Viktor M. Grishkevich Max Grishkevich Plastic and Reconstructive Surgery ooff BBuurrnnss An Atlas of New Techniques and Strategies 123 Plastic and Reconstructive Surgery of Burns Viktor M. Grishkevich • Max Grishkevich Plastic and Reconstructive Surgery of Burns An Atlas of New Techniques and Strategies Viktor M. Grishkevich, MD Max Grishkevich, MD Happy Valley, OR VIP MediSpa USA Clackamas, OR USA ISBN 978-3-319-78713-8 ISBN 978-3-319-78714-5 (eBook) https://doi.org/10.1007/978-3-319-78714-5 Library of Congress Control Number: 2018941866 © Springer International Publishing AG, part of Springer Nature 2018 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by the registered company Springer International Publishing AG, part of Springer Nature. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Preface For I neither received it from man, nor was I taught it, but I received it through a revelation of Jesus Christ. (Galatians 1:12) In the early 1970s, the first ever 55-bed inpatient Department of Plastic and Reconstructive Surgery opened in the A. V. Vishnevsky Institute of Surgery at the Russian Academy of Science in Moscow, Russia. Being a main referral burn center in Russia, we had an opportunity to oper- ate on thousands of burn patients and we came to the conclusion that more research was needed to develop more effective surgical techniques, especially for severely burned patients. Over the years, we studied the anatomical features of patients with burn complications and developed multiple advanced surgical methods to treat scar deformities of skin and soft tissues, especially postburn contractures of joints and other body areas. With divine help and revelations from the Creator, the anatomical structure of scar contrac- tures was successfully studied, which led to the development of new methods for the surgical treatment of burns that significantly improved outcomes for the surgical rehabilitation of burned patients. Some of the most significant results of this research include: • A direct anatomical cause of contractures was established: for most patients, it is a scar surface deficit of a trapezoid shape. This determines the trapezoid shape of the flap neces- sary to compensate for the surface deficit. • Research of the anatomy of the contractures led to a new classification of all contractures: Edge, medial, and total contractures, independent of their location and severity. • Based on the anatomical research, a more effective trapezoid-flap plasty surgical method was developed, which yields superior results for edge- and medial-type contractures (85% of all the contractures seen in clinical settings). • New methods of surgical treatments of face and neck deformities were developed due to the identification of axial blood supply to the skin of the neck. Various surgical techniques using split cervico-thoracic flaps were offered for the reconstruction of burned face tissue and contractures of the neck with great results. • Very important work was done in restoring function of the burned hand (syndactyly, finger contractures, tendinopathies, and arthropathies due to burns). Use of trapezoid-flap plasty for contractures along with mechanical traction devices and tendon transplantation can return function to many disabled patients. • An effective new method for the reconstruction of the shape, position, and skin of the burned breast was developed. • We developed a new treatment method for severe adduction contractures of the shoulders based on the use of axillary island skin or scar tissue in the form of a subcutaneous pedicle flap in combination with skin transplantation. • Sural flap with proximal base was developed and helped resolve the problem with ulcers and skin defects in the Achilles tendon area. v vi Preface We invite you to expand your knowledge and learn new approaches to burn treatment based on a three-dimensional understanding of tissue deficit and excess. Our extensive experience demonstrated that most contractures can be successfully and completely eliminated without re-contracture as long as the surface/tissue deficit is fully compensated. The first two chapters explain the anatomy of contracture surface deficit and classification based on the location of the scar fold and tissue surplus in relation to joint surfaces. Understanding these principles will enable surgeons to apply recommended surgical techniques to a variety of burn contractures regardless of location and severity. Many of the surgical procedures described in this atlas provide detailed planning, marking, and step-by-step surgical details, supported by pictures, schemes, and illustrations. We chal- lenge you to step out of the comfort zone of triangular flaps and try your first Y-shaped radial incision to see an additional 30% release of the contracture and the appearance of a trapezoid wound requiring a trapezoid flap. Once you perform your first successful trapezoid-flap plasty, there will be no going back to triangular flaps for most contractures encountered in your practice. The authors wish success to all surgeons using surgical techniques presented in this atlas. We want to see better outcomes and happy, thankful patients filled with gratitude to God and to the surgeons who offered them help. Happy Valley, OR Viktor M. Grishkevich Clackamas, OR Max Grishkevich Contents 1 Postburn Scar Contracture: Formation, Anatomy and Classification . . . . . . . . . 