With combined flaps, you can use multiple flaps in one design, which is helpful for correcting contractures in folds, such as the elbow crease or knee.

General principles

Combined flaps offer an additional option for treating burn contractures, next to the Z-plasty and interposition flaps. With this technique, you can combine multiple flaps into one design. It works well because post-burn contractures tend to form a fold with an affected (burned) side and a non-affected side. 

One combined flap design is a five-flap plasty that is often very effective in burn contracture reconstruction. It is a double-opposing Z-plasty combined with a central Y-V advancement. This is also known as the ‘jumping man’ flap, as it resembles a person jumping. The jumping man configuration can also be described as three release incisions on the affected scarred side, followed by three interposition flaps from the healthy side.

[Figure 2: Jumping man, knee contracture, healthy side]

Several designs exist; here we use the design by Hirshowitz as an example. It is formed by two mirrored Z-plasties, with an extra incision that allows the possibility of a Y-V advancement. 

To be effective, it is important to harvest from the healthy side the three triangular flaps to be transferred into the release incisions on the contracted side. The tetrahedral effect ensures that length and depth will be gained. This makes the combined flap well suited for correcting burn contractures, particularly those with a fold that has an affected and a non-affected side.

The combined flaps procedure is well suited for correcting contractures in folds – for example, a burn contracture of an axilla, elbow crease, webspace of the hand, finger, or knee fold.

Procedure

This guidance covers the combined flaps procedure from preparation, including the surgical instruments you will need, to the evaluation of results.

Preparing for combined flaps surgery

Marking the flap design

Before marking the flap, it is essential to determine the line of maximum tension (the direction of the contracture). You can do this by extending the affected joint or body part. It is also important to determine which side of the contracture contains the most damaged skin and which side contains the healthy skin.

After you have assessed the affected area, mark the design of the five-flap plasty. You usually do not draw the arms of the jumping man at the start; instead, draw these after you have mobilized the two lateral triangular flaps.

The line between the two rectangular flaps and the three triangular flaps should be in line with the contracture (perpendicular to the axis of rotation of the joint).

The two rectangular flaps (with the releasing incisions) should be located on the side with the most affected, contracted tissue.

The three triangular flaps should be located on the side with the most healthy, unaffected tissue.

Anesthesia

You can perform a five-flap plasty under local (WALANT), regional, or general anesthesia, depending on the location of the contracture, the estimated size and extent of the surgery, and patient characteristics.

For example, you would perform a small five-flap plasty to release a webspace contracture in an adult under local anesthesia, whereas general anesthesia would be more suitable for a large five-flap plasty on an elbow burn contracture in a child.

When using local anesthetic, anesthetize first and then disinfect and drape. This ensures that the anesthetic has sufficient time to work properly.

Even if the procedure is performed under general or regional anesthesia, infiltrate the operative site with local anesthetic and adrenaline/epinephrine. This will greatly reduce the bleeding during the operation, make the dissection easier, and provide postoperative pain relief. Allow 30 minutes for the adrenaline/epinephrine to have the optimal effect and use a long-lasting local anesthetic agent for optimal postoperative pain relief.

Positioning

The positioning of the patient depends on the location of the burn contracture.

Sterilization and dressings

Make sure that the entire site is disinfected and that the sterile drapes do not restrict movement, so that the affected body part can move freely during the procedure. This can help improve exposure and allows you to assess the effect of the contracture release immediately.

Surgery

Contractures are characterized by problematic amounts of skin tension. Due to this tension, the skin on the side of the contracture has a tendency to shrink and the tetrahedral effect of combined flaps is challenging to predict. Therefore, we advise dissecting the releasing incisions and the interposition flaps in stepwise fashion. Doing so gives you the opportunity to alter the design if necessary.

1. Start with the incision in the direction of the contracture (the shoulders of the jumping man).
2. Continue with the releasing incisions (the head of the jumping man) through all fibrotic scar tissue, then make the incisions forming both legs of the jumping man.
3. Raise the central triangular flap in between the legs of the jumping man. In an ideal situation, the Y-V advancement will reach the tip of the V almost at the level of the pivot point of the joint.
4. After you have lifted the central triangular flap, you can raise the two lateral triangular flaps on the healthier side of the contracture. By turning the lateral triangular flaps to their new position on the more affected side, the best position of for the lateral incisions of the rectangular flaps (the arms of the jumping man) become clear, and you can make adjustments if necessary.
5. In a well-designed five-flap plasty, the flaps will almost fall into place by themselves. Make sure that all dissected flaps are the same thickness all over, or slightly thicker at the base. The dissection can be within the subcutaneous tissue if this layer is extensive, but often a supra-fascial plane is preferable to ensure maximum blood supply to the flaps.
6. Check for active bleeding and coagulate if necessary. Be cautious when coagulating on the skin flap as this could damage the vascularization.
7. When suturing the five-flap plasty, start by putting the tips of the three triangular flaps in their new positions. You can use subcutaneous sutures to minimize tension on the skin.
8. We advise using monofilament sutures for the skin. In small children or difficult anatomical locations absorbable sutures can be convenient, as they avoid the need for removal.
9. Depending on the size and location, you can place a small drain.

Contracture release of the left elbow using the jumping man method, step-by-step.

Dressing and fixation

In most cases, you can apply a simple dressing with dry gauzes as a first layer. If the flaps tend to move away from the underlying tissue layer (this is called ‘tenting’), you can apply an elastic bandage or even a tie-over dressing.

