Postburn Contractures Research Articles

Interplast Italy: A 20-Year Plastic and Reconstructive Surgery Humanitarian Experience in Developing Countries

Interplast Italy is a nongovernment, nonprofit organization with the aim of providing high-quality standard reconstructive procedures, contributing to local medical and nursing education, in those countries where this is not available or where the local resources are inadequate to meet local needs. A recent debate about the real aim and the effectiveness of this kind of health support strategy in developing countries has been raised. The authors report a 20-year experience, explaining operative strategy, activities, and results, and contributing to the development and improvement of the philosophy of humanitarian missions. Since 1988, 47 missions and 5235 operations have been performed. A total of 2286 patients (43.7 percent) were younger than 18 years, and 2949 (56.3 percent) were above that age. Congenital cleft deformity was the most common diagnosis in 2415 patients (46.13 percent). Patients suffering from postburn contractures were operated on in 1956 cases (37.36 percent). The number of postburn children operated on was 922 (17.6 percent). Cooperation with local physicians is considered mandatory to guarantee adequate patient preselection, to organize the activity in situ, and to plan continuous effective work on a regular basis to build local capacity and facilitate sustainable models for health care. Furthermore, as local surgeons become interested in reconstructive surgery, continuous teaching through a multidisciplinary approach must be paramount. The activity of Interplast Italy contributed to building a plastic surgery service in Bangladesh. Combined multidisciplinary activities linked to established organizations such as the Interplast confederation are desirable to improve results. A link with structured organizations is needed to obtain financial resources to extend targets and to improve activities and outcomes.

V-M Plasty and Double Z-Plasty

The release of postburn contractures in the hand is one of the most commonly performed procedures in burn injuries. Various local flaps have been described for release of severe postburn contractures. As the largest burn center covering north and northwest of Iran, we always needed acceptable reliable methods to reconstruct postburn syndactyly and make it as a standard treatment. We used double Z-plasties for the first web in severe contractures (23 patients) and V-M plasties for the second, third, and fourth webs and minor first web contractures (V for the dorsal aspect and M for the volar aspect of the webs). A total of 50 patients from September 2005 to June 2007 with 130 web contractures were operated. Their age ranged from 1 to 75 years. In a 1-year follow-up, all of the patients had good mobility of the fingers with no recurrence. Three cases of necrosis of tip of Z-plasties and 2 cases of necrosis of tip of V-M plasties occurred which were under 3 mm and resolved gradually. Double Z-plasty in first web and V-M plasty in second to fourth webs are considered good choices for release and reconstruction of postburn syndactyly. They are straightforward in technique and can be carried out with little complications.

Pattern and outcome of children admitted for burns in Benin City, mid-western Nigeria

ABSTRACTChildren are a vulnerable to burns, an injury, which is often preventable. A study of the profile of cases of children admitted for burns will provide background information to suggest locally doable preventive strategies as well as supply basic information for future reference. We studied the records of 62 children aged 0-16 years, admitted for burns, at the University of Benin Teaching Hospital, Benin City, between January 2002 and December 2006. There were 34 male and 28 female children. Children under three years constituted 56.5%. Whereas the leading cause of burns in all the children was flame burns from kerosene explosions (52%), scalds were responsible for 68.6% of cases in those under three. The extent of burn injury ranged from 6 to 50% and most of them presented late. 64.6% were discharged within three weeks. Wound sepsis and post burn contractures were the most frequently encountered complications (19.4% and 9.7% respectively). There were two deaths (3.2%) related to sepsis. Particular attention to burn safety precautions in children (especially, in the >3 years age group), safer storage and dispensing of combustible chemicals particularly petroleum products is advocated. Fire safety awareness, correct first aid measures and early presentation in the hospital will reduce morbidity and mortality. Early physiotherapy and splinting strategies will reduce contractures. There is the need locally for the establishment of specialized burn centres both to treat these children and to stimulate interest in burn management.