1 2 Deficit of Postburn Scar Surface is Contracture Cause and Basis for Adequate Reconstructive Techniques Development and Choice . . . . . . . . . . 15 3 Single-Stage Upper Lip and Philtrum Reconstruction in Burned Patients . . . . . 33 4 Postburn Microstomia: Anatomy and Elimination with Trapeze-Flap Plasty . . 41 5 Elimination of Postburn Dorsal Nasal Contracture. . . . . . . . . . . . . . . . . . . . . . . . 47 6 Split Ascending Neck Flap in Burned Face Resurfacing . . . . . . . . . . . . . . . . . . . . 51 7 Burned Half-Cheek Resurfacing Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 8 Total Cheek Resurfacing with Split Ascending Neck Flap . . . . . . . . . . . . . . . . . . 75 9 Postburn Neck Scar Contracture Classification . . . . . . . . . . . . . . . . . . . . . . . . . . 87 10 Medial Neck and Submandibular Scar Contractures: Anatomy and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 11 Unilateral Neck Scar Contracture and Deformity Elimination with Contralateral Split Neck Flap . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 12 Lateral Neck Contractures: Anatomy and Treatment . . . . . . . . . . . . . . . . . . . . . 109 13 Total Neck Anterior Scar Contracture: Anatomy and Treatment with Local Scar-Fascial Trapezoid Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 14 Lateral Truncal Medial Contractures: Anatomy and Treatment with Local Adipose Scar Trapezoid Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 15 Restoration of the Shape, Location, and Skin of Severely Burn-Damaged Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 16 Shoulder Edge Anterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap . . . . . . . . . . . . . . . . . . . . . . . . . 147 17 Edge Shoulder Adduction Contracture in Pediatric Patients: Anatomy and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159 18 Shoulder Edge Posterior Adduction Contracture: Anatomy and Treatment with Axillary Adipose-Cutaneous Trapezoid Flap . . . . . . . . . . . . 167 19 Bilateral Shoulder Edge Adduction Scar Contractures: Anatomy and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 20 Total Shoulder Adduction Contracture Treatment with Preserved Skin in Axilla Apex: Anatomy and Treatment . . . . . . . . . . . . . . . 189 vii viii Contents 21 Shoulder Medial Adduction Contracture: Anatomy and Treatment with Local Adipose Scar Trapezoid Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197 22 Shoulder Total Adduction Contracture After Burns: Anatomy and Treatment with Quadrangular Local Subcutaneous Pedicle Flap . . . . . . . . 205 23 Elbow Edge Flexion Contracture: Anatomy and Treatment with Local Trapezoid Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 24 The Postburn Elbow Medial Flexion Scar Contracture Treatment with Trapeze- Flap Plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 25 Total Elbow Flexion Contracture Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 26 Wrist Scar Contracture, Hand Deviation: Anatomy and  Treatment with  Trapeze- Flap Plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 27 First Web Space Postburn Scar Contractures: Anatomy and Elimination with Local Trapezoid Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243 28 Postburn Dorsal and Palmar Interdigital Scar Contractures: Anatomy and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 29 Postburn Flexion Contractures of Fingers: Anatomy and Treatment with Trapeze-Flap Plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 30 Surgical Treatment of Postburn Boutonniere Deformity . . . . . . . . . . . . . . . . . . . 287 31 Burned Perineum: Anatomy of Medial Contracture and Reconstruction with Trapezoid Adipose-Scar Flaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297 32 Postburn Perineum Obliteration: Elimination of Perineal, Inguinal, and Perianal Contractures with the Groin Flap . . . . . . . . . . . . . . . . . . 303 33 Knee Edge Scar Flexion Contractures: Anatomy and Treatment . . . . . . . . . . . . 307 34 Knee Medial Scar Flexion Contractures After Burns: Anatomy and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317 35 Total Knee Flexion Contracture After Burns: Anatomy and Treatment . . . . . . . 325 36 Ankle Edge Dorsiflexion Scar Contractures: Anatomy and Treatment with Trapeze-Flap Plasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329 37 Medial Ankle Dorsiflexion Contractures and Techniques for Their Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 339 38 Total Ankle Contracture: Anatomy and Treatment . . . . . . . . . . . . . . . . . . . . . . . . 347 39 Proximally-Based Sural Adipose- Cutaneous/Scar Flap in  Elimination of Ulcerous Scar Soft Tissue Defect Over the Achilles Tendon and Posterior Heel Region . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353 40 Inguinal Scar Contractures: Anatomy and Treatment . . . . . . . . . . . . . . . . . . . . . 