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A new method in the treatment of postburn scar contractures: Double opposing V–Y–Z plasty
Burns 32 (2006) 499–503 www.elsevier.com/locate/burns
A new method in the treatment of postburn scar contractures: Double opposing V–Y–Z plasty Onder Tan a,*, Bekir Atik b, Duygu Ergen a a
Ataturk University, Medical Faculty, Department of Plastic Reconstructive and Aesthetic Surgery, 25240 Erzurum, Turkey b Yuzuncu Yil University, Medical Faculty, Department of Plastic and Reconstructive Surgery, Van, Turkey Accepted 10 November 2005
Abstract Purpose: Postburn scar contractures are fairly often seen in many parts of the body, and are still a considerable problem for reconstructive surgeons. Although the mild to moderate contractures can easily be managed by numerous surgical methods, serious contractures usually require more comprehensive surgical solutions including multiple Z plasties and rhomboid flaps, each of which have disadvantages. We used a new method called ‘‘double opposing V–Y–Z plasty’’ in this study. This technique is a combination of V–Y plasty with Z plasty in double opposing fashion, both ensuring primary donor site closure. Materials and methods: The technique was applied to 21 postburn scar contractures in 14 patients (9 males and 5 females). The localization most often seen was in the hand. Results: The mean follow-up time was 7.6 months. All flaps healed uneventfully. An adequate lengthening and functional recovery were achieved in all cases. The donor site scars were acceptable in all cases. None of the patients developed contracture recurrence in our series. Conclusions: Double opposing V–Y–Z plasty, as a good alternative to multiple Z plasties and multiple rhomboid flaps, is a very useful technique to insure more lengthening and to prevent recurrence in the treatment of serious postburn scar contractures. # 2005 Elsevier Ltd and ISBI. All rights reserved. Keywords: Burn; Contracture; Rhomboid; V–Y plasty; Z plasty
1. Introduction Postburn scar contractures are fairly often seen in many parts of the body, and are still a considerable problem for the reconstructive surgeons. So far, numerous surgical and nonsurgical treatment modalities have been presented in the treatment of postburn scar contracture which is perhaps one of the most disturbing late sequela of burn. The main goals of the surgical management should be to insure an adequate lengthening using flaps instead of skin grafts to avoid recurrence, to gain an acceptable aesthetic outcome with minimal scar, and to obtain a sufficient functional recovery. * Corresponding author. Tel.: +90 442 2361212x1194; fax: +90 442 2361301. E-mail addresses: [email protected], [email protected] (O. Tan). 0305-4179/$30.00 # 2005 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2005.11.016
Z plasty is one of the most popular techniques used in repair of postburn scar contractures [1]. However, distal flap necrosis may be seen in multiple Z plasty procedures which necessitates extensive undermining [2]. The effectiveness of the subcutaneous pedicled rhomboid flap has also been shown in literature [3,4]. With this technique, the contracture band is released using a rhomboid incision so as to design its long axis parallel to the contracture band. The two distinct advancements in V–Y and Y–V manner are then applied in two distinct planes which are perpendicular to each other. In more serious contractures, however, it is necessary to increase the number of the rhomboid flaps to assure more lengthening. It will result in supplementary and unnecessary scars, increase the recurrence rate, and damage of the delicate anatomical structures depending on the localization. To avoid all these complications concerning multiple Z plasties and rhomboid flaps in serious contractures, we used a new method called ‘‘double opposing V–Y–Z plasty’’,
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O. Tan et al. / Burns 32 (2006) 499–503
which was first described by Ertas et al. as a nameless procedure, in this study. This technique is a combination of V–Y plasty with Z plasty in double opposing fashion, both ensuring primary donor site closure.
2. Materials and methods Between March 2004 and February 2005, the double opposing V–Y–Z plasty technique was applied to 21 postburn scar contractures in 14 patients. There were nine males and five females patients in our series. The mean age was 14.2 years (ranged from 4 to 30 years). The major etiologic cause was scald in nine patients, followed by flame in three, and stove in two. The localization most often seen
was hand in 11 contractures, followed by elbow in 4, axilla in 3, and poplitea in 3. The lengths of the contractures ranged from 2 to 21 cm (mean length was 7.2 cm). All these contracture sites were released and repaired with one each V–Y–Z plasty. Routine supportive care including compressive garments and silicone gel application was followed postoperatively. 2.1. Surgical technique The operation can be performed under local or general anesthesia. A subcutaneous pedicled rhomboid flap which consists of double separate V–Y flaps in opposing manner is centered and marked along the long axis of the contracture to be lengthened with 120 and 608 angles (Fig. 1a).
