Super-thin abdominal skin pedicle flap for the reconstruction of hypertrophic and contracted dorsal hand burn scars

Abstract

Dorsal contracture is one of the most common complications of burned hand and can result in a spectrum of deformities and functional disabilities. The injury usually necessitates surgical reconstruction and to the majority of patients, cosmetic end result is a very important issue.

In this retrospective study, the authors present the technique of super-thin skin abdominal pedicle flap for the treatment of dorsal hand hypertrophic burn contracture, and review the results. Overall 42 medium or large hypertrophic and contracted scars of the dorsal hand in 34 patients were treated using this procedure. Generally, the functional and aesthetic outcomes were evaluated as good. The functional results were comparable to employment of other types of flap with no relapse of contracture. From the aesthetic point of view, the reconstructed skin was similar to the skin of the rest of the extremity, with good color match, bulkiness, laxity, and suppleness. The scar of the donor region was comparable to the scar of abdominoplasty procedures on the ipsi-lateral side of the lower abdomen. Therefore, this procedure can be considered a reliable and technically simple modality in the treatment of dorsal hand burn contractures.

Introduction

Dorsal contracture is one of the most frequent complications of burned hand, and if not primarily treated well, hypertrophic scar and joint deformation may occur resulting in hyperextension of metacarpophalangeal joints, hyperflexion of interphalangeal joints, and formation of unsightly contracted scars in the burned region.

Different methods of management of dorsal hand scars are available, but each technique has benefits and risks. The surgeon may apply one of these methods for each particular patient after assessment of reconstructive advantages and possible complications.

As a reconstructive procedure, simple scar incision and coverage of the resulting defect area with a skin graft is easy to perform, however, the aesthetic results are poor. Resection of the entire hypertrophic scar of dorsal hand and coverage of the resulting defect with a skin graft may aesthetically yield a more acceptable outcome [1], however, this technique may also result in some other drawbacks, such as donor site hypertrophic scars, relapse of contracture, and partial graft failure. Furthermore, even if no complication occurs, the grafted skin color, thickness, and flexibility do not match to the rest of the extremity [2].

When skin graft is not appropriate, different types of flaps have been recommended for the reconstruction of dorsal hand contracted scars. These include, local, regional, distant and even free flaps [3], [4], [5], [6], [7], and could result in good functional outcomes, nevertheless, these procedures result in bulkier than normal skin over the dorsum of the hand. Post-operative de-fatting improves flap bulkiness to some extent, however, even after several de-fatting procedures, flap appearance may not be satisfactory to most of the patients.

The authors were involved in the treatment of burned hypertrophic scars of dorsal hand for many years and have applied most of the above procedures. Considering this long personal experience and reviewing the literature, the authors realized that the majority of patients, especially females with dorsal hand burn scars are sensitive about the appearance of their hand. Even a small dyspigmented area in dorsal hand causes dissatisfaction of these sensitive patients [2]. Moreover, post-burn hand deformation, and reduced hand function can have negative impairing effects on patients’ quality of life from both functional and psychological perspectives [8], [9]. Hence, reconstruction must be performed in a way that results in skin coverage as similar as possible to the healthy undamaged skin, and could comply not only with the functional, but also the aesthetic requirements of the patients.

As an alternative technique for the treatment for vast dorsal hand hypertrophic burn contracture, with the advantages of both skin graft and flap, and also good aesthetic outcome, the authors present the technique of super-thin skin abdominal pedicle flap and review the results. Generally, the functional and aesthetic outcomes of this procedure were evaluated as good. The functional results were comparable to employment of other flaps with no relapse of contracture. From the aesthetic point of view, the reconstructed skin appearance is not bulky and is similar to the skin of the rest of the extremity. The scar at donor site is similar to the scar of abdominoplasty procedures in one side of lower abdomen. Therefore, this procedure could be considered a good reconstructive option in the majority of patients; however, the two-stage procedure may limit its application in some uncooperative or very ill patients with major co-morbid diseases.