Joints that have been affected by a contracture tend to return to their contracted position, and you must avoid this. Therefore, we advise fixation of the affected joint in a position opposing the contracture until the wounds have healed. You can achieve this with a Plaster of Paris slab splint. K-wires are a very useful alternative in the hands, fingers, and toes, where plaster may be less effective, especially in young children.

Postoperative care

After surgery, change the dressing after 3-5 days, or earlier if there is a risk of infection. Remove sutures after 2-3 weeks if they are non-absorbable. If you used K-wires, remove them after 3-4 weeks due to the risk of infection.

You can continue splinting for a longer period, until there is no further risk of the contracture recurring. If the affected joint is not fixed for long enough in the position opposing the contracture, there is a high risk of contracture recurrence.

Physiotherapy

The patient should start active movement and exercises as soon as wound healing permits to maintain the ROM they gained. The availability of physical therapy makes a big difference. If physical therapy is not available, emphasize the importance of exercises to the patient and provide adequate instructions.

You can continue splinting between exercises and during the night. Splinting during the night is sometimes continued for months, even after the wounds have fully healed and the affected limb has returned to normal use.

Splinting works well when the skin quality is good, but it is less effective for stretching remaining scar tissue. In these cases, additional surgery to add extra tissue where needed may be more effective, followed again by appropriate positioning after the additional procedure.

Evaluation of results

We recommend reevaluating the patient until the scars have healed, ideally at least after six weeks, three months, six months, and one year. Measure and document the ROM preoperatively and monitor the development of ROM postoperatively. Explained to the patient that the ROM can continue to improve for months, provided they do their exercises. One year post-procedure, you can make the final measurement and evaluate the result together with the patient.

Management of complications

As burn scars are very fibrotic and therefore often poorly vascularized, complications in wound healing are common. Wound breakdown, necrosis, and infection are the most common complications. This is particularly true when wounds are closed under skin tension. If a local flap such as a jumping man does not provide enough tissue to close the wound without tension, we advise either adding a skin graft or accepting that the joint cannot be fully extended (yet).

You can start antibiotic treatment when indicated for infection. Treat small areas of necrosis and minor wound breakdown conservatively by cleaning the wound and applying antibacterial dressings. The small defects will heal by secondary intention and the end result will often still be adequate in terms of contracture release, so no further treatment will be required.

Surgically debride larger breakdowns with extended necrosis. If the defects are substantial (for instance a complete triangle has become necrotic), treat the area with a skin graft as soon as the wound bed allows, and continue splinting.

Interposition flaps are a suitable surgical technique to treat broad contractures that cover larger areas.

General principles

Broad contractures that cover larger areas (e.g. are not a single-strand) are more extensive and often require a different approach to the archetypal Z-plasty.

If no slack is available in the surrounding skin, a skin graft might be the best option. But if there is slack next to the broad scar, an interposition flap might be a better option to provide vascularized elastic skin.

An interposition flap is like a Z-plasty with a 90-degree release incision in the pathological (scar) tissue, followed by an inlay of a triangular flap of (preferably healthy) tissue. While the Z-plasty angles are asymmetrical to facilitate this, interposition flaps do not necessarily need to be triangular – you can shape them to suit the local situation.

As contractures are characterized by problematic amounts of skin tension, incisions made in the affected skin in the direction of the contracture have a tendency to shrink, while the incision in the healthy skin has the ability to stretch. To account for these effects, it is often wise to release the contracture and dissect the interposition flap in a stepwise fashion.

Doing this gives you the opportunity to assess the need and availability of tissue intra-operatively. It also allows you to adjust the length of the incisions to meet the needs of the individual contracture at hand.

Procedure

This guidance covers the interposition flaps procedure from preparation, including how to mark the flap design, to the evaluation of results.

Here you can find guidance for a relatively simple interposition flap. As you gain experience, you will see more possibilities and solutions. You can then start varying, combining, and fine-tuning your technique to create the optimal treatment for each contracture.

Preparing for interposition flaps surgery

Marking the flap design

Before marking the flap, it is essential to determine the line of maximum tension (the direction of the contracture). You can do this by extending the affected joint or body part, then determining the direction and amount of slack using the pinch test.

After assessing the affected area, mark the contracture release incision perpendicular to the direction of the contracture. To be effective, the incision should run all the way down the scar tissue causing the contracture into the healthy skin. You can then design the interposition flap. The interposition flap itself should be on the healthy, non-contracted skin with the most available slack.

The width of the contracture defines the length of the flap, while both the amount of slack available and the amount of tissue needed to lengthen the contracture define the base of the flap, and thereby the angle of the triangle.

To ensure the blood supply to the tip of the flap, the length should not normally be longer than two to three times the length of the base of the flap.

With this design, the healthy tissue will be interposed into the defect created by the release of the contracture, with tension-free donor site closure.

Anesthesia

Depending on the location of the contracture, the estimated size and extent of the surgery, and patient characteristics, you can perform an interposition flap under local (WALANT), regional, or general anesthesia.

When using local anesthetic, anesthetize first, then disinfect and drape.

Even if the procedure is performed under general or regional anesthesia, infiltrate the operative site with local anesthetic and adrenaline/epinephrine. This will greatly reduce the bleeding during the operation, make the dissection easier, and provide postoperative pain relief. Allow 30 minutes for the adrenaline/epinephrine to have the optimal effect and use a long-lasting local anesthetic agent for optimal postoperative pain relief.