Fig. 1. Schematic drawing of the double opposing V–Y–Z plasty. (a) Planning of the subcutaneous pedicled rhomboid flap centered along the long axis of the contracture to be lengthened with 120 and 608 angles. This consists of double separate V–Y flaps in opposing manner. (b) Supplement of two Z plasties in each end of the rhomboid flap along the long axis. (c) Full lengthening achieved by each V–Y and Z plasties in opposing manner along the contracture line.
O. Tan et al. / Burns 32 (2006) 499–503
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Fig. 2. A 12-year-old boy admitted with a serious postburn contracture localized in left antecubital area due to scald. (A) Preoperative view and design of the technique. (B) Planning of the Z plasties in each end of the rhomboid flap. (C) A view after completing the procedure.
Wide angles are localized laterally, while the narrow ones proximally and distally to the contracture line. After rhomboid flap is incised down to the deep fascia, some release in the contracture line can be seen. The additional two Z plasties are then designed in both sites of the rhomboid flap along the long axis (Fig. 1b). Thus, the full lengthening is achieved by each V–Y and Z plasties in opposing manner along the contracture line (Fig. 1c).
3. Results The mean follow-up time was 7.6 months (ranged from 5 to 11 months). No early complication including hematoma, infection, and dehiscence of the sutures was seen in any of the patient. All flaps healed uneventfully without partial or total loss. An adequate lengthening and functional recovery were achieved in all cases. All patients regained the function of affected joints with full ranges of motion, postoperatively (Figs. 2–4). The donor site scars were acceptable in all cases. Patient satisfaction in the view of both function and aesthetic outcomes was good. None of
the patient who had this procedure developed contracture recurrence in our series.
4. Discussion The concept of subcutaneous pedicle flaps in the treatment of wide postburn scar contractures was mentioned by Suzuki et al. [5]. In 1994, Uzunismail et al. [3] first described the subcutaneous pedicle rhomboid flap and they used this technique successfully for the correction of digital and first web space contractures due to burn. Recently, Askar [6] also introduced a rhomboid flap based on subcutaneous pedicle to the literature and called this flap double reverse V–Y plasty. Ertas et al. [4] have then proved the subcutaneous rhomboid flap to be effective in the treatment of various postburn scar contractures. The reliable blood supply with a low risk of necrosis based on subcutaneous fat tissue, easy and rapid design are the well-known superiorities of the rhomboid flap. Nevertheless, major handicap of all these techniques mentioned above is that the flap donor site defect generated along the long axis of contracture is
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Fig. 3. An another case with axilar postburn contracture. (A) Preoperative appearance; (B) early postoperative appearance.
closed primarily with the V–Y advancement of the rhomboid flap. This results in linear scar and then recurrence in late phase. Moreover, one rhomboid flap design may also remain insufficient to achieve an adequate lengthening in serious contracture sites. The multiple rhomboid flaps have some disadvantages including supplementary and unnecessary scars, increase in the recurrence rate, and damage of the
delicate anatomical structures depending on the localization. In this case, the double opposing V–Y–Z plasty may be applied instead of adding one or more rhomboid flaps. The double opposing V–Y–Z plasty has some superiority to the single and multiple rhomboid flaps. On the contrary of the subcutaneous rhomboid flap, repairing the resultant large defects as the donor sites of bilateral V–Y flaps
Fig. 4. A case presented with popliteal postburn contracture limiting the knee functions. (A) An aspect prior to operation. (B) Late postoperative aspect shows full extension of the knee.
