joint medial flexion surface, where a trapezoid flap is
planned on each ankle surface of which there is insufficient
skin for scar surface deficit compensation. Therefore, only
one trapezoid adipose-cutaneous flap is planned (Fig. 36.5b,
right ankle, and 36.5d, left ankle of the same child). Severe
scar sheet surface deficit (wounds), which has a trapezoid
form (Fig. 36.5c, e), does not allow the scar sheet to cover
the donor wound, which is located beside the flap. The flap
involves the medial fold sheet and anterior ankle surface;
the flap’s base is at the malleolus. The mobilized flap is
transposed on the wound with moderate tension and its end
is connected to the wound’s edge near the malleolus
(Fig. 36.5c, e, right and left ankle, respectively). As a result,
the central zone of the ankle anterior surface is covered with
a healthy adipose-cutaneous layer; the wounds at both sides
of the flap are skin-grafted (Fig.  36.5f). The result and
scheme of simultaneous severe edge contracture reconstruc-
tion with combined trapeze-flap plasty of both ankles is
shown in Fig. 36.5f, g.
a
b
c
d
e
f
Fig. 36.5  Severe both ankles edge contractures elimination with trap-
ezoid flap and skin transplants. (a) Pre-surgery, both ankles: contrac-
tures caused by scars located on medial joints’ surface, leg with ulcers,
defect of distal foot, hypotrophy tissues; scars formed long crescent
folds in which the medial sheets are scars; the lateral sheets and anterior
joint surfaces are healthy skin; (b) right ankle: planning reconstruction
with one adipose-scar trapezoid flap; Y-line for contracted scars dissec-
tion; (c) right knee: scars dissected, trapezoid wound or scar surface
deficit (Dt) appeared; trapezoid flap (FP) mobilized; left picture: con-
tracted scars of FL surface dissected, trapezoid wound or scar surface
deficit (Dt) appeared; trapezoid flap (FP) mobilized. Right picture:
trapezoid flap covered most of the wound; (d) left ankle: planning one-­
flap trapeze-flap plasty; (e, left) scars dissected with a Y-incision; trap-
ezoid wound (scar surface deficit Dt—appeared, trapezoid flap (FP)
mobilized; (right picture: flap covered central part of wound; wounds
beside the flaps skin grafted; (f) (2 years after reconstruction with trap-
ezoid flap and skin transplants. (g) Reconstruction with flap and skin
grafts (combined trapeze-flap plasty, scheme)
Treatment of Edge Ankle Dorsiflexion Contractures with Trapezoid Flaps

336
g
Fig. 36.5  (continued)
36  Ankle Edge Dorsiflexion Scar Contractures: Anatomy and Treatment with Trapeze-Flap Plasty

337
Conclusion
Dorsiflexion ankle edge contractures are completely
eliminated using trapezoid flaps alone or in combination
with skin grafts. No flap loss takes place. Skin transplants
grow well with the underlying tissue. Repeated reconstruc-
tion is not needed. Small hematomas are removed with
transplant incision on the fifth day. The adipose-scar trap-
ezoid flap does not shrink; it continues to grow, more so in
pediatric patients, preventing contracture recurrence.
References
1. Grishkevich VM.  Ankle dorsilexion postburn scar contractures:
anatomy and reconstructive techniques. Burns. 2012;38:882–8.
2. Grishkevich VM.  Both ankles severe postburn edge dorsiflex-
ion contracture in pediatric patient: anatomy and treatment with
trapeze-­flap plasty-a case report and literature review. Clin Res Foot
Ankle. 2013;1:112.
References