Positioning

The positioning of the patient depends on the location of the burn contracture.

Sterile field

Make sure that the entire site is disinfected and that the sterile drapes do not restrict movement, so that the affected body part can move freely during the procedure. This can help improve exposure and allows you to assess the effect of the contracture release immediately.

Surgery

1. Start with the releasing incision down all the fibrotic tissue to the healthy skin, creating maximum release.
2. Determine whether the rest of the design (the interposition flap) is still adequate. Does the defect created by the release match the flap? Is it still possible to close the donor site (in other words: the base of the flap)? If so, continue with the next incision; if not, adjust the design.
3. When you have made all the incisions, dissect the transposition flap so that you can transpose the flap easily. In a well-designed transposition flap, the flap will almost fall into place by itself. Make sure that the dissected skin is the same thickness all over, or slightly thicker at the base. The dissection should be within the subcutaneous or suprafascial tissues, depending on the location of the contracture.
4. Check for active bleeding and coagulate if necessary. Be cautious when coagulating on the skin flap, as this could damage the vascularization.
5. When suturing the transposition flap, start by closing the donor site, because this is where the tension will be. You can then suture the interposition flap in place. If the local skin has a thick layer of subcutis, you can use subcutaneous sutures to minimize tension on the skin.
6. Ideally, use monofilament sutures for the skin layer, especially in small children or difficult anatomical locations, as they avoid the need for removal.
7. Depending on the size and location, you can place a small drain.

This example shows a patient with a neck burn contracture. It is an an example of a interposition flap described by a pioneer in developing local flaps, professor Limberg (1894–1974).

Dressing and fixation

In most cases, you can apply a simple dressing with dry gauzes as a first layer. If the flaps tend to move away from the underlying tissue layer (this is called ‘tenting’), you can apply an elastic bandage or even a tie-over dressing.

Joints that have been affected by a contracture tend to return to their contracted position, and you must avoid this. We recommend fixation of the affected joint in a position opposing the contracture until the wounds have healed. You can achieve this with a Plaster of Paris slab splint. K-wires are a very useful alternative in the hands, fingers, and toes, where plaster may be less effective, especially in young children.

Postoperative care

After surgery, change bandages after 3-5 days, or earlier if there is a risk of infection. Remove sutures after 2-3 weeks if they are non-absorbable.

If you used K-wires, remove them after 3-4 weeks due to the risk of infection. You can continue splinting for a longer period, until there is no further risk of the contracture recurring. If the affected joint is not fixed for long enough in the position opposing the contracture, there is a high risk of the contracture recurring.

Physiotherapy

The patient should start active movement and exercises as soon as wound healing permits to maintain the ROM they gained. The availability of physical therapy makes a big difference. If physical therapy is not available, emphasize the importance of exercises to the patient.

You can continue splinting between exercises and during the night. Splinting during the night is sometimes continued for months, even after the wounds are fully healed and the affected limb has returned to normal use. Splinting works well when the skin quality is good, but it is less effective in stretching remaining scar tissue. In these cases, additional surgery to add extra tissue where needed might be more effective, followed again by appropriate positioning after the additional procedure.

Evaluation of results

We recommend reevaluating the patient until the scars have healed, ideally at least after six weeks, three months, six months, and one year. Measure and document the ROM preoperatively, and monitor the development of ROM postoperatively. Explain to the patient that the ROM can continue to improve for months, provided they do their exercises. Make the final evaluation measurement one year after the procedure.

Management of complications

As burn scars are very fibrotic and therefore often poorly vascularized, complications in wound healing are common. Wound breakdown, necrosis, and infection are the most common complications. This is particularly true when wounds are closed under skin tension. If a local flap does not provide enough tissue to close the wound without tension, we advise adding a skin graft or accepting that the joint cannot be fully extended (yet).

You can start antibiotic treatment when indicated for infection. Treat small areas of necrosis and minor wound breakdown conservatively by cleaning the wound and applying antibacterial dressings. The small defects will heal by secondary intention and the end result will often still be adequate in terms of contracture release, so no further treatment will be required.

Surgically debride larger breakdowns with extended necrosis. If the defects are substantial (for instance a complete triangle of the Z-plasty has become necrotic), treat the area with a skin graft as soon as the wound bed allows. Without this secondary surgery, these cases will very likely end with a recurrence of their contracture.

The Z-plasty is a surgical technique often used for burn contractures on mobile parts of the body that uses local flaps.

General principles

In a Z-plasty, a Z-shaped incision creates two convergent, triangular-shaped transposition flaps, which subsequently swap positions. 

This exchange recruits adjacent tissue, increasing the length of tissue in the direction of the contracture. The angles and limb lengths of the Z-plasty determine its result and can be tailored to its intended effect, making the Z-plasty very versatile.

The asymmetrical Z-plasty is also known as a ‘banner flap’, as the triangle of healthy tissue resembles a ‘banner’.

You can use a Z-plasty to reposition misaligned tissues, redistribute tension and lengthen scars. Z-plasties are often used for burn contractures on all mobile parts of the body (the neck, axilla, elbow crease, hands, groin, knees, ankles etc.).