O. Tan et al. / Burns 32 (2006) 499–503
with two Z plasties instead of primary closure, breaks the resulting linear scar line and prevents future contracture development in our technique. It has a low risk of recurrence. Furthermore, the double opposing V–Y–Z plasty leaves fewer scars and has low risk to damage the delicate anatomical structures, when compared with the multiple rhomboid flaps. Z plasty procedures are an alternative in the repair of scar contractures. However, distal flap necrosis especially in the centre of the scar may be seen as the number of flap increases because the flaps are prone to distal necrosis and wound breakdown secondary to extensive undermining and decreased local vascularity from previous injury [2]. In addition, multiple Z plasties produces dog ears and a bulging effect over the contracture line [1]. We did not see any such tip necrosis and contour deformities due to Z plasties in our technique, since the present technique uses only two separate Z plasties, not too many, and they are located at the periphery of the contracture line where it has relatively low tension and a good tissue quality. It reduces the risk of distal flap necrosis in triangular flaps. Our technique lengthens the centre of the contracture line which has the most tension and scared tissue using more reliable flaps, subcutaneous pedicle double reverse V–Y flaps, while the lengthening in the periphery is achieved by two Z plasties. Gokrem et al. have applied a technique called V–Y–Z plasty similar to the present technique in correction of a mild breast burn contracture in a 16-year-old female patient. Their technique had a one-sited design (not double opposing) compared to that of ours and thus provided a limited lengthening [7]. In 2004, Ertas et al. [4] incorporated Z plasty to both ends of the sutured rhomboid flap to achieve sufficient lengthening in three cases of their clinical series where the subcutaneous pedicle rhomboid flap was used for postburn scar contractures. They concluded that using multiple rhomboid flaps instead of incorporating Z plasty to the technique was more rational since they experienced tip necrosis of triangular flaps in one of the three Z plasty cases. We believed that the three cases were inadequate to evaluate the outcomes of this nameless method and a clinical study was needed. Then, we successfully used this technique in 21 postburn scar contractures of 14 patients with no complications and named it ‘‘double opposing V–Y–Z plasty’’.
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On the contrary to the technique used by Ertas et al., we therefore strongly advise to use our technique for postburn scar contractures. The double opposing V–Y–Z plasty provides an acceptable reconstruction aesthetically with good color and texture matching since this technique uses only local flaps. Moreover, no contour deformities appeared in reconstructed site postoperatively. Our technique is very simple to design and apply, and donor sites are closed primarily without skin grafting after V–Y advancement and Z plasty transposition. The double opposing V–Y–Z plasty is also a fairly versatile technique which can be applied to lengthen all scar contractures in any region of the body due to various causes, including burn. We used this technique in both scarred and skin grafted areas in our series uneventfully. The technique can be applied under general or local anesthesia depending on the patient’s age, and location and the length of the contracture band. In conclusion, double opposing V–Y–Z plasty is a very useful technique to ensure more lengthening and to prevent recurrence in the treatment of serious postburn scar contractures. Thus, this method may be a good alternative to multiple Z plasty and multiple rhomboid flaps in the treatment of long and wide postburn scar contractures.
References [1] Suzuki S, Um SC, Kim BM, Shin-ya K, Kawai K, Nishimura Y. Versatility of modified planimetric Z-plasties in the treatment of scar with contracture. Br J Plast Surg 1998;51:363–9. [2] Rohrich RJ, Zbar RI. A simplified algorithm for the use of Z-plasty. Plast Reconstr Surg 1999;103:1513–8. [3] Uzunismail A, Kahveci R, Ozdemir A, Bozdogan N, Yuksel F. The rhomboid release: a new approach to the management of digital burn contractures. Ann Mediterran Burns Club 1994;8:94–7. [4] Ertas NM, Bozdogan N, Erbas O, Uscetin I, Kucukcelebi A, Celebioglu S. The use of subcutaneous pedicle rhomboid flap in the treatment of postburn scar contractures. Ann Plast Surg 2004;53:235–9. [5] Suzuki S, Isshiki N, Ishikawa K, Ogawa Y. The use of subcutaneous pedicle flaps in the treatment of postburn scar contractures. Plast Reconstr Surg 1987;80:792–8. [6] Askar I. Double reverse V–Y-plasty in postburn scar contractures: a new modification of V–Y-plasty. Burns 2003;29:721–5. [7] Gokrem S, Ozdemir OM, Demirseren ME, Katircioglu A, Can Z, Sevin K. Correction of a mild breast contracture with a new technique: ‘‘V-YZ-PLASTY’’. Eur J Plast Surg 2003;26:255–7.