339
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Medial Ankle Dorsiflexion Contractures
and Techniques for Their Treatment
Introduction
Burns and scars of the ankle anterior surface and dorsal foot
restrict joint dorsi extension, walking, and the wearing of
shoes, and present a severe cosmetic defect. Foot develop-
ment is delayed in children. Early reconstruction is therefore
indicated along with simultaneous correction of all contrac-
tures and deformities. Scars form a fold, which is the scar
surface surplus. The real contracture cause is the scar surface
deficit in length. The presence of scar surface surplus in
width allows for contracture elimination with local flaps.
Treatment with triangular flaps does not allow for complete
contracture release. Trapezoid-flap plasty is more efficient
per se or in combination with skin transplantation. Rough
mature scars undergo excision through an intermediate layer
and wounds are covered with whole skin transplants.
Functional Zones of Ankle Joint
and Anatomy of Ankle Medial Flexion
Contracture
Functional Zones of Ankle Joint Surface
in Medial Contractures (Fig. 37.1)
The ankle joint’s surface is divided functionally into flexion
surface (F) and extension surface (E). A dividing line passes
between these surfaces through the malleolar apex or joint
rotation axis (“+”). The flexion surface is divided into flexion
lateral (FL) and flexion medial (anterior) (FM) surfaces; a
boundary passes along the curvature of the flexion surface,
between the anterior and lateral surfaces. The curvature of
the ankle joint flexion surface is less expressed than in other
big joints. The joint extension surface is located behind the
malleolus. Ankle medial contracture is caused by scars cov-
ering the joint FM or anterior surface.
Anatomy of Ankle Medial Flexion Contracture
Medial dorsiflexion contracture is characterized by scars
located on the joint anterior surface (FM), which form a cres-
cent fold, the crest of which is located along the medial joint
line. Both sheets of the fold are scars and spread from the
fold crest (Cr) to the joint flexion lateral (FL) surface
(Fig. 37.1a, b). Malleolar zones (“+”) are healthy skin. The
fold is a new anatomic structure, the scar’s surface surplus.
The contracted scars have surface deficiency in length (cause
of contracture) and surface surplus in width, which allows
contracture elimination with local flaps. The fold can be
small and short, or it may spread to the leg and foot, causing
toe extension contractures.
37

340
The form and size of the scar sheet surface deficiency in
length is estimated in the following way (Fig. 37.1c, d):
The fold sheets are divided with an incision along the
fold’s crest; the contracture is released by a perpendicular
Y-shaped incision to both malleolus; after ankle dorsi
extension, the wounds of both sheets, as a rule, accept a
trapezoid form. Consequently, adequate contracture elimi-
nation can be performed by means of surface deficit com-
pensation with trapezoid flaps. Anatomy of contracture
release with two radial Y-incisions and flap mobilization is
shown in Fig. 37.1d (FP flap; Dt scar surface deficit; DW
donor wounds).
a
b
c
d
Fig. 37.1  Functional zones of ankle joint, anatomy, and scar surface
deficit of ankle medial scar contracture. (a, b) Scars cover the joint
flexion medial (FM) or anterior surface; scars form the fold, the crest
(Cr) of which passes along the joint medial line; FL—flexion lateral
zone located between malleolus (“+”—joint rotation axis) and joint
anterior (FM) surface; E—extension surface; (c) scar surface deficit
(contracture cause) determining: radial lines mark one pair of trapezoid
flaps in FM zone; (d) flaps mobilized and joint extended: two trapezoid
flaps and wounds appeared laterally from the middle line; wounds
beside the flaps’ central zones have trapeze-shaped scar surface deficit,
which is maximal at the medial line; lateral wound edges are the scar
surface deficit DT at the boundary between FL surfaces
37  Medial Ankle Dorsiflexion Contractures and Techniques for Their Treatment