Scar contractures can vary from a single strand to a large three-dimensional area. This variation calls for different approaches. Symmetrical Z-plasties in burn contracture treatment are often very effective for single-strand contractures.

Surgical burn contracture release

Example of a contracture of the axilla

Considerations

You should always assess tissue slack when designing a Z-plasty, as it determines the maximum angle and length of the Z-plasty limbs.

The larger the angle and the longer the limbs, the greater the lengthening. But this requires more dissection, and more slack has to be available.

In a classical linear band contracture with an equal amount of non-affected skin on both sides, a symmetrical Z-plasty with angles between 50° and 70° provides the best results.

A 60° Z-plasty provides a length increase of approximately 75% of the central limb, though this increase in length is only possible if there is sufficient tissue slack available in the direction perpendicular to the contracture. This means that the sides of the triangles should not be designed longer than the amount of this tissue slack + 33% of the slack.

For example, to design a 60° Z-plasty with limbs of 4cm, you will need 3cm slack in the direction perpendicular to the central limb.

In practice, the real length gained by a Z-plasty is often less than the theoretical gain indicated by geometry. The elasticity of the skin plays an important role here: the better the elasticity of the adjacent skin, the greater the amount of length gained.

In cases where there is little tissue slack and a relatively long contracture, multiple Z-plasties are indicated. A singular large Z-plasty often provides a greater increase in length than multiple, smaller Z-plasties of the same total length. This means that if there is adequate slack, one larger plasty is better.

The three-dimensional characteristics of a Z-plasty

A Z-plasty has a natural tendency to provide depth in addition to length – this is its tetrahedral effect. A tetrahedron, also known as a triangular pyramid, is a shape characterized by four triangular surfaces, four corners, and six edges.

The tetrahedral effect is most evident when conducting a Z-plasty on non-elastic materials such as neoprene or paper. When conducting a Z-plasty on an elastic cutaneous surface, this depth is witnessed less clearly because the skin stretches and shapes itself to follow the body contours.

However, in specific areas such as an axillary or interdigital fold, you can put the tetrahedral effect to use by adding depth to the flexor crease over the affected joint when performing a release of a burn contracture.

Due to the three-dimensional tetrahedral effect of the Z-plasty, the tissue does not fit into a two- dimensional plane. This means closing a Z-plasty in a flat, two-dimensional configuration gives rise to dog ear deformities – a characteristic bunching of excess tissue above the surface of the skin at the end of a scar after wound closure.

Procedure

This guidance covers the Z-plasty procedure from preparation, including the surgical instruments you need, to post-operative care and the management of complications.

Preparing for a Z-plasty

Marking the flap design

Before marking the flap, it is essential to determine the line of maximum tension (the direction of the contracture). You can do this by extending the affected joint or body part, then determining the direction and amount of slack using the pinch test.

After assessing the affected area, mark the design of the Z-plasty. The archetypal Z-plasty consists of a central limb, typically in line with the scar (shown as a-b in the figure) and two peripheral limbs of equal size at an angle of 60° (a-c and b-d in the figure).

Anesthesia

You can perform a Z-plasty under local, regional, or general anesthesia, depending on the location of the contracture, the estimated size and extent of the surgery, and patient characteristics.

For example, WALANT (Wide Awake Local Anesthesia No Tourniquet) is suitable for a small Z-plasty to release a webspace contracture in an adult, while you should use general anesthesia for multiple Z-plasties on a major burn contracture in a child.

When using local anesthetic, anesthetize first, then disinfect and drape. This ensures that the anesthetic has sufficient time to work properly.

Even if the procedure is performed under general or regional anesthesia, infiltrate the operative site with local anesthetic and adrenaline/epinephrine. This will greatly reduce the bleeding during the operation, make the dissection easier, and provide postoperative pain relief. Allow 30 minutes for the adrenaline/epinephrine to have the optimal effect and use a long-lasting local anesthetic agent for optimal postoperative pain relief.

Positioning

The positioning of the patient depends on the location of the burn contracture.

Sterilization and dressings

Make sure that the entire site is disinfected and that the sterile drapes do not restrict movement, so that the affected body part can move freely during the procedure. This can help improve exposure and enables you to assess the effect of the contracture release immediately.

Z-plasty surgery

1. Start with the central limb incision (the incision in the direction of the contracture).
2. Make the incision that gives the maximal release (one of the peripheral limbs) through all the fibrotic tissue, into the subcutaneous fat down to the level of the fascia. Elevate the triangular flap between the two incisions. The depth of the dissection can be within the subcutis, or in a suprafascial plane. A subfascial plane is often not recommended because it limits the mobility and elasticity of the flap. Maintaining adequate blood supply to the flap while achieving the required mobility are also important factors to consider.
3. You can now transpose the flap and determine the adequacy of the rest of the design. If the design is still adequate, continue with the next incision; if not, adjust the design.
4. Once you have made all the incisions, dissect the second triangular flap so that you can transpose the flaps easily. In a well-designed Z-plasty, the flaps will almost fall into place by themselves. Make sure that the flaps are the same thickness all over, or that they become thicker at the base.
5. Check for active bleeding and coagulate if necessary. Be cautious when coagulating on the skin flaps as this could damage the vascularization.
6. Suture the flaps. It is best to start by putting the tips of the triangular flaps in their new position. If the flaps include a thick layer of subcutis, you can use subcutaneous sutures to minimize tension on the skin. Continue to suture one limb of the Z-plasty. You may often need to cut a small piece of (one) of the flaps to ensure that the size of flap matches the size of the defect.
7. Ideally, use monofilament sutures to close the skin. In small children or difficult anatomical locations, absorbable sutures can be convenient and avoid the need for removal.
8. Place a small drain, depending on the size and location.