A new method in the treatment of postburn scar contractures: Double opposing V–Y–Z plasty Onder Tan a,*, Bekir Atik b, Duygu Ergen a a
Ataturk University, Medical Faculty, Department of Plastic Reconstructive and Aesthetic Surgery, 25240 Erzurum, Turkey b Yuzuncu Yil University, Medical Faculty, Department of Plastic and Reconstructive Surgery, Van, Turkey Accepted 10 November 2005
Abstract Purpose: Postburn scar contractures are fairly often seen in many parts of the body, and are still a considerable problem for reconstructive surgeons. Although the mild to moderate contractures can easily be managed by numerous surgical methods, serious contractures usually require more comprehensive surgical solutions including multiple Z plasties and rhomboid flaps, each of which have disadvantages. We used a new method called ‘‘double opposing V–Y–Z plasty’’ in this study. This technique is a combination of V–Y plasty with Z plasty in double opposing fashion, both ensuring primary donor site closure. Materials and methods: The technique was applied to 21 postburn scar contractures in 14 patients (9 males and 5 females). The localization most often seen was in the hand. Results: The mean follow-up time was 7.6 months. All flaps healed uneventfully. An adequate lengthening and functional recovery were achieved in all cases. The donor site scars were acceptable in all cases. None of the patients developed contracture recurrence in our series. Conclusions: Double opposing V–Y–Z plasty, as a good alternative to multiple Z plasties and multiple rhomboid flaps, is a very useful technique to insure more lengthening and to prevent recurrence in the treatment of serious postburn scar contractures. # 2005 Elsevier Ltd and ISBI. All rights reserved. Keywords: Burn; Contracture; Rhomboid; V–Y plasty; Z plasty
1. Introduction Postburn scar contractures are fairly often seen in many parts of the body, and are still a considerable problem for the reconstructive surgeons. So far, numerous surgical and nonsurgical treatment modalities have been presented in the treatment of postburn scar contracture which is perhaps one of the most disturbing late sequela of burn. The main goals of the surgical management should be to insure an adequate lengthening using flaps instead of skin grafts to avoid recurrence, to gain an acceptable aesthetic outcome with minimal scar, and to obtain a sufficient functional recovery. * Corresponding author. Tel.: +90 442 2361212x1194; fax: +90 442 2361301. E-mail addresses: [email protected], [email protected] (O. Tan). 0305-4179/$30.00 # 2005 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2005.11.016
Z plasty is one of the most popular techniques used in repair of postburn scar contractures [1]. However, distal flap necrosis may be seen in multiple Z plasty procedures which necessitates extensive undermining [2]. The effectiveness of the subcutaneous pedicled rhomboid flap has also been shown in literature [3,4]. With this technique, the contracture band is released using a rhomboid incision so as to design its long axis parallel to the contracture band. The two distinct advancements in V–Y and Y–V manner are then applied in two distinct planes which are perpendicular to each other. In more serious contractures, however, it is necessary to increase the number of the rhomboid flaps to assure more lengthening. It will result in supplementary and unnecessary scars, increase the recurrence rate, and damage of the delicate anatomical structures depending on the localization. To avoid all these complications concerning multiple Z plasties and rhomboid flaps in serious contractures, we used a new method called ‘‘double opposing V–Y–Z plasty’’,
500
O. Tan et al. / Burns 32 (2006) 499–503
which was first described by Ertas et al. as a nameless procedure, in this study. This technique is a combination of V–Y plasty with Z plasty in double opposing fashion, both ensuring primary donor site closure.
2. Materials and methods Between March 2004 and February 2005, the double opposing V–Y–Z plasty technique was applied to 21 postburn scar contractures in 14 patients. There were nine males and five females patients in our series. The mean age was 14.2 years (ranged from 4 to 30 years). The major etiologic cause was scald in nine patients, followed by flame in three, and stove in two. The localization most often seen
was hand in 11 contractures, followed by elbow in 4, axilla in 3, and poplitea in 3. The lengths of the contractures ranged from 2 to 21 cm (mean length was 7.2 cm). All these contracture sites were released and repaired with one each V–Y–Z plasty. Routine supportive care including compressive garments and silicone gel application was followed postoperatively. 2.1. Surgical technique The operation can be performed under local or general anesthesia. A subcutaneous pedicled rhomboid flap which consists of double separate V–Y flaps in opposing manner is centered and marked along the long axis of the contracture to be lengthened with 120 and 608 angles (Fig. 1a).
