A New Refinement in Rhomboid Release of Contractures by Adding Four Flap Z-Plasties

Abstract

Sir: Since 1992, rhomboid release has been used in the reconstruction of flexion contractures. The flap is planned in the center of the contracture. The defects that arise after release are closed in the V-Y fashion.1 This prototype was modified by adding Z-plasties on both edges of the flap to close the defects and prevent linear scar formation.2 The technique was reviewed by Ertaş et al.3,4 In this communication, we present a new refinement. The rhomboid flap is combined with four adjacent flap Z-plasties on both sides. Between 2001 and 2005, four patients with 10 different postburn contractures and one patient with a congenital pubic web were treated utilizing the new modification. The rhomboid subcutaneous flap with 60-degree and 120-degree angles is planned at the center of the contracture band. The parts of the flap with 60-degree angles follow flexion creases. The four flap Z-plasties are planned on both edges of the flap (Fig. 1, above). After the release, triangular flaps are transposed and sutured in their new locations (Fig. 1, below).Fig. 1.: (Above) Preoperative drawing. (Below) Triangular flaps are sutured in their new locations.Adequate contracture release and gain in range of motion were achieved in all cases postoperatively. All of the rhomboid flaps and adjacent Z-plasties healed well. The patients received physiotherapy. After a follow-up of 1 year, no contracture recurrence was seen. The use of subcutaneous pedicle flaps to treat burn contractures was first mentioned by Suzuki et al. in 1987.5 The subcutaneous pedicled flaps have turned into perforator flaps in which the perforators have been identified. They have the advantage of primary closure of the donor area. The versatility of the subcutaneous flaps has led plastic surgeons to use them in geometric shapes. The rhomboid flap is one such flap. Rhomboid release has many advantages, especially in the reconstruction of contractures involving important anatomical landmarks, such as the axilla, elbow, pubic area, nipple-areola complex, and digital flexor surfaces. By designing the rhomboid flap on the hairy axilla, the axillary hair will be preserved in its original position and will continue to grow. In case of a burn contracture involving the nipple-areola complex, the nipple and areola can be included in the rhomboid flap, keeping them undisturbed. These important areas may be transposed in their original positions when needed. The rhomboid flap is safer because it is not undetermined, so that important anatomical landmarks can be preserved. This is especially important in burn contractures of areas where there are important vessels and nerves underneath, such as the popliteal area or the inguinal region. Leaving the present contractured tissue in rhomboid fashion over these areas prevents them from being damaged. This new refinement can be added to the plastic surgeon’s armamentarium in release and reconstruction of postburn contractures involving various areas of the body. Adnan Uzunismail, Prof. Dr. Hasan Findik, M.D. N. Sinem Eroğlu Çiloğlu, M.D. Department of Plastic and Reconstructive Surgery Haydarpasa Numune Teaching and Research Hospital Istanbul, Turkey