341
Medial Dorsiflexion Ankle Contracture
Treatment with Trapezoid-Flap Plasty
The fold’s sheets (on all their extents) from the fold crest to
the malleolus, had to be converted into flaps of a form (trap-
ezoid) similar to that of the scar surface deficiency [1].
Because the fold has a crescent shape, the fold’s sheets could
be converted into trapezoid flaps only with radial Y-shaped
incisions. Depending on contracture severity and the fold’s
length, one, two, or several pairs of adipose-scar trapezoid
flaps are mobilized.
Medial Contracture Elimination with Two Pairs
of Trapezoid Adipose-Scar Flaps
Moderate-to-severe contracture is caused by a long fold in
which the scar surface deficit cannot be removed with one
pair of flaps. The long fold allows for preparation of two
pairs of trapezoid flaps (Fig. 37.2a, b). Planning (Fig. 37.2a)
consists of drawing several lines: one line along the fold
crest and four radial lines, outlining two pairs of trapezoid
flaps in the central ankle zone. The distance between radial
lines (incisions) at the fold crest (flap width) is about 4 cm;
the flap length covers all ankle anterior surfaces to the mal-
leolus. Radial lines convert the fold sheets into trapezoid fig-
ures because the fold has a crescent shape. Following the
tracing lines, the sheets along the fold crest are divided and
trapezoid flaps are mobilized, including a full subcutaneous
fat layer that secures steady blood circulation. The flaps are
counter-transposed, covering the wound and elongating the
surface by more than twice its previous length.
After adipose scar flap mobilization, a large wound
appears, consisting of two trapezoid wounds (Fig.  37.2b,
beside white strip), reflecting the form and size of the scar
surface deficit, or real contracture cause. Transposed oppo-
site flaps fully compensate for the scar surface deficit and
eliminate contracture (Fig. 37.2c). In all cases, it is profitable
to transform the fold on all its extensions into the trapezoid
flaps, creating some over-correction. The result is shown in
Fig. 37.2d.
It is often clear during surgery that a planned pair is insuf-
ficient for complete contracture release (Fig. 37.3a, b); addi-
tional pairs of adipose-scar flaps are mobilized until the
contracture is fully released (Fig. 37.4a, b).
Multiple trapezoid-flap plasty and a variant of trapezoid-­
flap plasty for ankle medial contracture treatment are shown
in Fig. 37.4.
Flexion contractures of ankle, leg, foot, toes, and syndac-
tyly are eliminated simultaneously by trapezoid-flap plasty
and V-Y technique (Fig. 37.5; FP flap; Dt deficit of scar sur-
face; DW donor wound where flaps are elevated).
a
b
c
d
Fig. 37.2  Ankle medial contracture is removed with two pairs of trap-
ezoid adipose-scar flaps. (a) Pre-operative review, planning two pairs of
the flaps; (b) adipose-scar flaps mobilized, scar surface deficit has the
form of two trapezoid figures depicted with white strips; (c) counter
transposed flaps compensate scar surface deficit and eliminate contrac-
ture (end of operation); (d) good follow-up result
Medial Dorsiflexion Ankle Contracture Treatment with Trapezoid-Flap Plasty

342
a
b
Fig. 37.3  The number of
pairs of flaps increased during
the operation. (a) Moderate
ankle medial contracture; one
pair of trapezoid flaps was
planned; (b) two flaps were
not enough, so two additional
adipose-scar trapezoid flaps
were elevated; complete
contracture released
37  Medial Ankle Dorsiflexion Contractures and Techniques for Their Treatment

343
a
b
A
B
C
Fig. 37.4  Severe ankle contracture released by converting the long
fold’s sheets in trapezoid adipose-scar flap and its counter transposition.
(a) Result of reconstruction: all scar flaps are alive, complete contrac-
ture is eliminated; (b) variants of ankle medial flexion contracture treat-
ment with trapezoid flaps (A—one pair of flap method; B—treatment
with two pairs of flaps; C—three-pairs, or more, are used if the fold is
long and contracture severe)
Medial Dorsiflexion Ankle Contracture Treatment with Trapezoid-Flap Plasty

344
a
d
e
b
c
Fig. 37.5  Ankle medial dorsiflexion, dorsal foot, toes syndactyly and
extension contractures reconstruction with trapeze-flap and V-Y pasties.
(a) Pre-surgery, planning; (b) dorsal foot contracture released with
V-incision; two trapezoid flaps planning (c) adipose-scars trapezoid flaps
(FP) mobilized; (d) step of reconstruction; flaps (FP) counter transposed;
(e) end of operation, all contractures removed with local flaps
37  Medial Ankle Dorsiflexion Contractures and Techniques for Their Treatment

345
Conclusion
Ankle medial dorsiflexion contracture is caused by the
scar’s fold, located on the joint’s flexion medial surface.
Both sheets of the fold are scars, in which there is a trap-
ezoid scar surface deficit in length (true cause of the con-
tracture) and a scar surface surplus in width. The
contracture is released with trapezoid-flap plasty: the
fold’s sheets are converted into one or more pairs of trap-
ezoid flaps that are counter-transposed.
References
1. Grishkevich VM.  Ankle dorsilexion postburn scar contractures:
anatomy and reconstructive techniques. Burns. 2012;38:882–8.
References

347
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Total Ankle Contracture: Anatomy
and Treatment
Introduction
Burn scars of the distal part of the lower extremities are often
complicated by being rough, thick, and hard. Scars in this
region are predisposed to excessive growth, which impairs
all forms of motion. Walking increases the size of the con-
tracture. The distal segment of the extremity has a thin sub-
cutaneous fat layer, and the relatively low blood circulation
in scars stimulates keloid tissue growth. Such scars create
serious functional and cosmetic problems. Therefore, these
scars should be excised. Scars should be mature, and they
should be excised through the intermediate layer, which can
be accomplished without bleeding. Skin transplantation fol-
lows without complications.
Anatomy
In an ankle contracture, rough, thick, contracted scars tightly
surround the ankle and neighboring regions without a fold
(Fig. 38.1). The scar surface deficit, which is the reason for
contracture, is severe; therefore use of the local-flap tech-
nique is not recommended. In most cases; burns have also
injured the leg and foot. The rough, thick scars are prone to
ulceration.
38
Fig. 38.1  Total ankle contracture caused by keloid scars. Thick, rough
scars; severe foot deformation