Fig. 1. Schematic drawing of the double opposing V–Y–Z plasty. (a) Planning of the subcutaneous pedicled rhomboid flap centered along the long axis of the contracture to be lengthened with 120 and 608 angles. This consists of double separate V–Y flaps in opposing manner. (b) Supplement of two Z plasties in each end of the rhomboid flap along the long axis. (c) Full lengthening achieved by each V–Y and Z plasties in opposing manner along the contracture line.
O. Tan et al. / Burns 32 (2006) 499–503
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Fig. 2. A 12-year-old boy admitted with a serious postburn contracture localized in left antecubital area due to scald. (A) Preoperative view and design of the technique. (B) Planning of the Z plasties in each end of the rhomboid flap. (C) A view after completing the procedure.
Wide angles are localized laterally, while the narrow ones proximally and distally to the contracture line. After rhomboid flap is incised down to the deep fascia, some release in the contracture line can be seen. The additional two Z plasties are then designed in both sites of the rhomboid flap along the long axis (Fig. 1b). Thus, the full lengthening is achieved by each V–Y and Z plasties in opposing manner along the contracture line (Fig. 1c).
3. Results The mean follow-up time was 7.6 months (ranged from 5 to 11 months). No early complication including hematoma, infection, and dehiscence of the sutures was seen in any of the patient. All flaps healed uneventfully without partial or total loss. An adequate lengthening and functional recovery were achieved in all cases. All patients regained the function of affected joints with full ranges of motion, postoperatively (Figs. 2–4). The donor site scars were acceptable in all cases. Patient satisfaction in the view of both function and aesthetic outcomes was good. None of
the patient who had this procedure developed contracture recurrence in our series.
4. Discussion The concept of subcutaneous pedicle flaps in the treatment of wide postburn scar contractures was mentioned by Suzuki et al. [5]. In 1994, Uzunismail et al. [3] first described the subcutaneous pedicle rhomboid flap and they used this technique successfully for the correction of digital and first web space contractures due to burn. Recently, Askar [6] also introduced a rhomboid flap based on subcutaneous pedicle to the literature and called this flap double reverse V–Y plasty. Ertas et al. [4] have then proved the subcutaneous rhomboid flap to be effective in the treatment of various postburn scar contractures. The reliable blood supply with a low risk of necrosis based on subcutaneous fat tissue, easy and rapid design are the well-known superiorities of the rhomboid flap. Nevertheless, major handicap of all these techniques mentioned above is that the flap donor site defect generated along the long axis of contracture is
502
O. Tan et al. / Burns 32 (2006) 499–503
Fig. 3. An another case with axilar postburn contracture. (A) Preoperative appearance; (B) early postoperative appearance.
closed primarily with the V–Y advancement of the rhomboid flap. This results in linear scar and then recurrence in late phase. Moreover, one rhomboid flap design may also remain insufficient to achieve an adequate lengthening in serious contracture sites. The multiple rhomboid flaps have some disadvantages including supplementary and unnecessary scars, increase in the recurrence rate, and damage of the
delicate anatomical structures depending on the localization. In this case, the double opposing V–Y–Z plasty may be applied instead of adding one or more rhomboid flaps. The double opposing V–Y–Z plasty has some superiority to the single and multiple rhomboid flaps. On the contrary of the subcutaneous rhomboid flap, repairing the resultant large defects as the donor sites of bilateral V–Y flaps
Fig. 4. A case presented with popliteal postburn contracture limiting the knee functions. (A) An aspect prior to operation. (B) Late postoperative aspect shows full extension of the knee.