How a contracture of the left axilla is released with a z-plasty, step-by-step.

Postoperative care

After surgery, change the dressing after 3-5 days, or earlier if there is a risk of infection. Remove sutures after 2-3 weeks if they are non-absorbable.

If you used K-wires, remove them after 3-4 weeks due to the risk of infection. You can continue splinting for a longer period, until there is no further risk of the contracture recurring.

If the affected joint is not fixed for long enough in the position opposing the contracture, there is a high risk of the contracture recurring.

Physiotherapy

The patient should start active movement and exercises as soon as wound healing permits to maintain the range of motion (ROM) they have gained.

The availability of physical therapy makes a big difference. If physical therapy is not available, emphasize the importance of exercises to the patient and provide adequate instructions.

Continue splinting between exercises and during the night. Splinting during the night is sometimes continued for months, even after the wounds have healed fully and the affected limb has returned to normal use. Splinting works well when the skin quality is good, but it is less effective in stretching remaining scar tissue. In these cases, additional surgery to add extra tissue where needed may be more effective, followed again by appropriate positioning after the additional procedure.

Evaluation of results

Patients should continue to visit a doctor until the wound is completely healed. Measure and document the ROM preoperatively, and monitor the development of ROM postoperatively. Explain to the patient that the ROM will continue to improve for months, provided that they do their exercises. One year post-procedure, you can take the final measurement and evaluate the result together with the patient.

Management of complications

As burn scars are very fibrotic and therefore often poorly vascularized, complications in wound healing are common. Wound breakdown, necrosis, and infection are the most common complications. This is particularly true when wounds are closed under tension. If a local flap such as a Z-plasty does not provide enough tissue to close the wound without tension, we advise either adding a skin graft or accepting that the joint cannot be fully extended (yet).

You can start antibiotic treatment when indicated for infection. Treat small areas of necrosis and minor wound breakdown conservatively by cleaning the wound and applying antibacterial dressings. The small defects will heal by secondary intention and the end result will often still be adequate in terms of contracture release, so no further treatment will be required.

Surgically debride larger breakdowns with extended necrosis. If the defects are substantial (for instance a complete triangle of the Z-plasty has become necrotic), treat the area with a skin graft as soon as the wound bed allows. Without this secondary surgery, these cases will very likely end with a recurrence of their contracture.

Contractures from burn injuries are seen all over the human body, but some areas often present in a similar way. This enables us to provide useful tips and tricks from past experience.

Face and head

Burn contractures and defects on the face and scalp can cause functional impairment and social problems and isolation due to cosmetic disfiguration.

Functional problems are often seen around the eyes, due to loss or retraction of the eyelids causing lagophthalmos, ectropion or inadequate eye opening. Reconstructive surgery of the eyelid can be quite complex, and you should not perform this without proper training. However, contracture release and full thickness grafting are relatively simple procedures that can be of great help for these contractures.

Even relatively small grafts can make a big difference to eyelid function.

Contractures around the mouth can cause problems in lip function and thereby inadequate closure of the mouth. This can lead to impairment of speech, mastication and swallowing. Z-plasties can be very useful in this region, but sometimes grafts are needed – preferably FTGs. You can find the best donor sites around the ear or supraclavicular region, as they provide the best match in color and texture.

Defects on the scalp can lead to necrosis of the exposed skull, especially if there is no remaining vital galea or periosteum. In these cases, skin grafting has little chance of success, as there is no vital wound bed for the graft. You can use large rotation flaps of the scalp to close these defects. You can often close the donor site primarily, but if this is not possible, you can use a skin graft on the vital periosteum, with good chance of success. Another way of creating a vital wound bed for a skin graft is to chisel away the outer table of the skull. The cancellous bone can then be skin grafted.

Hand

Flexion contractures of the hand are common in young children that burn their palmar hands and fingers. The result is a mitten-like appearance of the hand, with the fingers contracted into the palm of the hand.

In most cases, you can obtain a complete functional range of motion after contracture release. In some cases, you may be able to use local flaps to cover parts of the created skin defect, but in almost all cases you will need skin grafts. We advise using full thickness skin grafts, as they provide a better skin quality on the palmar surface of the hands and fingers.

You can easily obtain sufficient skin for a graft from the groin. Do not take the graft too small; you are likely to need more than you think. The skin from the groin is good quality, and it is thin enough to be pliable and have a good take. The groin scar will be hidden under the clothing.

When you release contractures of the fingers, it is of utmost importance to fix the fingers in extension, as the body has a tendency to pull the fingers into a flexed position again. This will hamper the take of the grafts and facilitate recurrence of the contracture.

Finger fixation

We strongly advise axial K-wires through all affected joints in order to provide a stable fixation. Often 1.0- or 1.2-mm wires are strong enough, and you can leave the wires sticking out of the fingertips for easy removal. It can be helpful to bend the K-wires at the tip to prevent them from getting lost inside the body. They usually stay in place for three to four weeks, until the full thickness grafts have healed completely. If a pin tract infection occurs, you will need to remove the K-wires earlier.