348
Surgical Technique
Reconstruction is performed using wide mature scar exci-
sion through the intermediate layer; a large wound is covered
with whole split skin transplants (Figs. 38.2 and 38.3) [1].
The scar must be mature, which allows the subcutaneous fat
layer to remain in situ, undamaged, and with only light
bleeding. Skin transplants are fixed to each other and to the
underlying tissue with U-shaped sutures; a gauze bolster is
tied above, creating compression on the transplant
(Fig. 38.2c). Skin grafts and wound tissues grow together
more effectively when more sutures are placed, yielding bet-
ter results. After reconstruction, the ankle joint is fixed with
a gutter splint for wound healing; after skin grafting, a com-
pression is applied to the transplants.
Wide scar excision and the wound covering with whole
split skin transplants yield good outcomes (Figs. 38.3, 38.4,
and 38.5).
a
b
c
d
Fig. 38.2  Contracture and
scar deformation treatment by
scar excision and skin
grafting. (a) Rough, thick,
keloid scars covered ankle
and neighboring regions; (b)
scars excised, dissecting
connective tissue under scars,
no bleeding; (c) wound of
ankle, foot, and leg covered
with whole skin transplants
and fixed with wound tissue
with U-shaped sutures; edges
of transplants have excess
skin; (d) 2 weeks after
surgery: transplants are alive
and contracture is removed
38  Total Ankle Contracture: Anatomy and Treatment

349
a
b
c
Fig. 38.3  Total ankle
contracture is caused by
pathologic ulcerous scars. (a)
Pre-operation: pathologic
scars covered the ankle, foot,
and leg, caused toe extension
contracture; ulcer on ankle;
(b) all pathologic scars
excised through the
intermediate layer; the fat
layer was not damaged;
therefore, the wound is “dry”
without bleeding; syndactyly
removed with trapezoid-flap
plasty; (c) the wound is
skin-grafted, contracture
released, and ankle contours
restored (10 days after
reconstruction)
a
b
Fig. 38.4  Follow-up results
of surgical treatment of total
ankle and foot contractures
and deformations caused by
pathologic ulcerous scars. (a)
Pre-surgery; (b) 2 years after
scar excision and wound
coverage with the whole split
skin transplants
Surgical Technique

350
a
b
Fig. 38.5  Severe deformed
left ankle and foot
reconstructed in child using
wide scar excision, toe
separation, and the wound
covered with whole split skin
transplants. (a, b) Ten days
after surgery
38  Total Ankle Contracture: Anatomy and Treatment

351
Conclusion
Ankle dorsiflexion total contracture and scar deformation is
often complicated by pathologic scars prone to ulceration.
Reconstruction consists of pathologic scar excision without
damaging the fat layer and wound coverage with whole split
skin transplants. Scar excision eliminates soft tissue con-
striction and joint contracture and normalizes lympho-
venous circulation and lower extremity development.
References
1. Grishkevich VM.  Ankle dorsiflexion postburn scar contractures:
anatomy and reconstructive techniques. Burns. 2012;38:882–8.
References