O. Tan et al. / Burns 32 (2006) 499–503
with two Z plasties instead of primary closure, breaks the resulting linear scar line and prevents future contracture development in our technique. It has a low risk of recurrence. Furthermore, the double opposing V–Y–Z plasty leaves fewer scars and has low risk to damage the delicate anatomical structures, when compared with the multiple rhomboid flaps. Z plasty procedures are an alternative in the repair of scar contractures. However, distal flap necrosis especially in the centre of the scar may be seen as the number of flap increases because the flaps are prone to distal necrosis and wound breakdown secondary to extensive undermining and decreased local vascularity from previous injury [2]. In addition, multiple Z plasties produces dog ears and a bulging effect over the contracture line [1]. We did not see any such tip necrosis and contour deformities due to Z plasties in our technique, since the present technique uses only two separate Z plasties, not too many, and they are located at the periphery of the contracture line where it has relatively low tension and a good tissue quality. It reduces the risk of distal flap necrosis in triangular flaps. Our technique lengthens the centre of the contracture line which has the most tension and scared tissue using more reliable flaps, subcutaneous pedicle double reverse V–Y flaps, while the lengthening in the periphery is achieved by two Z plasties. Gokrem et al. have applied a technique called V–Y–Z plasty similar to the present technique in correction of a mild breast burn contracture in a 16-year-old female patient. Their technique had a one-sited design (not double opposing) compared to that of ours and thus provided a limited lengthening [7]. In 2004, Ertas et al. [4] incorporated Z plasty to both ends of the sutured rhomboid flap to achieve sufficient lengthening in three cases of their clinical series where the subcutaneous pedicle rhomboid flap was used for postburn scar contractures. They concluded that using multiple rhomboid flaps instead of incorporating Z plasty to the technique was more rational since they experienced tip necrosis of triangular flaps in one of the three Z plasty cases. We believed that the three cases were inadequate to evaluate the outcomes of this nameless method and a clinical study was needed. Then, we successfully used this technique in 21 postburn scar contractures of 14 patients with no complications and named it ‘‘double opposing V–Y–Z plasty’’.
503
On the contrary to the technique used by Ertas et al., we therefore strongly advise to use our technique for postburn scar contractures. The double opposing V–Y–Z plasty provides an acceptable reconstruction aesthetically with good color and texture matching since this technique uses only local flaps. Moreover, no contour deformities appeared in reconstructed site postoperatively. Our technique is very simple to design and apply, and donor sites are closed primarily without skin grafting after V–Y advancement and Z plasty transposition. The double opposing V–Y–Z plasty is also a fairly versatile technique which can be applied to lengthen all scar contractures in any region of the body due to various causes, including burn. We used this technique in both scarred and skin grafted areas in our series uneventfully. The technique can be applied under general or local anesthesia depending on the patient’s age, and location and the length of the contracture band. In conclusion, double opposing V–Y–Z plasty is a very useful technique to ensure more lengthening and to prevent recurrence in the treatment of serious postburn scar contractures. Thus, this method may be a good alternative to multiple Z plasty and multiple rhomboid flaps in the treatment of long and wide postburn scar contractures.
References [1] Suzuki S, Um SC, Kim BM, Shin-ya K, Kawai K, Nishimura Y. Versatility of modified planimetric Z-plasties in the treatment of scar with contracture. Br J Plast Surg 1998;51:363–9. [2] Rohrich RJ, Zbar RI. A simplified algorithm for the use of Z-plasty. Plast Reconstr Surg 1999;103:1513–8. [3] Uzunismail A, Kahveci R, Ozdemir A, Bozdogan N, Yuksel F. The rhomboid release: a new approach to the management of digital burn contractures. Ann Mediterran Burns Club 1994;8:94–7. [4] Ertas NM, Bozdogan N, Erbas O, Uscetin I, Kucukcelebi A, Celebioglu S. The use of subcutaneous pedicle rhomboid flap in the treatment of postburn scar contractures. Ann Plast Surg 2004;53:235–9. [5] Suzuki S, Isshiki N, Ishikawa K, Ogawa Y. The use of subcutaneous pedicle flaps in the treatment of postburn scar contractures. Plast Reconstr Surg 1987;80:792–8. [6] Askar I. Double reverse V–Y-plasty in postburn scar contractures: a new modification of V–Y-plasty. Burns 2003;29:721–5. [7] Gokrem S, Ozdemir OM, Demirseren ME, Katircioglu A, Can Z, Sevin K. Correction of a mild breast contracture with a new technique: ‘‘V-YZ-PLASTY’’. Eur J Plast Surg 2003;26:255–7.