363 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371 Postburn Scar Contracture: Formation, 1 Anatomy and Classification Introduction Functional Zones of Joint Surfaces Despite significant achievements in burns treatment, the In the plane of surgical treatment, a joint’s surface is divided number of scar contractures is high [1]. Among three burn into flexion (F) and extension (E) surfaces; the boundary consequences—scar deformity, contracture, and tissue among them passes along the joint rotation axis level (“+” defect—contractures most often lead to disability. Therefore, symbol) (Figs. 1.1, 1.2, 1.3, 1.4, 1.5, and 1.6). The flexion sur- efficient treatment of scar contractures is of primary impor- face (F) of large joints (axilla, elbow, knee, ankle, and first tance in the surgical rehabilitation of burned patients. interdigital space) has a curvature of nearly 90°, which divides Treating burn scar contractures remains a challenging prob- it into two parts: flexion lateral (FL) and flexion medial (FM). lem for reconstructive surgeons, and no definitive conclu- The dividing line passes along the edges of joint fossa, ankle sions have been reached about the effectiveness of different anterior surface, and first web space fossa or between the flex- techniques [2]. ion lateral and medial surfaces. The flexion lateral surface of “According to the World Health Organization (WHO) the large joints (one or both joint sides) spreads from the edge burns are a huge global health problem resulting in death of the joint fossa to the joint rotation axis level. The scars, and devastation to those who survive large burns as they are forming the edge commissural contractures (syndactyly, faced with significant functional limitations that prevent microstomia), spread from the fold crest on the dorsal and pal- purposeful and productive living” [3]. For many years, the mar hand to the metacarpophalangeal joints or from the cheek classic approach to contracture treatment used triangular to the normal level of the mouth orifice angle location. Medial local-flap techniques and skin transplantation. Existing flexion surface covers the fossa of large joint, interdigital anatomical contracture names or classifications (linear, fossa, ankle anterior, and neck anterior and lateral surfaces. wide, wide linear, web straight linear, narrow, long, qua- All flexion rounded surfaces of the small (interphalan- dratic, cordlike) do not characterize the contracture anat- geal) joints, neck, trunk, and perineum are considered as one omy that is the basis for successful surgical treatment. The flexion/adduction surface. Scars located on joint flexion sur- techniques based on skin grafting and triangular flaps have faces (lateral and medial) cause the corresponding flexion known disadvantages; therefore, rehabilitation of burned contracture: edge or medial. Scars located on the joint exten- patients with contractures is far from perfect. Our observa- sion surface (beyond joint rotation axis level), do not partici- tions show that the absence of progress in scar contracture pate in the flexion contracture formation. The flexion surfaces treatment with local triangular flaps is caused mainly by of the small (interphalangeal) joints, neck, lateral trunk, and insufficient study of contracture formation, contracture perineum are considered as one flexion medial surface. Scars anatomy, scar surface deficit (contracture cause), and the located on joint flexion lateral surfaces cause “edge” con- lack of anatomical classification of scar contractures. Our tracture. Contracted scars covering flexion medial surfaces classification, based on the anatomy of thousands of clini- form “medial” contracture. Scars that stretch through flexion cal observations, divides all scar contractures into three lateral (FL) and flexion medial (FL) surfaces cause “total” types: edge, medial, and total [4, 5]. contracture. And scars located on the joint extension(E) © Springer International Publishing AG, part of Springer Nature 2018 1 V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns, https://doi.org/10.1007/978-3-319-78714-5_1 2 1 Postburn Scar Contracture: Formation, Anatomy and Classification surface (beyond joint rotation axis level) do not contribute to flexion contracture formation. Scars covering the joint flex- ion lateral or medial surface and causing contractures are strongly connected to undamaged neighboring surfaces— flexion and extension surfaces. Fig. 1.1 Functional zones of big joint surface and shoulder edge con- tracture. E extension surface above the shoulder joint rotation axis (“+”); F joint flexion surface, which is divided by surface curvature into flexion lateral (FL) and flexion medial (FM); the flexion lateral surface is scars, the medial flexion surface (joint fossa) is healthy skin; scars formed the fold (Fd) along the edge of joint fossa; the crest of the fold (Cr) is the edge of scars; Y-line—the distance from the fold’s crest to the joint rotation axis or joint FL surface a b Fig. 1.2 Edge joint flexion contracture formation. (a) Scars on the a different quality: the lateral surface comprises scars and is the cause joint anterior lateral flexion surface and neighbor zones spread down- of the contracture; the medial sheet and the flexion medial surface are ward (distally), involving healthy skin of flexion medial surface (FM) healthy skin (FM). The scar has a surface deficit in length from the fold and form the fold (Fd) located along anterior joint fossa edge, among crest to the joint rotation axis (“+”) and is the cause of the contracture, the flexion lateral and flexion medial surface. (b) The flexion medial and both sheets have a surface surplus; the fold sheets are used for scar surface of the joint is undamaged (FM); therefore, the fold’s sheets have surface deficit compensation and contracture elimination