After removing the K-wires, the patient should perform exercises several times a day, and splinting in extension is recommended during the night. This should be done for an extended period of time, sometimes up to one year.

The ideal removable splint is made from plastic and has Velcro straps for fixation. These will not be available in many places, but a thick splint, made of Plaster of Paris and fixed with an elastic bandage will also be sufficient and will last for months, provided it is made thick enough.

Elbows and knees

Contractures of elbows and knees are often very similar: they have a scarred area on one side (lateral or medial) and the other side is unaffected (type III contracture). When the scar pulls up and away from the pivot point, it forms a fold in line with the axis of the extremity, thereby stretching the good skin on the unaffected side and enlarging the surface area. This means that on one side of the contracture, there is an area of good skin, and on the other side there is contracted damaged skin. Together they form the fold.

The good skin is ideally situated for a local flap – for example a 5-flap plasty, also known as a jumping man. In these cases, the flaps are made of good skin and you insert them into the release incisions made in the contracted skin. This works best if the two sides of the fold are close together. Due to the typical configuration of these contractures, they can often be released with local flaps only, without the need for grafts. However, do not hesitate to use grafts if you need to.

How to perform combined flaps

Hip/groin and shoulder/axilla

The hip/groin and shoulder/axilla regions are complex in their anatomy and functional mobility. It is crucial to correctly assess the contracture and the amount of release needed, as defects can be substantial and should not be underestimated.

In these regions, you will often need large flaps. The thoracic wall can provide a large flap that you can insert into the contracture after release. You can achieve this using a banner flap, or an asymmetrical Z-plasty (also called an interposition flap). 

How to perform Archetypal Z-plasty

Often the burn scar, and therefore the contracture, is either on the dorsal or ventral side, but rarely on both. You should take the banner flap from the unaffected side to ensure good skin quality.

You can close the donor defect primarily, but if a skin graft is needed a split-thickness skin graft (SSG) will normally be sufficient, and it should not cause problems or risk recurrence if the design is well chosen. In the groin area, you can raise the banner flap from the inner aspect of the thigh or take it from the infragluteal region. You can design interposition flaps around a vascular pedicle that perforates the fascia and use these as perforator-based flaps, which you can island and rotate around their vascular pedicles (though this is beyond the scope of our guidance).

After you have released the contracture, you should close the defect.

You can use the reconstructive ladder as a stepwise approach to the different options available for tissue reconstruction.

The reconstructive ladder

According to the reconstructive ladder, it is best to use the easiest and safest method that will achieve an adequate result. For example, it is advisable not to use a microvascular free flap if you can obtain an equally good result with a local flap.

Options for tissue reconstruction following contracture release, according to the reconstructive ladder.

1. Do nothing
2. Primary closure
3. Skin grafting
4. Local flaps
5. Regional flaps
6. Distant flaps
7. More complex and difficult procedures, such as microvascular free flaps or microvascular allotransplants

There are no mandatory rules here; the reconstructive ladder helps you consider your options carefully. It’s important to note that in addition to patient factors, the skills and experience of the medical team and the setting in which they work will influence the choice you make.

1 Do nothing

Doing nothing may be preferable for the contracture of the mucosa inside the mouth. Due to the fast re-epithelialization in this area, healing by secondary intention of the defect can be preferable to grafting, especially when local flaps are not possible.

The easiest first step on the reconstructive ladder is to do nothing – i.e. to not reconstruct the defect – instead allowing the wound to heal by secondary intention. This is always an option, though often not the best one. 

2 Primary closure

Primary closure is rarely an option in contracture release surgery because there is often a shortage of skin that needs to be addressed.

3 Skin grafting

Skin grafting is often needed for broad band contractures (type IV). The broad scarring caused by an extensive burn wound limits the availability of nearby normal tissue for local flaps.

Considerations for the use of skin grafts in reconstructive surgery include: 

• Shrinkage of the graft (and therefore recurrence of the contracture)
• Infection
• Loss of the graft
• The availability of required equipment, including dressings
• Means of fixation in difficult areas (groin, axilla)
• Color match
• Expected functional and aesthetic outcome

Full thickness grafts (FTG) are likely to have less shrinkage and provide better skin quality than split skin grafts (SSG), but they are limited in their size and availability. The addition of a dermal matrix can improve the quality of an SSG, but dermal substitutes are very expensive and not available in many countries.

Harvesting Full Thickness Graft (FTG)

4 Local flaps

Local flaps are more complex and difficult than skin grafts, but in scar contracture treatment local flaps are preferable to skin grafts. This is because they provide superior results to skin grafting with the correct indication and execution.

Local flaps use local skin and the underlying subcutaneous fat, including its blood supply, to close a defect. This leads to better quality of tissue if performed well. However, it also requires sufficient skin that can reach the defect while preserving the blood supply of the flap.

The design of local flaps is based on judgment of the quality of the local tissues; skin availability, quality, laxity, and blood supply are all important factors to consider.

In general, the rule is that the tissue added to the length will be removed from the width. In the extremities, width means circumference. Local flaps are often a good option in type I, II and III contractures.

When designing local flaps, it is very important to take the three-dimensional configuration of the affected area into consideration. In burn contractures, the scar has often moved away from the axis of the joint, thereby causing the contracture. The elbow is a perfect example that demonstrates this principle.

In textbooks, flaps are often explained with two-dimensional drawings, making it difficult to understand the importance of the third dimension in a clinical case.