A comparative study to evaluate the effect of honey dressing and silver sulfadiazene dressing on wound healing in burn patients

ABSTRACTTo compare the effect of honey dressing and silver-sulfadiazene (SSD) dressing on wound healing in burn patients. Patients (n=78) of both sexes, with age group between 10 and 50 years and with first and second degree of burn of less than 50% of TBSA (Total body surface area) were included in the study, over a period of 2 years (2006-08). After stabilization, patients were randomly attributed into two groups: ‘honey group’ and ‘SSD group’. Time elapsed since burn was recorded. After washing with normal saline, undiluted pure honey was applied over the wounds of patients in the honey group (n=37) and SSD cream over the wounds of patients in SSD group (n=41), everyday. Wound was dressed with sterile gauze, cotton pads and bandaged. Status of the wound was assessed every third and seventh day and on the day of completion of study. Patients were followed up every fortnight till epithelialization. The bacteriological examination of the wound was done every seventh day. The mean age for case (honey group) and control (SSD group) was 34.5 years and 28.5 years, respectively. Wound swab culture was positive in 29 out of 36 patients who came within 8 hours of burn and in all patients who came after 24 hours. The average duration of healing in patients treated with honey and SSD dressing at any time of admission was 18.16 and 32.68 days, respectively. Wound of all those patients (100%) who reported within 1 hour became sterile with honey dressing in less than 7 days while none with SSD. All of the wounds became sterile in less than 21 days with honey, while tthis was so in only 36.5% with SSD treated wounds. The honey group included 33 patients reported within 24 hour of injury, and 26 out of them had complete outcome at 2 months of follow-up, while numbers for the SSD group were 32 and 12. Complete outcome for any admission point of time after 2 months was noted in 81% and 37% of patients in the honey group and the SSD group. Honey dressing improves wound healing, makes the wound sterile in lesser time, has a better outcome in terms of prevention of hypertrophic scarring and post-burn contractures, and decreases the need of debridement irrespective of time of admission, when compared to SSD dressing.

Burned Perineum Reconstruction: A New Approach

The treatment of postburn contractures of perineum remains a complex and an unsolved problem. Fourteen patients were operated. According to our observations, the perineum contracture can have two formations: (a) transverse scar folds formed between both the thighs and (b) obliteration of perineum by scar tissues. The first type, most common, is successfully eliminated by using local trapezoid flaps. The flaps are prepared from the divided sheets and adjacent tissues on both inner thighs' surfaces. The flaps are performed by cross-incisions of the fold; several pairs of adipose-scar flaps are formed. Because of the crescent shape of the fold, the flaps acquire a trapezoid shape. Then, they are transposed toward each other without rotation, doubling the surface of maximum tension thus eliminating the contracture completely. This technique allows releasing the contracture without skin grafting. The flaps are 4 to 5 cm wide, and they contain subcutaneous fat layer and have no sharp angles. All this assures stable circulation and prevents necrosis, flap loss, and contracture recurrence.

The effect of epidural anaesthesia on the reverse-flow fasciocutaneous flap: An experimental study in rabbits

Background: The reverse-flow fasciocutaneous flap has been popularised as a feasible alternative to reconstruction of the post-burn contractures around lower-extremity joints. The effect of epidural anaesthesia (EA) on the haemodynamics of reverse-flow fasciocutaneous flap (RFFF) has not yet been investigated. Therefore, it was our primary objective to determine how EA impacts on vascular haemodynamics and tissue perfusion. Materials and methods: This study included 30 New Zealand white rabbits. The reverse-flow saphenous fasciocutaneous island flap in rabbit model was used. In group I ( n = 10), epidural catheterisation of the rabbits were performed and they received an epidural infusion of 0.1 ml kg −1 0.125% bupivacaine 12-h periods until the 10th day. In group II ( n = 10), epidural catheterisation of the rabbits was performed and they received an epidural infusion of 0.1 ml kg −1 isotonic sodium chloride solution. In group III ( n = 10), epidural catheterisation of the rabbits was not performed. Intra-arterial blood pressure (IABP) and intravenous blood pressure (IVBP) was recorded at time intervals of 5, 15, 30 and 60 min, respectively, after tourniquet release on the first and 10th day. Microcirculatory flow was measured by laser Doppler flowmetry at 2, 4, 6, 8 and 10 days in all the groups. Results: Throughout the experiment, the flaps showed complete survival. A significant difference was noted in the microcirculatory flow measurements in the flap surfaces between group I and groups II–III throughout the experiment ( p < 0.05). A significant difference was noted in IVBP and IABP between group I and groups II–III ( p < 0.05). On the first and the 10th day, however, there were no significant differences between groups II and III ( p > 0.05). Conclusion: EA improves blood flow to RFFF and prevents the progression of venous congestion.

