Total cheek resurfacing with split ascending neck flap: a new approach.

BACKGROUND: Burn scars and other forms of extensive cheek deformities are a tragedy for patients and pose a great challenge to surgeons due to limited availability of well-matching donor sites. The skin of distant regions and skin transplants contrasts with the facial skin. The most suitable site for tissue in cheek reconstruction is the neck, but this resource is limited. Cervical skin expansion is often complicated by tissue necrosis. A new approach (technique) for resurfacing the scarred cheek with a split cervical flap is presented in this paper. METHODS: Sixteen patients with extensive (covering more than half the area) cheek deformities (10 unilateral and 6 bilateral) were operated upon; ages ranged from 6 to 32 years old. First, the split neck flap is transposed on the cheek/cheeks, restoring the lower half; after stabilization of transferred tissues, the cervical flap on the cheeks undergoes balloon extension. Second, the cheek reconstruction is finished with an expanded neck flap. RESULTS: Axial flap circulation prevented tissue necrosis after the first stage of reconstruction. The cervical flap on the cheek tolerated the expander well. In all cases, the cheeks were resurfaced in full with optimally matching sensate skin posing no serious post-operative complications. Cervical skin on the face preserved its natural properties without soft tissue excess and donor site morbidity; neck and cheeks preserved normal contours. CONCLUSION: Good cosmetic outcomes make this technique preferable for adults and children, and the technique is indicated as the first step for deformed cheek resurfacing for patients with uninjured neck.

Postburn neck anterior contracture treatment in children with scar-fascial local trapezoid flaps: a new approach.

One of the dramatic consequences of burns is scar contracture and deformities of the neck. Cervical contracture in children is especially dangerous, leading to face disfigurement and kyphosis; therefore, early reconstruction is indicated. Despite the existence of many various surgical techniques, the successful neck contracture treatment in pediatric patients remains a challenge for surgeons. Eleven children (aged 5 to 14 years) with postburn neck anterior contractures were studied to develop a new approach for reconstruction that would employ the use of local scar-fascial flaps. The new approach and technique for postburn pediatric contracture treatment was developed which is especially effective in the treatment of children who cannot undergo complex and long surgical procedures that are aimed at both contracture elimination and neck skin restoration. The technique consists of two trapezoid scar-fascial flaps mobilization which includes all the anterior neck surfaces and consists of scars, fat layer, platysma, and deep cervical fascia. Counter transposition of flaps with tension elongated neck anterior surface was 100 to 200%. The contracture was fully eliminated, and neck contours, mentocervical angle, and head movement were restored. In case of severe contracture, residual wound in submandibular region and above clavicles were skin-grafted. The full range of head motion (functional results) was achieved in all the 11 patients. The flaps continued to grow and the skin grafts shrinkage was moderate. Local trapeze-flap plasty allows neck contracture elimination in children in the cases when a more complex technique is impossible or undesirable to use. Early surgical intervention prevents secondary complications, allotting enough time for patients to mature and be ready for more complex procedures.

Postburn Neck Lateral Contracture Anatomy and Treatment: A New Approach.

Lateral contracture of the neck is a rare and insufficiently researched burn consequent. Contracture restricts head motion, can cause a secondary face deformity, presents severe cosmetic defects, and, therefore, requires surgical reconstruction. Literature does not sufficiently address the issue; therefore, anatomy not researched and treatment techniques not developed. The anatomy of postburn lateral cervical flexion contracture was studied in 21 operated patients. Using obtained data, new approaches were investigated, which were directed toward maximal efficacy of the local tissues use. Follow-up results were observed from 6 months to 9 years. Lateral cervical contractures were divided into two types based on their anatomy: edge and medial. Edge contractures were caused by burns and scars located on the posterior neck surface and were characterized by the presence of the fold in central lateral zone. In the fold, only one (posterior) sheet is scars that cause the contracture. Medial contractures were caused by scars located on the lateral cervical surface and were characterized by the presence of the fold in which both sheets were scars. In both types, contracture was caused by scar sheet surface deficiency in length, which has a trapezoid form (contracture cause). In all cases, there was surface surplus in the fold's sheets allowed contracture release with local tissue. The technique that allows the maximum local tissue use and ensures full contracture elimination is the trapeze-flap plasty. Two anatomic types of lateral cervical scar contractures were identified: edge and medial. An anatomically justified efficacy reconstructive technique for both types is trapeze-flap plasty.

