Correction of Cord Like Scars Using Running Opposing Y-V Plasty

INTRODUCTION
In spite of great advances in surgical management
of deep burn wounds, delayed complications
like hypertrophic scars, keloid and contracture
scars may occur [1]. Skin contracture is a frequent
complication, which may occur after deep burns
either healed by secondary intension or skin grafts
[2].
Scars over moving areas like face, neck [3] or
upper extremity joints [4] may result in limitation
of movement and creation of contracture scars.
Many surgical options were used for the correction
of burn scar contractures like partial thickness skin
grafts [5], local flaps [6], regional flaps [7], distal
flaps [8] and free flaps [9].
Linear post-burn scar contractures are usually
corrected by surgical release of the scar and recon-
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struction of the created skin defect by single Zplasty,
multiple Z-plasties [10] or W-plasty [11] to
overcome scar contracture with the aid of interposition
of healthy skin into the longitudinally arranged
fibrous tissue of the contracture bands.
Nevertheless, these techniques need separation of
cutaneous flaps from its bed and moving it in an
angled direction through the previously scarred
skin and by doing this, the flaps become more
liable to ischemic complications [12].
In this article, we used the running opposing
Y-V plasty technique for correction of post-burn
contracted scars. Using this technique, we did not
perform either flap undermining nor flap transposition;
thus, we preserve the integrity of the blood
supply regarding such compromised flaps.
MATERIAL AND METHODS
From January 2016 to April 2017, we used
multiple Y-V plasties for correction of 20 contracture
scars in 15 patients. We obtained the approval
of the Institutional review board for this study.
Patients included in this study were complaining
of post burn linear scars affecting a moving part
of the body and causing limitations of movement.
There was enough lateral tissue laxity in all
cases that allow tissue mobilization. Patients with
extensive scaring or who had comorbid conditions
like Diabetes Mellitus or vascular diseases were
excluded from the study.
Surgical technique (Fig. 1):
After the patient was anaesthetized, exposure
of scar was done and the surgical field was sterilized
and draped. First, we marked the contracted scar.
Then, the lateral margin of the contracture band
was identified and outlined. Then, a zigzag line is
drawn along the length of the scar in the form of
multiple connected V shaped lines (Fig. 1 A).
The angles of the V flaps ranges from 60 degrees
to 90 degrees. From the tip of the V flaps, a line
is drawn converting the shape of the flaps from
the V pattern to Y pattern. The length of this line
is usually kept at one third of the length of the
limbs of the V flaps, but it can be extended in a
'cut-as-you-go' technique during surgery to accomplish
maximal advancement regarding the V flaps.
Note that these flaps were marked while the
limb in a relaxed position to avoid the occurrence
of marked primary flap contraction if the flaps
were marked in an extended limb position.
We start by skin incision throughout the epidermis
and dermis in all of the already marked flaps.
Deep incisions are avoided because it results in
marked primary contraction of the flap and marked
distortion of the other flaps' markings. Then, the
incision is deepened into the scar and the underlying
subcutaneous fatty tissue. After minimal undermining,
the apex of the V flaps advance in the bottom
of the congruent limbs of the Ys shaped flaps, thus
continuous running V flaps are created (Fig. 1).
Atraumatic manipulations of the tips of these flaps
were needed. Bleeding points were cauterized. If
the contracture were in an extremity, an inflated
tourniquet was applied until complete wound closure
was accomplished and a compression bandage
was applied.
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Postoperative care included stiches removal
after 2 weeks followed by application of Pressure
garments which were used for at least 3 months.
RESULTS
During this study, we operated upon 20 contracture
scars in 15 patients. The average age was
28 years (range from 10 to 55 years). Nine cases
were males and six cases were females. The causes
of burn injuries were flame, scald and contact with
hot objects. Table (1) shows various sites of postburn
contractures.
