An otherwise healthy 17 year-old female patient presented at the outpatient burn clinic with scars due to a burn that had been sustained at the age of three. She had already undergone multiple reconstructive surgeries in, or adjacent to, the inframammary region; her last contracture release was more than two years prior to presentation. A contracture release and split skin graft had been performed; however, further development of her breasts and body had led to an increasing tightness on the right side of her chest.

Scars were visible on the right arm, the right side of the chest, the abdomen, and the mammary and inframammary regions. The scar tissue had caused the breasts to become asymmetrical as they developed, with the right nipple being 5 centimeters lower than the left. The patient could raise her arm, but it was difficult and uncomfortable due to the tightness of scar tissue in the inframammary region, especially in the inframammary fold.

The main goal of surgery was to provide a long term reconstruction that would not re-contract, leading to easier and more comfortable movement of the chest and right arm. Therefore, the surgeon opted for a local pedicled flap based on a perforator (Photo 2). As shown in the pre-operative drawing, a second local flap on the lateral side of the breast was also planned so it could be used if needed. 

To identify the perforating arteries, the operating reconstructive surgeon performed color Doppler sonography one day before surgery. A suitable perforator (red circled P) was identified in the epigastric region, and a second perforator at the right flank 

(Photo 3).

During surgery, the medial flap was created first; after assessing its size and confirming proper circulation, the contracture release was performed in the inframammary fold (photo 4). The most lateral point of the contracture release was chosen by aligning the flap with the defect (photo 5). The release was continued up to this lateral point, allowing for release of the strand of scar tissue on the lateral thorax. The defect after releasing the scar contracture could be completely covered by the medial perforator-based interposition flap, therefore the second more lateral flap was not needed.

To secure the inframammary fold, the flap was anchored cranially using non-absorbable sutures. Subcutaneously, a size 4.0 absorbable suture was used for the flap and donor site, and the skin was closed using rapidly absorbable monofilament sutures (photo 6).

The wound was covered with dry gauzes. Outpatient follow up was planned nine days post-procedure. By then, the tip of the graft was quite dark (photo 7) and after four weeks crusts had formed. These were partially removed and a non-adhesive gauze was applied. On day 37 post-procedure a superficial wound was still present on the lateral side of the thorax (photo 8).

Four months postoperatively the wound had healed without surgical intervention. The donor site showed a broadening of the scar and the tension was reduced, but the patient still experienced some tightness when she elevated her right arm (photo 9).

Two years after the surgery the patient was very satisfied with the functional and cosmetic outcomes. When interviewed for this book, eleven years after the procedure, she was still happy that she had opted for a surgical release. Later, during pregnancy, the elasticity of the flap had shown its benefit by increasing its surface area as the pregnancy developed (photo 10).

The strategy for a contracture release is related to a patient’s context and future. Aspects to consider in female patients with burns in a similar area are breast development and future pregnancy. In reconstructive surgery it is recommended to explore different treatment options as shown in the drawings in the patient file (photo 3). The patient is this example shared that she was very happy that she was involved in the decision making for the contracture release surgery.

The split skin grafts had been a safe and relatively simple solution for this patient in the past, however, SSGs are subject to shrinkage. This time, a perforator-based interposition flap was chosen because, compared to skin grafts, flaps do not tend to shrink, and even possess the ability to increase in surface area. 

To increase the chances of survival of local flaps, duplex sonography (or simple handheld Doppler sonography) can be helpful to identify perforating arteries in the base of flap. As a rule, normal local flaps should be designed with a length that is approximately 2-3 times that of the base of the flap, depending on the region. Flaps with significant perforators can be longer due to the increased blood supply at the base of the flap. Note that in this example the perforator flap was not islanded, and therefore the perforator blood supply was only contributary, and the flap was not solely dependent on the perforator. Not islanding the flaps also aids in a better venous outflow (photo 3). Even in experienced hands it can be difficult to predict if the tip of the flap will survive, as shown in this example.