Proximally based sural adipose-cutaneous/scar flap in elimination of ulcerous scar soft-tissue defect over the achilles tendon and posterior heel region: a new approach.

Scar ulcers that spread over the Achilles tendon and posterior heel disturb patients by causing pain, impeding hygiene, and creating difficulty in finding appropriate shoe wear. As this region undergoes pressure, effective reconstruction is based on the flap use. The most popular flaps currently used are distally based sural fasciocutaneous flap, calcaneal artery skin flap, and free flaps. These flaps, however, are insensate, can create soft-tissue excess, and cause donor site morbidity. Ulcerous soft-tissue defects over Achilles tendon and posterior heel after burns, frost, and trauma were studied and reconstructed in 16 patients, using proximally based sural adipose-cutaneous flap, the anatomy of which was studied on lower extremities of 27 cadavers. Ulcerous soft-tissue defect consists of two parts: ulcer and surrounding pathologic scars that should be excised in one block. Resulting soft-tissue defects with exposed tendon and calcaneal bone varied from 6 to 20 cm in length and 6 cm in width. For such wound resurfacing a flap was developed that was sensate, thin, large, and having steady blood circulation. The flap was harvested from the lower third of the leg and lateral foot, consisting of skin and subcutaneous fat layer (without fascia), including the sural nerve and lesser vein. The blood supply was ensured through peroneal and anterior tibial artery perforators, which formed a vascular net in the flap. In 14 of 16 cases excellent and stable functional and good cosmetic results with acceptable donor site morbidity were achieved. In two patients the distal flap loss took place because of arteriitis obliterans (one case) and because of the cross-cutting of the sural nerve and vessels during previous surgeries (another case). Proximally based sural adipose-cutaneous/scar flap is the only flap that satisfies all requirements for Achilles tendon and posterior heel region resurfacing. The author believes that this technique, based on this flap use, is anatomically justified, clinically profitable, and should be considered as the first choice operation.

Shoulder adduction contracture after burn: anatomy and treatment with quadrangular local scar subcutaneous pedicled flap, a new approach.

BACKGROUND: Axillary adduction contracture is caused by scars that tightly surround the shoulder joint impairing the function of the upper limb. Due to severe scar surface deficiency, contracture release presents a challenge for surgeons since a method of release is transfer of tissue in the form of a large pedicled or free flap(s). Thus, development of simpler, less traumatic techniques, using local tissues, persists. METHODS: Anatomic studies of shoulder adduction contractures after burn (pre-operative, during surgery, post-reconstruction) were done in 346 pediatric and adult patients. All were divided into three groups according to contracture types: with edge contractures (80%), medial (6%) and total (14%). Anatomical study covered peculiarities of total contractures and possibilities for their treatment using local scarred tissue. RESULTS: Total contractures (48 patients) were caused by scars tightly surrounding the joint on three sides: anterior, posterior, and axillary. There were two specific forms of contracture: (a) shoulder close to the chest wall (22 of 48 patients) which was treated with thoracic pedicled or free flaps; (b) in 26 out of 48 patients a flat scar and skin graft surface laid along the shoulder and chest wall, in axillary projection, which were used for contracture release in the form of a subcutaneous pedicled quadrangular flap. The flap was mobilized only peripherally, descending to the apex of the axilla, forming the central axillary zone, and suspension of the axilla on a normal level. Wounds aside the flaps were covered with skin graft. Acceptable functional and cosmetic results were achieved in all 26 patients. CONCLUSION: Total shoulder adduction contractures have two forms: (a) shoulder close/fused with the chest wall; and (b) along the chest wall and shoulder there is a flat surface, the tissue of which can be used for reconstruction in a form of scar subcutaneous pedicled quadrangular flap. Based on this flap, a new technique is described which is relatively easy to perform.

