Treatment of axillary burn scar contracture using opposite running Y–V-plasty
Introduction
Axillary burn scar contractures constitute one of the most complicated challenges to all burn patients and surgeons. Some authors have advocated that the best therapy for the burned axilla is split-thickness skin grafting as soon as possible after injury [1], [2]. However this is followed immediately by immobilization of the shoulder in an abduction splint with constant pressure therapy over the axillary wound. Although variable splints have been devised for the comfort, applicability, and durability, this is in itself a difficult task [3], [4], [5]. Skin grafting tends to contract in spite of splint, massage, and rehabilitation. Several alternatives have been proposed, including Z-plasty, local flaps, regional flaps, transposition flaps, rotating flaps, axial flaps, perforator flaps, and free flaps [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], but these flaps still have some disadvantages such as a bulky, unattractive appearance, the distortion of axillary hair with possible vascular disturbance, and brachial plexus injury [19].
Early in 1975, Hirshowitz et al. combined double Z-plasty and Y–V advancement for thumb web contracture [20]. Four years later, King used the multiple Y–V-plasty to treat Dupuytren's contracture by extensive fasciectomy [21]. The same year, Shaw and Li resurfaced with multiple Y–V advancement flaps to release broad scar contracture following burn [22]. Later, “continuous Y–V-plasty” was presented by Olbrisch for cord-like scar release and the technique has superseded the Z-plasty in the treatment of contracted burn scars [23]. The term “running Y–V plasty” was first clinically used by Xu in 1988 [24]. Olbrisch and Lai et al. subsequently reported the use of running Y–V-plasty for lengthening cord-like burn scar without the complication of tips of transposed skin flaps necrosis from Z-plasty in 1991 and 1995, respectively [25], [26].
Running Y–V-plasty, in the literature, has been defined as keeping the stems of the Ys keeping on the same side of the tip in each V flap at about 1/3–1/2 length of the Vs’ arm or modified in a ‘cut-as-you-go’ manner [25], [26]. What we present here is different from the traditional running Y–V-plasty in that the stems of the Ys are located alternately in opposite tip of V flap to get more advancement and lengthening. We carried out a total eight cases of axillary burn scar contracture using this “Opposite Running Y–V-Plasty (ORYVP)” technique and we report here on the results.
Section snippets
Patients and methods
The demography of these eight cases is summarized in Table 1.
Results
A total of eleven ORYVP procedures (six in anterior and five in posterior axilla) were performed in eight cases (three in right and five in left side) (Table 1). There were six male and two female patients and their mean age was 18.8 years old (range from 4 to 43 years old). The cause of accident was evenly distributed between scald (four cases) and flame burns (four cases). The average period from burn injury to ORYVP procedures was 64.5 months. The mean range of motion in shoulder abduction
Discussion
Traditional running Y–V-plasty could lengthen quite well to release the burn scar and apply in many clinical conditions [24], [25], [26]. The question, though, is why the opposite running Y–V-plasty (ORYVP) may lengthen more than traditional running Y–V-plasty. The reason is that ORYVP can advance in two directions but running Y–V plasty only advances to one side.
Theoretically, we assume that the angle of preoperative zigzag Vs is 90° and the stem of each of Ys equals the arm of the Vs. For
Acknowledgements
We are deeply indebted to Hui-Lan Lin SN and An-Pei Kao MPH for their diligent and careful collection of the data in this study. We also acknowledge Miss Chii-Shur Chiou and Miss Jing-Yi Tian for their kind help in the preparation of this manuscript.
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Cited by (20)
Postburn shoulder medial-adduction contracture: Anatomy and treatment with trapeze-flap plasty
2013, BurnsCitation Excerpt :All these contractures can be easily classified and referred to specific types, and the classification becomes a key for the most appropriate choice of surgical technique. According to various classifications, for treatment of contractures of types 1–3 (which include edge contractures), most aforementioned authors recommend local triangular-flap techniques: Z-, Y-V, V-M, 5-, 7- and 9-flap and rhomboid-flap plasty [15–19]. According to the literature, numeric types 3 and 4 (the entire axillary fossa (dome) is involved) are considered a case when local flaps should be excluded and reconstruction can be efficient when only pedicled or free flaps are used, as skin grafts are correlated with an extremely high incidence of contracture recurrence [20].
Surgical principles for achieving a functional and cosmetically acceptable scar
2013, Actas Dermo-SifiliograficasCitation Excerpt :In the Y-V plasty the skin is incised in the form of a Y, and the triangular flap of the Y is advanced towards the stem of the Y, converting the incision into a V shape.2,27 Although this flap has fewer applications than the V-Y flap, it can be useful for resituating distorted facial structures in a more natural position.28–30 Numerous other plasties have been developed to achieve optimal results in different situations.12,31
Double opposing rectangular advancement flap is an alternative technique in the treatment of wide linear postburn scar contractures
2011, BurnsCitation Excerpt :Preoperative pinching test helps to determine the length and width of the flaps. Most of the techniques used in the treatment of contracture bands (i.e. Z-plasty, Y–V plasty, rhomboid flap) provide elongation along the band in the expense of narrowing of the plane 90 degrees from the desired plan [2,3,7,8]. The elongation and narrowing are often unpredictable with these techniques preoperatively.
Advances in the Care of Children with Burns
2009, Advances in PediatricsCitation Excerpt :Surgical interventions, proven to be beneficial in decreasing scar tension, are generally performed when inflammatory and hypervascular patterns diminish or tissue integrity improves; but nonsurgical methods fail in improving scar hypertrophy. Various surgical techniques are used, including interlesional geometric rearrangements of tissue (Z, W, and Y-V-plasty) and the release of augmenting areas of tension (scar excision with full-thickness skin graft, or biosynthetic, skin flap, free flap, and tissue expanders) [3,131,132]. Other surgical techniques include dermal abrasion (optional adjunct to scar excision that removes epidermis and partial-thickness dermis, smoothing surface irregularities); scalpel sculpturing (uses a scalpel blade to micro-shave and feather the skin edges); cryosurgery (applies nitrous oxide once a month for over 3 months); and laser (removes injury precisely).
A circumferential incision technique to release wide scar contracture
2008, Journal of Plastic, Reconstructive and Aesthetic SurgeryCitation Excerpt :After the operation, the patient could fully extend his knee, and the hypertrophic scar became softer and flatter (Fig. 5B). Linear scar contracture is usually treated by means of a Z plasty, V-Y plasty, or various types of local flaps.11–13 However, these techniques are not very effective for cases involving wide contractures or two or more contracture bundles.14