353
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Proximally-Based Sural Adipose-­
Cutaneous/Scar Flap in Elimination
of Ulcerous Scar Soft Tissue Defect Over
the Achilles Tendon and Posterior Heel
Region
Introduction
Scar ulcers that spread over the Achilles tendon and posterior
heel disturb patients by causing pain, impeding hygiene, and
creating difficulty in finding appropriate shoes. This region
naturally endures pressure, so effective reconstruction is
based on flap use. The most popular flaps currently used are
distal sural fascial-cutaneous flaps, calcaneal artery skin
flaps, and free flaps. These flaps, however, are insensate, can
create soft-tissue excess, and cause donor site morbidity.
Ulcerous soft-tissue defects over the Achilles tendon and
posterior heel after burns, frostbite, and trauma were studied
and reconstructed using a proximal sural adipose-cutaneous
flap, the anatomy of which was studied on the lower extremi-
ties of cadavers.
Anatomy of Ulcerous Soft Tissue Defects
and Proximally-Based Sural Flap [1]
An ulcerous scar surface, for which reconstruction is per-
formed, consists of two zones: the Achilles tendon (nearly
8 cm in length) and the posterior heel (4 cm in length); their
combined length totals 12 cm (Fig. 39.1a). The size of ulcers
varied from 4 to 7 cm in length and 3–6 cm in width. The
form and size of ulcers and soft-tissue defects varied from
case to case. Tissue defects and surrounding pathologic
scars, which had to be excised, are significantly larger than
ulcers. Pathologic scars are typically rough, thick, solid, and
can cover the foot, ankle, and leg (Fig. 39.2a). The base and
edges of the ulcers’ bottoms are gray scars without signs of
regeneration. Ulcer scars are tightly connected with the ten-
don and calcaneal bone. The flap is planned based on the
tissue defect and its size and form (Figs. 39.1a and 39.2b).
The flap is 20–22 cm in length and can be divided into two
segments: vertical (nearly 10–12 cm in length), which covers
the lower third of the leg, and horizontal (8 cm in length),
which is harvested from the lateral foot, between the malleo-
lus and plantar edge. The flap’s base is situated on the
posterior-­lateral legs for preserving the sural nerve. The pos-
terior flap’s border is the wound’s edge; the anterior border
advances the malleolar apex. The flap’s width is about
6–7 cm. The flap consists of skin/scars, a full subcutaneous
fat layer, and includes the sural nerve and lesser vein; the
blood inflow comes through the peroneal and anterior tibial
artery perforators. The ratio of the vertical part of the flap to
the horizontal part varies depending on the level of the tissue
defect and wound surface size. The study of donor sites of
cadavers’ lower extremities showed that the sural nerve, pro-
viding sensory innervations, and lesser vein are present in
the flap over its entire extension. Several perforators origi-
nating from the peroneal and anterior tibial artery form the
vessels’ net in the subcutaneous fat layer (Fig. 39.2e, f).
39

354
a
f
h
i
g
c
b
d
e
Fig. 39.1  Anatomy of ulcerous scar soft tissue defect over the Achilles
tendon and posterior heel and elimination with proximally based sural
adipose-cutaneous flap. (a) Outline of ulcer (Ulc) and pathologic scars
over the tendon to be excised; (b) flap’s (F) contours: the vertical part
covers the posterior-lateral of distal third of the leg. The horizontal part
covers the lateral foot; the flap’s length is nearly 20 cm; (c) pathologic
scars and ulcer are excised, the wound bottom is tendon; (d) flap (F)
mobilized, deep fascia not included in flap; (e) minimally rotated flap
covered tendon and posterior heel; (f) scheme of operation; (g) cadaver
flap specimens; white dots are perforators; (a) sural nerve shown in the
flap and entrance of arterial perforators in subcutaneous fat layer (white
dots); (h, i) perforators and blood supply of proximally based sural
adipose-cutaneous flap (cadaver specimens)
39  Proximally-Based Sural Adipose-Cutaneous/Scar Flap in Elimination of Ulcerous Scar Soft Tissue Defect Over the Achilles

355
a
b
c
d
f
e
Fig. 39.2  Big round ulcerous
tissue defect of Achilles-­
calcaneal zone treatment with
sural scarred flap. (a)
Pre-surgery view: big ulcer
surrounded by scars; D defect,
F flap; (b) scars covered
donor site; F flap, SC scars,
planning; (c) ulcer excised,
flap mobilized; (d) flap (F)
rotated on the wound and
covered tendon and posterior
heel; (e) 1 month after
reconstruction: flap is alive,
tissue defect is eliminated,
superficial scar flap border
necrosis, skin graft covering
the donor site well; (f) scheme
of reconstruction
Anatomy of Ulcerous Soft Tissue Defects and Proximally-Based Sural Flap