Postburn shoulder medial-adduction contracture: anatomy and treatment with trapeze-flap plasty.

BACKGROUND: Shoulder-adduction contractures after burn, most frequent among big joints, cause functional deficiency of the upper limb and, therefore, benefits from surgical correction. Many reconstructive techniques and flaps have been suggested for contracture treatment, but the problem in choosing an adequate reconstructive technique based on the anatomy of the contracture remains. Shoulder-adduction contracture has been given less emphasis in research than any other type and its surgical reconstructive technique remains of concern. METHODS: Anatomic features of scar shoulder-adduction contractures were studied in 346 patients, personally operated upon. This allowed us to classify all contractures into three types: edge, medial and total. New surgical techniques specifically for medial contractures were developed. RESULTS: Eighty percent of patients had edge contractures in which the axillary fossa was spared. In 20% of patients, axilla, including the hairy dome, was involved. These cases were anatomically classified into two types: medial, making up 30% of the cases, when contracted scars involved only axilla, and total caused by scars, tightly surrounding the shoulder joint. The scars, causing medial contracture, form a crescent-shaped fold along the medial axillary line. The fold's sheets are scars in which there is skin surface surplus in width, which allows the contracture release with local tissues. Surface deficiency in length has a trapezoid form. Medial contracture can be successfully treated with opposite transposition of trapezoid adipose-scar flaps prepared from both sheets of the fold. CONCLUSION: Medial shoulder-adduction contracture is a newly described type with specific anatomic features. Contracture can be successfully treated with local tissues using trapeze-flap plasty.

Ankle dorsiflexion postburn scar contractures: anatomy and reconstructive techniques.

BACKGROUND: Postburn ankle scar contractures cause functional limitations of all lower extremities and create a serious cosmetic defect, not allowing patients to use normal foot wear, and, therefore, needing surgical reconstruction. The anatomic features of ankle dorsiflexion contractures and their treatment have been covered in the literature far less than other joint contractures, and their treatment is still a challenge for many surgeons. A common treatment method is incisional release of the contracture and defect resurfacing with skin graft. Rarely, distally based sural or free flaps and Ilizarov fixator are used. METHODS: Anatomy of postburn ankle scar contractures in 55 patients was studied and contractures were surgically treated using a specific approach and technique. Follow-up results were observed from 6 months to 16 years. RESULTS: According to the anatomic features, dorsiflexion scar contractures were divided into three types: edge, medial, and total. Edge contractures were caused by burns and scars located on the lateral or medial ankle surface and were characterized by the presence of the fold along the anterior edge ankle; the skin of the anterior ankle surface was not injured. Medial contractures were caused by scars located on the anterior ankle surface and were characterized by the presence of the fold along the medial ankle line. Total contractures were caused by scars tightly surrounding the ankle. In fold's sheets of edge and medial contractures there is a trapeze-shaped surface deficit in length (cause of contracture) and a surface surplus in width which allows contracture release with local trapezoid flaps. For total contractures, wide scar excision and skin grafting were indicated. CONCLUSION: Three anatomic types of ankle dorsiflexion scar contractures were identified: edge, medial, and total. An anatomically justified technique for edge and medial contractures is trapeze-flap plasty; total contractures are effectively eliminated with scar excision and skin grafting.

Burned unilateral half-cheek resurfacing techniques.