Example of a pedicled groin flap used for a burn contracture release on the dorsal side of the wrist

Local flaps and skin grafts

In contracture release surgery for type IV contractures, local flaps alone are usually not enough. In these cases, you will need additional skin grafts. Sometimes skin grafting is the only option, but often a combination of skin grafts and local flaps is possible. In this case there generally two options.

The first (and preferred) option is to use one or more local flaps to form a bridge of comparatively good skin over the most important part the joint, the joint crease, and graft the areas proximal and distal to this bridge.

The second option is to graft the central portion (the area around the flexor crease) and create smaller flaps proximally and distally. An example of the second option is a symmetrical Z-plasty that does not provide enough length alone. In cases with a well vascularized wound bed, you can add a skin graft in the middle.

5 Regional flaps

Regional flaps originate from a nearby area, mostly unaffected by the burn. In general, they are raised from their origin and stay attached via only their vascular pedicle, thus enabling great freedom of movement around this vascular pedicle.

These flaps can be muscle only, musculocutaneous, or fasciocutaneous. Examples of muscle flaps are the latissimus dorsi flap, the pectoralis major flap, and the gastrocnemius muscle flap. These muscle flaps can be used for contracture release, but they will have to be covered with a skin graft.

Therefore, you should limit the use of muscle flaps to situations where the use of a skin graft alone is impossible or undesirable – for instance, when tendons, nerves and blood vessels are exposed.

Some muscles, such as the latissimus dorsi and the pectoralis major, can be used as musculocutaneous flaps, where the overlying skin is transposed with the muscle. This provides excellent skin quality, but the additional bulk can be an unwanted side effect. Mostly, the donor sites can be closed primarily.

An example of a commonly used fasciocutaneous flap is the proximally or distally based radial artery flap, frequently used for soft tissue reconstruction of the elbow or the hand respectively. In recent decades, perforator flaps have become more and more important and their use has significantly increased. These are locoregional flaps based on a small vascular pedicle, allowing translation and/or rotation.

6 Distant flaps

Distant flaps are pedicled flaps from another body part. The best known and most commonly used distant flap is the groin flap, frequently used for deep defects in the hand. The cross-leg flap is another example, but it is used less often today.

Example of a pedicled groin flap used for a burn contracture release on the dorsal side of the wrist

7 More complex and difficult procedures

Microvascular tissue transfer 

This has become an important part of reconstructive surgery over the past decades, but it requires technical equipment, time and specific expertise. Even in high-resource settings, this technique is often not required in contracture release surgery. Therefore, we recommend using local flaps, skin grafts or regional flaps if possible.

If a free flap is needed there are many options. However, more detailed information goes beyond the focus of this website.

Tissue expansion 

You can achieve tissue expansion by implanting an inflatable silicone prosthesis under a healthy area of skin and subcutaneous tissue. By inflating this prosthesis, you can stretch the overlying tissue and induce growth.

After repetitive inflation to the desired size, allow a two to three-month period of consolidation to allow a substantial increase in skin surface area in the desired region. After removing the tissue expander, you can use this tissue as a local, locoregional or regional transposition flap to cover an adjacent defect.

This method is a way of enlarging flaps before using them. Defects on the scalp are frequently treated in this way. Tissue expanders are foreign bodies and therefore have a considerable risk of infection. They are also expensive and not readily available in many countries.

In burn contracture release surgery, it is vital to plan the release incision and reconstruction of the defect.

Scars can contract to varying degrees, from a narrow single line to a large three-dimensional area. Different scars require different approaches. This is where knowledge and experience can make a huge difference.

In general, you can release a scar most effectively with an incision perpendicular (at a 90-degree angle) to the contracture formed by that scar.

In joint contractures, you should make the release incision perpendicular to the direction of the restricted movement of the affected joint, and in line with the axis of that joint. In practice, this means the release incision ‘points’ at the pivot of the joint.

When you plan the release incision, you must also plan the reconstruction technique for the defect.

However, this does not mean you have to make the release incision from one side to the other in the flexor crease of the joint, as this will interfere with the local flaps. Only use this approach when it is clear from the outset that local flaps are not feasible and that a skin graft will be used.

When you use local flaps, you need to design, plan and measure them carefully to achieve the best effect. This will help ensure you avoid designing local flaps that subsequently fail to form skin bridges across the defect, which results in a larger defect with frayed, undermined edges.

How to perform Archetypal Z-plasty

A contracture has various characteristics, like size, depth, location, shape and quality of surrounding skin. It is important to address these before selecting an adequate treatment option.

Scar assessment

Based on specific characteristics, experts have proposed classifications for post burn scar contractures. In our experience, these classifications are useful for understanding contracture release surgery.

However, every contracture has its own characteristics. Describing different classifications for specific joints and developing this into flowcharts oversimplifies the reality.

The classification of axillary contractures into five types (Ogawa et al., Br. J. Plast. Surg. 2003) is an example of a classification system used to select the right surgical methods according to the type of contracture. More recently, Botman and Hendriks used and modified this system (Plast. Reconstr. Surg. Glob. Open 2020).

Contracture classification

A simplified but practical burn scar contracture classification

Type 1

Small and thin burn contractures (a superficial or small part of the joint is affected).

Type 2

Linear band burn scar contracture (creating a fold with two healthy sides).