356
Technique of Ulcerous Soft Tissue Defect
Resurfacing with a Proximally-Based Sural
Adipose-Cutaneous Flap
The borders of pathologic scars, including the ulcer, are out-
lined for excision. The flap is also outlined (Figs. 39.1, 39.2,
and 39.3). The flap’s base corresponds to the upper wound’s
edge and includes the posterior part of the leg. The posterior
flap’s border is a lateral scar’s edge (wound’s edge) that
extends distally along the plantar edge on the foot for about
8 cm. The anterior flap’s border (line) passes parallel to the
rear line, advancing for nearly 6 cm ahead and including the
posterior-lateral lower leg, lateral ankle, and foot surfaces.
The planned flap is 4–5 cm longer than the wound’s length
because of shrinkage of mobilized flaps; for tendon and heel
coverage the flap is distended in width for complete solid
structure coverage, which makes the flap shorter.
The ulcer with pathologic scars is excised in one block,
reaching deeply into the healthy skin. The wounds varied
from 6 to 20 cm in length and 6 cm in width. Depending on
the extent of pathologic scars, wounds are of different shapes:
triangular, round, or trapezoid. The wound’s bottom is the
Achilles tendon and calcaneal bone (Fig. 39.1c). The tendon
should be freed from scars posteriorly and laterally. Flap
mobilization begins from its end on the foot, according to the
deep fascia, which is not included in the flap. Following the
fascia, the flap is raised carefully, not injuring the subcutane-
ous fat layer (Fig. 39.1d). For malleolar apex coverage, the
skin of the anterior ankle surface is displaced posteriorly and
fixed, with absorbable sutures, to the fascia, posterior to the
apex. Then, if the wound narrows in the proximal direction,
the flap is placed longitudinally over the tendon and poste-
rior heel and the flap’s rotation is minimal (Figs. 39.1 and
39.3); the medial flap’s edge is connected to the wound’s
border, and the lateral flap’s border is sutured to the fascia
laterally from the tendon (Fig. 39.1e). In the case of a big,
round soft-tissue defect, the flap is rotated between 60° and
90° to cover the proximal wound’s zone; after fixation, the
flap is directed longitudinally (Fig. 39.2a–d).
The scarred flap preserves sensation and has a steady
blood circulation supplied through the subcutaneous fat
layer, which prevents tissue necrosis; the flap tolerates the
pressure of footwear well. Pathologic scars, spreading on the
medial ankle region, can be excised and the wound can be
skin-grafted (Fig. 39.3d, g).
In all cases, the apex of the malleolus should be covered
with adipose-cutaneous layer displaced from the flexion lat-
eral surface (Fig. 39.4).
Ulcerous scar soft-tissue defect after frostbite can be
complicated by blood inflow reduction in the leg and foot. In
these cases, flap training takes place (delayed ­reconstruction):
the bipedicle elevated sural flap is sutured at the place;
4 weeks later, the reconstruction is successfully completed
(Fig. 39.5).
If ulcers and pathologic scars involve the posterior heel
(Figs. 39.6a, b and 39.7) or plantar heel (Fig. 39.8a–c), the
vertical part of the flap is shorter, and reconstruction is per-
formed using the horizontal flap’s segment for the most part.
Ulcers located over the proximal part of the Achilles ten-
don can be eliminated with a bipedicle sural flap (Fig. 39.9).
After flap elevation, it becomes longer and is easily dis-
placed; owing to the presence of plenty of circulation, exten-
sion of the flap not dangerous. The donor wound is covered
with a skin transplant.
After surgery, a gutter splint is used for the ankle joint
support in a rectangular position for 2–3 weeks.
39  Proximally-Based Sural Adipose-Cutaneous/Scar Flap in Elimination of Ulcerous Scar Soft Tissue Defect Over the Achilles

357
a
b
c
e
f
g
d
Fig. 39.3  Reconstruction of the Achilles tendon, posterior heel, and
medial malleolar region; donor site scarring. (a, b) Pre-surgery: ulcer
and pathologic scars over tendon and posterior heel and medial malleo-
lus; flap planning; (c, d) operation: scars excised, flap mobilized and
placed over tendon and calcaneal bone; (e–g) result of operation
a
b
Fig. 39.4  (a, b) Large round
ulcerous soft tissue defect
over Achilles tendon
successfully eliminated with
the proximally based sural
flap
Technique of Ulcerous Soft Tissue Defect Resurfacing with a Proximally-Based Sural Adipose-Cutaneous Flap

358
a
b
c
Fig. 39.6  (a–c) Ulcerous soft-tissue defect over heel treatment mostly with lower flap’s segment
a
b
c
d
e
f
Fig. 39.5  Surgical training of the flap in case the ulcerous deep tissue defect
of the left heel region after frostbite. (a) Pre-surgery: ulcerous tissue defect
in Achilles tendon and heel region; (b) left leg: bipedicle flap planning and
(c) elevation (surgical training); (d) mobilized trained adipose-cutaneous
sural proximally based flap; (e) flap-covered Achilles tendon and heel poste-
rior region; donor wound is skin-grafted; (f) good follow-up result
39  Proximally-Based Sural Adipose-Cutaneous/Scar Flap in Elimination of Ulcerous Scar Soft Tissue Defect Over the Achilles