Postburn cheek deformities are a tragedy for patients and pose a great challenge to surgeons due to a limited number of well-matching donor sites. In cases of unilateral half-cheek deformity, the flap's skin should match the contralateral cheek and the residual skin of the deformed cheek. The skin of a distant flap does not match the facial skin and resembles a patch. The most suitable skin type is the neck's skin and residual cheek's skin transposed on the defect with special techniques. Seventy-six patients with unilateral cheek scars covering nearly half of cheek's surface (total cheek deformities are not included in this series) were personally operated. The deformities were divided into four types or forms: lower cheek, lateral, medial, and upper. The flaps and techniques were designed for each type. The cervical skin, residual cheek skin, and periauricular skin (most matching the cheek's skin) was used in form of different flaps, depending on the scar location on the cheek. The basic flap used was the cervical split flap which could include A) a thoracic adipose-cutaneous layer (cervico-thoracic flap); B) periauricular fasciocutaneous layer (cervico-periauricular and cervico-thoraco-periauricular flaps); C) residual healthy facial adipocutaneous layer (cervico-facial, cervico-facio-periauricular, and cervico-thoraco-facioperiauricular flaps). Cervical flap has axial circulation and is elevated without platysma; it is transposed on the cheek with some tension. The lower and lateral cheek deformities were eliminated most successfully with the cervico-thoraco-periauricular flap by one-stage procedure. Medial and upper cheek deformities were eliminated with the cervico-facio-thoraco-periauricular flap. The facial segment can be expanded (usually in cases of upper cheek reconstruction); in such cases, the thoracic region is not included in the flap (cervico-facio-periauricular flap). The cheeks were reconstructed in all patients without serious complications. The flap's skin matched the contralateral cheek and surrounding healthy skin; the donor site's damage was minimal; operation scars' line was maximally shortened. The use of cervical split flap in combination with thoracic, facial, and periauricular adipose-cutaneous layer opens, in author's opinion, a reliable and most successful way for postburn half-cheek resurfacing.

Postburn edge shoulder adduction contracture: anatomy and elimination with trapeze-flap plasty--a new approach.

Postburn scar shoulder adduction contracture is the most common among big joints' contractures. As the contracture impedes all upper limb function, surgical reconstruction is indicated as early as the contracture is formed. Many flaps and techniques have been suggested, yet the problem is not resolved completely. Three hundred forty-six edge scar shoulder adduction contractures were eliminated personally in 277 patients. Contracture anatomy was studied before and during surgery. Effectiveness of the existing and newly developed techniques was evaluated. Edge shoulder scar adduction contracture is caused by scars located on anterior and/or posterior shoulder joint surface and is characterized by the presence of the fold along the axillary fossa edge. Crest of the fold is the edge of scars. The fold's lateral sheet is scars (causes contracture); medial sheet and axillary fossa skin stay uninjured. Lateral scar sheets have surface deficit in length; the deficit spreads from the fold's crest to the shoulder joint rotation axis and has a trapezoid form. The conclusion was made that the adequate technique should consist of sheet surface deficit compensation with the flap of the same (trapezoid) shape. The medial fold sheet and axillary fossa served as an excellent donor site for the flap. Depending on contracture severity, several variants of the trapeze-flap plasty were developed: trapeze-flaps alone or in combination with skin grafts. In all cases, contractures were eliminated completely with trapeze-flap plasty without serious complications. No flap loss and contracture recurrence took place. The proposed techniques are based on the anatomy of the contracture. They are easy to plan and perform, allow complete restoration of the upper limb's function, and improve shoulder joint region appearance in general. The author believes that the trapeze-flap plasty procedure is a preferred technique for adult and pediatric patients with edge scar shoulder adduction contracture.

Unilateral cervical burn scar deformity elimination with contralateral cervicothoracic flap--a new approach.