Reconstruction of postburn inguinal contractures using the pedicled anterolateral thigh flap

Reconstruction of postburn inguinal contractures using the pedicled anterolateral thigh flap

Uso de sustituto dérmico en niños con secuelas de quemaduras: Tres casos clínicos

Introduccion: En COANIQUEM se realizan cirugias reconstructivas de secuelas de quemaduras en forma ambulatoria, en pacientes pediatricos durante su tratamiento de rehabilitacion. Una de estas cirugias es la tecnica tradicional del desbridamiento mas injerto dermo-epidermico. Una nueva alternativa ha sido la aparicion del sustituto dermico Integra (Dermal Regeneration Template). En Chile, no existe experiencia con este sustituto dermico aplicado en forma ambulatoria en ninos con secuelas de quemaduras. Objetivo: evaluar la utilizacion de un sustituto dermico en forma ambulatoria, en pacientes pediatricos con secuelas de quemadura y su evolucion a dos anos plazo. Casos clinicos: cirugias realizadas durante 2004 en tres pacientes de 9 a 13 anos de edad, con secuelas estetico-funcionales de extremidad superior. Se aplico protocolo de evaluacion de rehabilitacion a 24 meses y administracion de test de calidad de vida (BSHS). Resultados: No hubo complicaciones quirurgicas en los tres pacientes; el porcentaje de prendimiento vario entre 75 y 100%. Todos requirieron presoterapia por 13 meses. La elasticidad y plegabilidad fue similar a la piel normal a los dos anos de evolucion, con ausencia de fibrosis y contraccion del injerto. BSHS resulto favorable. Hubo presencia de infeccion leve en un caso. Conclusion: El sustituto dermico Integra® es una buena alternativa de tratamiento y es posible su uso en forma ambulatoria sin mayores complicaciones quirurgicas.

Pattern and outcome of children admitted for burns in Benin City, mid-western Nigeria

Children are a vulnerable to burns, an injury, which is often preventable. A study of the profile of cases of children admitted for burns will provide background information to suggest locally doable preventive strategies as well as supply basic information for future reference. We studied the records of 62 children aged 0-16 years, admitted for burns, at the University of Benin Teaching Hospital, Benin City, between January 2002 and December 2006. There were 34 male and 28 female children. Children under three years constituted 56.5%. Whereas the leading cause of burns in all the children was flame burns from kerosene explosions (52%), scalds were responsible for 68.6% of cases in those under three. The extent of burn injury ranged from 6 to 50% and most of them presented late. 64.6% were discharged within three weeks. Wound sepsis and post burn contractures were the most frequently encountered complications (19.4% and 9.7% respectively). There were two deaths (3.2%) related to sepsis. Particular attention to burn safety precautions in children (especially, in the >3 years age group), safer storage and dispensing of combustible chemicals particularly petroleum products is advocated. Fire safety awareness, correct first aid measures and early presentation in the hospital will reduce morbidity and mortality. Early physiotherapy and splinting strategies will reduce contractures. There is the need locally for the establishment of specialized burn centres both to treat these children and to stimulate interest in burn management.

A comparative study to evaluate the effect of honey dressing and silver sulfadiazene dressing on wound healing in burn patients.