359
a
d
b
c
Fig. 39.7  (a–c) Ulcerous soft-tissue defect over heel treatment mostly with lower flap’s segment; (d) scheme of plasty; D tissue defect, F flap
a
b
c
d
Fig. 39.8  (a–c) Treatment of
ulcerous soft tissue defect in
the plantar heel region; F flap;
D tissue defect; (d) scheme of
operation
Technique of Ulcerous Soft Tissue Defect Resurfacing with a Proximally-Based Sural Adipose-Cutaneous Flap

360
a
e
f
g
b
c
d
Fig. 39.9  Results of elimination of ulcerous soft tissue defect over the
proximal part of Achilles tendon with bipedicle sural adipose-­cutaneous
flap. (a) Before operation; (b) bipedicle sural flap planning; (c, d) ulcer-
ous rough scars excised, flap elevated; (e) flap displaced posteriorly and
covered Achilles tendon; (f) donor wound skin-grafted; (g) excellent
follow-up result (2 years after reconstruction)
39  Proximally-Based Sural Adipose-Cutaneous/Scar Flap in Elimination of Ulcerous Scar Soft Tissue Defect Over the Achilles

361
Conclusion
The transposed proximally-based sural adipose-cutane-
ous/scar flaps were alive and completely covered and pro-
tected the posterior heel and Achilles tendon, allowing the
tendon to move and shift freely. Skin transplants merged
well with wound tissues. Necrosis of the distal part of the
flap can occur if the leg’s arterial flow is obliterated.
Marginal superficial flap scar necrosis rarely occurred and
had no effect on final outcomes. The skin of the flap pre-
served sensation and tolerated pressure caused by foot-
wear well. Because the flaps are thin, no tissue excess and
no debulking is needed. The flaps continue to grow and
become wider because of tension created during the oper-
ation. Donor site deformation is minimal, as the soft tis-
sue defect is small; with time, the skin transplant changes
into well-functioning, well-matched surrounding skin
that can be easily hidden by footwear. Sural nerve cutting
caused no complaints regarding disorders of distal foot
sensitivity.
References
1. Grishkevich VM.  Proximally based sural adipose-cutaneous/scar
flap in elimination of ulcerous scar soft-tissue defect over the
Achilles tendon and posterior heel region: a new approach. J Burn
Care Res. 2014;35:e143–50.
References

363
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Inguinal Scar Contractures: Anatomy
and Treatment
Introduction
Scars of the inguinal anterior surface produce a fold along
the border with undamaged medial inguinal surface. The
contracture prohibits hip joint extension and requires recon-
struction. The contracture is of the edge type: the lateral fold
sheet and lateral inguinal zone are scar; the medial inguinal
zone, sheet of the fold, and upper inner thigh surfaces are
healthy skin and are good donor sites. After contracted scar
dissection in the inguinal region with a Y- incision, a trape-
zoid wound appears. The scar surface deficit is compensated
for, and the contracture is successfully released with an
adipose-­cutaneous trapezoid flap taken from above-named
donor site. Vast severe abdomen contracture is eliminated by
scar excision and wound resurfacing with whole skin
transplants.
Edge Inguinal Contracture: Anatomy
and Treatment with Thigh Adipose-Scar
Trapezoid Flap
Vast burns of the anterior abdomen and thigh surfaces and
the inguinal region treated with skin transplantation can
result in edge inguinal contracture formation (Figs. 40.1 and
40.2). Such contracture removal requires the use of an adi-
pose cutaneous flap. Widespread skin damage presents a
challenge for surgeons. We noticed that the thigh’s upper
zone is a good donor site for the required flap harvesting.
Anatomy (Fig. 40.1)
Burns and skin transplant covering the inguinal zone are ter-
minated along the curvature where the inguinal region trans-
verses into the perineal zone (Fig. 40.1a). The fold forms
along the boundary of scars and healthy skin, among the
inguinal and the perineum (Fig. 40.1a). The lateral (inguinal)
fold’s sheet is scar, the medial sheet (perineal) is healthy
skin, connecting with the healthy medial thigh surface and
perineum. The lateral fold’s sheets have a surface deficit in
length, which spreads along the ligamentum inguinal and
causes contracture; both sheets are surface surplus, which is
used for scar surface deficit compensation. The medial fold’s
sheet is connected to the inner surface of the thigh, where
there is a surplus of adipose-cutaneous layer; therefore, the
inner surface of the thigh serves as the optimal donor site for
the inguinal edge scar contracture elimination.
40