Unilateral postburn cervical deformity is a severe cosmetic and functional defect and a challenging reconstructive problem. Many flaps have been suggested; however, after surgery, operational scars, located along the anterior neck's middle line, and the flap's skin differ from cervical healthy skin. A small flap resembles a patch. A more effective and safer technique is neck resurfacing with cervicothoracic adipocutaneous flap which had been used by the author in 32 burned patients. The flap's peculiarities are as follows: axis blood circulation via superficial cervical artery perforator; exclusion of platysma (flap is thin and elastic); and undamaged donor site. The mobilized healthy neck's skin with thin fat layer and adipocutaneous layer of the chest wall are elevated as a whole large flap. After scar excision, the cervicothoracic flap is advanced on the wound with tension. As a result of flap tension, the skin of neck's back, thoracic wall, and axilla are displaced to the anterior neck surface covering the donor wound. On an average, 6 cm of the deformed neck anterior surface was restored. No flap loss but only local superficial scar necrosis along the flap's border occurred. The cervical contracture and scar deformity (25 patients) were eliminated in all cases by a single procedure. For complete neck skin restoration, seven patients underwent staged reconstruction using the same technique. Excellent functional and good cosmetic follow-up results were achieved. The proposed technique is easy to plan and perform and yields good results; therefore, the author believes that the contralateral cervicothoracic flap's use is an exclusive option for unilateral cervical contracture and deformity elimination in adults and pediatric patients.

The elimination of postburn nasal contracture in children with trapeze-flap plasty.

One consequence of a facial burn is nasal contracture. In pediatric patients, scar tension presents a particular problem because of facial growth. The forehead and nasal scar contraction deform the nose dorsum, especially between the eyes. The nasofrontal angle becomes smoothened, wide, and flat; the scar edges cover the inner canthus. The dorsum nose scar stretching delays nasal development, pulls the nose up, making it shorter, and causes nasal ectropion. Secondary deformity of the nose's solid structures develops as a consequence of scar contracture, and its reconstruction poses a major problem. At the same time, it is suggested that nasal reconstruction in the pediatric patients should be planned as a staged procedure. Therefore, scar contracture release should be performed early, at the first stage of pediatric nasal reconstruction, to create conditions for normal nasal development. In this author's opinion, the most suitable procedure is trapeze-flap plasty. The scar tissue surplus in the nasofrontal angle allows contracture release with local tissues. Reconstruction with local trapezoid flaps releases the scar tension and elongates the nasal dorsum surface by approximately 1.5 cm; the epicanthus is eliminated, and the nasofrontal angle (nasal root) is restored. Eight children were operated. Good results were observed in all patients for the duration of 3 years.

First web space post-burn contracture types: contracture elimination methods.

First web space adduction contractures are a common consequence of hand burns. Many reconstructive techniques are used and investigation for more effective methods continues. Effective hand reconstruction usually considers anatomy as its foundation. Based on the experience of over 500 web space contracture elimination cases, three anatomical types of thumb adduction contractures were identified: edge, medial and total. Edge contractures (80% of all thumb adduction contractures) are caused by a fold in which only one sheet is scarred, either the palmar or dorsal surface. The contraction is caused by a trapeze-shaped length deficiency of the scar sheet, which has a surface surplus in width. Reconstruction consists of surface deficiency compensation with trapezoid flap prepared from the non-scarred side and skin-fat tissues of the web space. In most cases, the small scar-fat trapezoid flaps should be prepared from the non-scarred side to cover the donor wounds on both sides of the main flap. Medial contractures (10% of thumb adduction contractures) are caused by the fold, both sheets of which are scarred and have trapeze-shaped surface deficiency in length and surplus in width. Both fold sheets are converted into one or several pairs of trapezoid scar-fat flaps by radial incisions. The oppositely located flaps are transposed towards each other. As a result of the counter flaps transposition, the contracture is eliminated; the web space's shape and depth are restored by the use of flaps alone or in combination with skin grafting. The trapeze-flap plasty is very simple and effective with the length gain of up to 100-200%. Neither flap loss nor re-contracture occurs. Total contractures (about 10% of all) have no fold. Reconstruction consists of the creation of the central zone of the first web space depth with the rectangular subdermal pedicle flap; the wounds on both sides of the flap are skin grafted. The flap sustains normal web depth and prevents the contracture recurrence and skin graft shrinkage.