All contracture scars were released using multiple
Y-V flaps. All flaps but one survived completely
(Fig. 2). In 2 cases, venous congestion was
noted and improved over days. In one case, there
was partial flap necrosis which was managed by
dressing changes and application of local antibiotics.
All patients were followed-up for a period of
6 months at least. Scars lengthening were obtained.
Two cases developed hypertrophic scars at the
incision site and were managed conservatively by
compression garments and local steroid therapy.
During the follow-up period, only one case showed
recurrence of contracture and required release and
local advancement flap.
Fig. (2): A 14 year old female with postburn contracture scar of the elbow and wrist where preoperative photograph was obtained
(A) postoperative view after making multiple Y-V flaps and release of the contractures (B).
Fig. (1): A 10 year old boy with postburn contracture scar of the neck, anterior axillary fold, elbow and forearm where preoperative
marking was done in the form of a zigzag incision (A) postoperative view after making multiple Y-V flaps and release
of the contractures (B).
(A) (B)
(A) (B)
Egypt, J. Plast. Reconstr. Surg., July 2018 413
DISCUSSION
In this case series, we used running Y-V flaps
for reconstruction of 20 cord-like contracture scars
in 15 patients. All flaps survived completely except
one flap which showed partial necrosis at its tip
and was managed conservatively. All cases were
followed-up for at least six months with satisfactory
results as scar lengthening was achieved.
The technique of running Y-V-plasty was a safe
and reliable option for treatment of cord like scars.
It also was associated with few complications [13].
It was used by many surgeons for correction of
contracture bands resulted from burns [14], congenital
cutaneous defects, traumatic wounds [15] and
Dupuytren's contracture [16].
Some lateral skin laxity frequently exists on
both sides of the contracture band; the gained extra
length of the scar could be obtained by the advancement
of the nearby skin for reconstruction of the
defects created after scar incision [17].
One of the advantages of running opposing YV-
plasty technique is that the surgeon can adjust
the extent of the flap advancement during surgery
by modifying the length of the stems of the Y flaps.
Usually the length of the stems of the Y flaps id
longer than the width of the scar in order to achieve
complete interruption of the scar fibrous tissue.
So, the extent of advancement of the V flap is
conducted in a 'cut-as-you-go' technique during
surgery [18].
The presence of lateral skin laxity on the lateral
borders of the scar is the major determinant of the
technique used to reconstruct the released scar
bands. If there is no skin laxity, skin grafts [19] or
large flaps may be needed [20], but if there is an
abundant lateral skin laxity, which can be determined
by pinch test, on the lateral border of the
scar bands, the technique of running Y-V flaps can
be used safely and effectively. Thus, if we can
grasp the contracture scar with the thumb and index
fingers and these two fingers can meet together,
we can conclude that there is an adequate lateral
skin laxity around the scar and the technique can
be utilized safely [21].
The second determinant of the choice of the
running opposing Y-V flap technique is the required
extent of scar lengthening which is measured by
comparing the length of scared tissue with contralateral
healthy unscarred tissues. If the required
scar lengthening is not more than twice the actual
scar length, the running opposing Y-V flaps can
be beneficial for this case. There are numerous
minor factors which affect the extent of extralength
gained by the running opposing Y-V-plasty
technique. These factors include flap number, flap
size, angle of the v flaps and the length of Y stem
[22].
In this study, one case out of 20 scars reconstructed
showed partial flap necrosis. We think
that this low complication rate is due to minor
need for flap undermining or transposition during
flaps elevation and flap necrosis secondary to
compromised blood supply is avoided.
One of the shortcomings of this technique is
that some residual thick scar band is present after
scar release. However these remnant bands could
be flattened over time after tension release and the
application of external pressure by pressure garments
and local scar therapy like steroid injection
and silicone sheets.
Conclusion:
The running opposing Y-V-plasty have many
benefits like being simple and safe technique with
minimal donor site morbidity nor skin distortion. it
is effective in treatment of cord like scar bands with
favorable results.