364
a
b
c
d
Fig. 40.1  Anatomy of edge
inguinal contracture and
treatment with trapeze-flap
plasty in a 10-year-old female
patient. (a) SC scars; Sk skin,
Cr crest of the fold.
Widespread skin transplants
covered the inguinal zone and
neighboring area of the
abdomen and thigh; the
perineum and thigh inner
surface is healthy skin (donor
site); genitalia deformed; (b)
FP flap; planning of
operation: Y-line for scars’
dissection, separation of scars
from healthy skin, trapezoid
flap’s borders; (c) end of
operation; FP flap (d)
3 weeks after surgery:
contracture released,
appearance of inguinal zone
improved
40  Inguinal Scar Contractures: Anatomy and Treatment

365
Surgical Technique
Planning consists of marking several lines: One along the
fold crest for dividing the healthy skin from scars; a Y-shaped
line along the ligamentum inguinal projection, and two lines
depicting the borders of the trapezoid flap (Figs.  40.1b,
40.2b, and 40.3a). After the fold’s sheet separation and scar
dissection with a Y-shaped incision up to complete the ingui-
nal contracture release, the trapezoid wound appeared.
Corresponding to the form and size of the wound (scar sur-
face deficit), the thigh adipose-cutaneous flap is elevated.
The upper incision for the flap preparation passes nearly
2 cm distally from the perineal fold. Large veins remain in
situ, and almost the entire fat layer is included in the flap.
The flap is transposed on the wound with tension and com-
pensates for the scar surface deficit (Fig. 40.2a). Due to the
flap’s transposition, bulking near the perineal fold disap-
pears, which produces a positive cosmetic effect. “Dog ears”
appearing near the flap’s base are removed by scar excision
(Figs. 40.1c and 40.2c).
As the flap is transposed with tension, it grows inten-
sively, which prevents contracture recurrence in children; in
adults, the flap can be narrower than the wound.
Severe inguinal one-side adduction contracture can be
combined with the inner and anterior thigh surface (donor
site) injury (Fig. 40.4a). If the abdomen wall is undamaged,
reconstruction is performed with a bi-lobed groin flap
(Fig. 40.4b).
a
b
c
Fig. 40.2  Treatment of
severe inguinal contracture,
both sides, with thigh
trapezoid adipose-cutaneous
flaps. (a) SC scars; Sk skin, Cr
crest of the fold. Abdomen,
anterior thigh, and inguinal
zones covered with the skin
transplant; the fold is formed
between the inguinal zone and
the perineum, causing
inguinal both-side
contracture; the lateral fold’s
sheet is scars; the medial
sheet and the neighboring
thigh and perineum are
healthy skin; (b) FP flap;
planning: lines for contracted
scars’ dissection with a
Y-shaped incision, scar
separation from healthy skin,
flaps borders on upper inner
sigh surface; (c) mobilized
adipose-cutaneous trapezoid
flaps covered the wound and
compensated scar surface
deficit
Edge Inguinal Contracture: Anatomy and Treatment with Thigh Adipose-Scar Trapezoid Flap

366
a
b
Fig. 40.4  One-side severe
inguinal adduction
contracture treatment with
bi-lobed groin flap. (a)
Pre-surgery: severe right-­
sided inguinal contracture
with injury to pubis and upper
thigh area (donor site); the
abdomen wall is healthy;
planning of reconstruction
with a bi-lobed groin flap; (b)
view after surgery (scheme)
a
b
c
Fig. 40.3  Inguinal two-sided edge contracture anatomy and elimina-
tion in an adult male with the thigh adipose-cutaneous trapezoid flaps.
(a) Pre-surgery: SC scars; Sk skin; contractures appeared after burns
and skin grafting of abdomen, anterior surface of the thigh and inguinal
zones; contractures caused by the fold in which the lateral sheet is scars,
the medial sheet, perineum, and upper thigh less injured and serve as
donor sites; (b) operation planning; FP flap; (c) 7 days after reconstruc-
tion: FP flap; contracture released, adipose-cutaneous/scar flaps alive
40  Inguinal Scar Contractures: Anatomy and Treatment