Type 3

Linear band burn scar contracture with diffuse scarring of the surrounding skin (often one side is more affected than the other side).

Type 4

Broad band burn scar contracture.

Burn scars are known for their poor cosmetic appearance and contracture formation, and patients may therefore require surgery.

Contracture formation often leads to functional impairment, requiring surgical reconstruction. Poor cosmesis and deformation anywhere, but especially of the face, can cause social rejection and isolation, so cosmetic reconstruction may also be important.

Contractures often reduce mobility and impair function. Most commonly, contractures involve one or more joints, but they can also form a constricting band around the circumference of an extremity, interfering with muscle function. If this is around the thorax or abdomen, it can debilitate respiratory function; if it is in the genital area, contracture can interfere with normal urogenital function.

A common misconception is that anything is possible in plastic surgery. Burn victims will often bear visible scars due to their trauma.

The main principle in reconstructive surgery is the restoration of function, with the ideal reconstruction restoring both form and function.

Functional improvement often also means aesthetic improvement. Although reconstruction for functional movement of the extremities is different from reconstruction of burn scars and defects of the face, the same principles apply.

Other features of burn scars, such as discoloration and itching, can cause functional impairment.

Principles of scar management.

General principles of burn scar contracture treatment

Contractures can be caused by deformities of bone, ligaments, tendons, muscle, and skin.

Often, burns and burn contractures are limited to the skin and subcutaneous tissue, and in these cases all the underlying tissues and structures are normal and functional. However, this is not always the case. Fibrosis of deeper layers or loss of functional tissue (nerves, tendons, arteries, veins, ligaments, and cartilage) can seriously impair the outcome of reconstructive surgery and should be taken into consideration.

Always evaluate the scar carefully before attempting reconstructive surgery.

After prolonged exposure to the cause of the burn (for example due to loss of consciousness or epilepsy), the burn wound can be particularly deep and may involve deeper functional structures. 

You can learn a lot about the affected area by examining it carefully. For example, if the joint is easily mobile within the limits of the contracture, it is less likely that the deeper structures are affected. If the joint is completely immobile, but the skin over it can be moved up and down, the contracture may reach the deeper structures and release of a skin contracture will not result in adequate functional improvement.

Assessing the potential of skin release surgery

In most burn contractures, the functional restriction lies in the skin, therefore surgical treatment often means releasing the skin contracture and closing the created skin defect with a flap or a graft.

If the muscles feel supple and normal upon palpation, you may achieve a good result with skin release surgery. But if the muscle feels hard and fibrotic, the functional gain of this surgery is likely to be limited.

Setting up a service for treatment of burn contractures always requires a multidisciplinary approach.

In general, surgery for contractures is only successful if the patient can be given the correct aftercare, such as splinting and physiotherapy.

Muscles and ligaments will shorten over time if their movement is restricted by a contracture of the skin, even when they are not primarily affected by the burn. These structures need to be gently stretched, trained, and sometimes even splinted over a long period of time to regain adequate function.

The longer a contracture has been present, the more difficult it will be to restore full range of motion (ROM) and the more important the aftercare becomes.

Burns can be incredibly painful and difficult to manage. The most comfortable position for the patient depends on the anatomical location of burns and follows the path of least resistance. By following these strategies, we can help to reduce pain and improve the patient's quality of life.

Examples of anti-contracture positioning

Adequate burn wound treatment is essential to minimize problematic scarring.

Scar assessment

After the burn wound has healed and a scar is present, patients often experience scar-related problems. It is vital to first identify the scar-related problems before starting treatment. Therefore, scar management always starts with proper scar assessment.

Scar assessment

Once you have identified the scar-related problems, you can make a treatment plan. This may focus on symptoms requiring non-invasive treatment, such as pain and itchiness, or on those requiring surgical treatment, including functional limitations such as limited range of movement due to contractures.

How to prevent scarring

Adequate burn wound treatment during the wound healing phase is essential to minimize problematic scarring, including contracture formation. Inflammation, infection, prolonged reepithelialization, extracellular matrix production, and remodeling may all influence scar formation.

There are a number of measures you can take to prevent problematic scarring, during the wound-healing phase and the maturation phase (one to two years after the burn injury).

Prevention during the wound-healing phase

Prevention during the maturation phase

Physiotherapy rehabilitation

You should start specific measures to prevent the formation of contractures as early as possible to minimize contractures and achieve optimal range of motion (ROM). This should include a physiotherapy rehabilitation program with key components: stretching and mobilization, anti-contracture positioning, and splinting.

Anti-contracture positioning

Splinting

The most important indications for splinting during burn rehabilitation are tissue and skin graft protection, joint positioning, and tissue lengthening. Using splints forces the tissue to lengthen in a controlled state, and to follow the desired anatomical contour.

Splinting is not an alternative way to prevent contractures for skin grafting in large deep and full thickness burns.

Splinting without an exercise regime could still lead to contracture development.

In the early stages, the patient should be splinted day and night. When you have achieved the desired range of motion (ROM), you can gradually reduce the frequency of splinting.

There are two types of splints: static and dynamic splints.

Static splints immobilize the joint and should be worn during the night. However, the effect of mechanical tension on the wound during the healing process suggests that static splinting may counteract its own purpose by stimulating myofibroblast activity. Therefore, you must be alert and monitor scar development continuously.

Dynamic splints position the joint but allow mobilization against resistance and should be worn during the day, except when exercising.