Post-burn microstomia: anatomy and elimination with trapeze-flap plasty.

Perioral contractures after burn (microstomia) is a common consequence of facial burns. A small oral opening creates a problem for oral hygiene, food intake and intubation. Therefore, contracture treatment is beneficial once severe limitation of function is realised. Traditionally, this type of contracture is released and the defect is closed with Y-V or Z-plasty. A commonly used technique consists of scar excision in the zone of the commissural apex down to the mucosal lining; the mobilised mucosal flaps are rotated up and down to cover the defect. Anatomical studies and surgical treatment experience for scar microstomia (345 patients) showed that a microstomia contracture could be described as an 'edge' contracture and is caused by a fold located at the oral angle. The lateral (exterior) sheet of the fold the scar causing the contracture; the medial sheet is the mucosa. The scar-surface deficit exists in the exterior sheet of the fold and the angle zone. Therefore, additional excision of scar deforms the oral angle. The contracture release, with a Y-shaped incision, and wound coverage (scar-surface-deficit compensation) with the single mucosal flap allows complete microstomia release and oral angle restoration. After the incisional contracture release, the wound, as a rule, accepts a trapezoid form. The defect (wound) is closed with a similar-shaped mucosal advancement flap. Good functional and cosmetic results were achieved in all cases. The commissural angle accepted a normal shape; the mucosal flap was invisible when the mouth was closed; the mouth had a normal appearance when the mouth orifice was open. After an adequate correction, no recurrence of contractures took place. Thus, scar dissection and wound coverage with the trapeze-flap plasty becomes a preferred reconstructive technique for microstomia release after burn.

Trapezoid adipose scar local flap: postburn lateral truncal contracture elimination with trapeze-flap plasty.

Trunk burns result in various complications, deformities, and contractures. Contracture of the lateral surface of the trunk is one of the serious complications that limits movements of the spine; children experience structural changes in the form of scoliosis. Therefore, the lateral truncal contracture should be the subject of early surgical treatment. The currently used method has been the stage-by-stage incisions on the contracture scars and skin grafting or Z-plasty. Skin grafts have a tendency to shrink; thus, compression garments are recommended for an extended period of time after surgery. Triangular flaps are small to complete contracture elimination. The need for development of a more effective surgical technique is apparent. Lateral truncal contracture is caused by a crescent-shaped fold; both sheets of the fold are scars. The sheets have a trapeze-shaped surface deficit in length, which causes the contracture and creates the skin surplus in width. The contracture is of medial type; therefore, it is subject to treatment with local tissues using trapeze-flap plasty. The fold and the adjacent contracted scars are converted into trapezoid flaps by radial incisions. The distance among incisions ranges from 4 to 5 cm, which determines the width of the flap's top. One or several trapezoid flap pairs are planned. The scar flaps are elevated with the subcutaneous fat layer and transposed one toward another with tension, so that the end of one flap reaches the base of the counter flap. As a result, the zone of the plasty is elongated by 100 to 150%. Twelve patients with lateral truncal contractures were operated using trapeze-flap plasty. Good immediate and late results have been achieved. It is the author's belief that trapeze-flap plasty is the most effective technique in light of today's proposed methodology.

Postburn perineal obliteration: elimination of perineal, inguinal, and perianal contractures with the groin flap.

