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.