Deep burns of the perineum result in perineal obliteration, hip adduction contracture, and limitation of hip range of motion. Bodily hygiene becomes difficult to maintain. Perineal obliteration is often combined with inguinal and perianal contractures and genitalia injury. These factors present a challenge for the surgeon. The extreme scar surface deficit and the fold absence in the perineal region do not allow contracture elimination with local tissues. As skin grafts shrink, success can be achieved only by using pedicled or free flaps. The groin flap is an excellent tissue for simultaneous perineal, inguinal, and anal reconstruction. In cases involving both perineal and inguinal contractures, two groin flaps can be used simultaneously. The groin flap has steady axis blood circulation that prevents postoperative complications. The donor wound is primarily closed or partially covered with superficial inferior epigastric artery flap (bilobed flap). Corrective procedure is required for "dog-ear" elimination. In children, the flap continues to grow, thus preventing contracture recurrence. Good results have been achieved in four operated patients. This allows one to make the following conclusion: In cases in which the abdominal wall is healthy or not severely injured by scars, groin flap plasty can be considered as a preferable technique for obliterated perineum and multiple perineo-inguino-anal reconstruction in burned adult and pediatric patients.

Postburn hand border contractures and eliminating them with trapeze-flap plasty.

The hand burns can be complicated with the scar contracture of the ulnar or radial hand border. The contracture restricts the mobility of adjacent joints (fifth interphalangeal, wrist joints), causing deviation of the small finger and the whole hand. The contracture and deviation are caused by semilunar fold sheets of which are scars (medial contracture). The fold sheets have the trapeze-shaped surface deficiency in length and surface surplus in width. Thus, the local tissue flaps should have the corresponding form (trapeze-shaped flaps) for surface deficiency compensation. The sheets are transformed into trapezoid flaps along the total length of the semilunar fold with radial incisions until the full tension release is achieved. The incision's ends are split to complete the scar tension release. The distance between radial incisions at the fold's top is approximately 2 to 3 cm, which matches the width of the flap's end. The flaps are mobilized with the full fatty layer and transposed toward each other until the end of one flap reaches the base of the opposite flap. As a result, the skin surface lengthens by two to three times, which allows complete contracture elimination. The contractures were liquidated in all 16 patients without complications. The trapeze-flap plasty is recommended for a wide use in treatment of hand boarder contractures.

Post-burn philtrum restoration.

One of the consequences of face burn is upper lip deformation with philtrum injury. The philtrum's absence poses severe cosmetic defects. A literature review shows no effective developed technique which allows the surgeon to restore the upper lip and the philtrum in a single-stage procedure. The article presents a new method for burn-damaged philtrum restoration. Two scar stripes are deliberately left in place above the upper lip where the normal philtral ridges should be. The width of these two stripes (ridges) should be around 4mm. The upper lip scars, lateral both ridges and between them, are excised forming the philtral dimple. The wound is covered with a split thickness skin graft. Two U-shaped sutures are led through the skin graft, both scar stripes and deeper through the underlying tissues between stripes. A bolster is plunged between the ridges in order to fill the dimple and is fixed by the tie-over dressing with tension. The skin transplant lying laterally to the ridges is covered with a separate tie-over dressing. The bolster is being kept in place for the duration of 7 days. As a result, the scar ridges preserve their height and the dimple keeps its depth. Good long-time follow-up results (up to 7 years) were observed in all 18 patients. In most cases the dimple can be slightly smoothed with time. The suggested method of philtrum restoration is an important component of the burned upper lip reconstruction as part of the post-burn facial resurfacing.

Trapeze-flap plasty: effective method for postburn neck contracture elimination.

The new method for postburn neck contracture management is presented. The method is found to be most effective when using the local flap procedures on patients who cannot undergo complex and long surgical procedures that are aimed at both contracture elimination and neck skin restoration (children, elderly patients, patients with inadequate donor sites, and patients with cosmetically acceptable scar appearance). The method consists of the opposite transposition of trapezoid scar-fascial flaps which are prepared one on each antero-lateral neck surface. Both flaps include scars, fat, platysma and deep cervical fascia. As a result of the trapeze-flap plasty, the anterior surface of the neck is lengthened approximately by 100-200%, the contracture is eliminated and mentocervical angle and head movement are restored. The flaps have reliable blood circulation through the superficial cervical artery perforators, therefore flap loss is rare. The functional results were good in 24 out of 26 patients. The flaps surface does not decrease; therefore, the mild contracture becomes an exception.