To compare the effect of honey dressing and silver-sulfadiazene (SSD) dressing on wound healing in burn patients. Patients (n=78) of both sexes, with age group between 10 and 50 years and with first and second degree of burn of less than 50% of TBSA (Total body surface area) were included in the study, over a period of 2 years (2006-08). After stabilization, patients were randomly attributed into two groups: ‘honey group’ and ‘SSD group’. Time elapsed since burn was recorded. After washing with normal saline, undiluted pure honey was applied over the wounds of patients in the honey group (n=37) and SSD cream over the wounds of patients in SSD group (n=41), everyday. Wound was dressed with sterile gauze, cotton pads and bandaged. Status of the wound was assessed every third and seventh day and on the day of completion of study. Patients were followed up every fortnight till epithelialization. The bacteriological examination of the wound was done every seventh day. The mean age for case (honey group) and control (SSD group) was 34.5 years and 28.5 years, respectively. Wound swab culture was positive in 29 out of 36 patients who came within 8 hours of burn and in all patients who came after 24 hours. The average duration of healing in patients treated with honey and SSD dressing at any time of admission was 18.16 and 32.68 days, respectively. Wound of all those patients (100%) who reported within 1 hour became sterile with honey dressing in less than 7 days while none with SSD. All of the wounds became sterile in less than 21 days with honey, while tthis was so in only 36.5% with SSD treated wounds. The honey group included 33 patients reported within 24 hour of injury, and 26 out of them had complete outcome at 2 months of follow-up, while numbers for the SSD group were 32 and 12. Complete outcome for any admission point of time after 2 months was noted in 81% and 37% of patients in the honey group and the SSD group. Honey dressing improves wound healing, makes the wound sterile in lesser time, has a better outcome in terms of prevention of hypertrophic scarring and post-burn contractures, and decreases the need of debridement irrespective of time of admission, when compared to SSD dressing.

Flap choices to treat complex severe postburn hand contracture

Flap choices to treat complex severe postburn hand contracture

Supraclavicular bilobed fasciocutaneous flap for postburn cervical contractures

Supraclavicular bilobed fasciocutaneous flap for postburn cervical contractures

A study of the use of the supraclavicular artery flap for resurfacing of head, neck, and upper torso defects

The head and neck region is an aesthetically demanding area to resurface because of its high visibility. Tissue defects in this area often require distant flaps or free flaps to achieve an aesthetically acceptable result. The use of the Supraclavicular artery flap represents an extremely versatile and useful option for the resurfacing of head, neck and upper torso defects. Furthermore, islanding the flap gives it a wide arc of rotation and the color and texture match is superior to that of free flaps harvested from distant sites. In our study, we used the flap (both unexpanded and expanded) predominantly for resurfacing neck defects resulting from the release of post-burn contractures. However, its applicability in other indications would also be similar. Except one, all our flaps survived almost completely and the post-operative morbidity was very low. We conclude that the supraclavicular artery flap not only provides a reasonably good color and texture match but also maintains the multi-directional activity in the neck region.

A study of the use of the supraclavicular artery flap for resurfacing of head, neck, and upper torso defects

ABSTRACTThe head and neck region is an aesthetically demanding area to resurface because of its high visibility. Tissue defects in this area often require distant flaps or free flaps to achieve an aesthetically acceptable result. The use of the Supraclavicular artery flap represents an extremely versatile and useful option for the resurfacing of head, neck and upper torso defects. Furthermore, islanding the flap gives it a wide arc of rotation and the color and texture match is superior to that of free flaps harvested from distant sites. In our study, we used the flap (both unexpanded and expanded) predominantly for resurfacing neck defects resulting from the release of post-burn contractures. However, its applicability in other indications would also be similar. Except one, all our flaps survived almost completely and the post-operative morbidity was very low. We conclude that the supraclavicular artery flap not only provides a reasonably good color and texture match but also maintains the multi-directional activity in the neck region.

Recurrence after correction of acquired ankle equinus deformity in children using Ilizarov technique

To describe our Ilizarov technique for the treatment of acquired equinus deformity in children and to determine if compliance with continuous use of an ankle foot orthosis (after removal of the fixator and until skeletal maturity) can influence the severity of recurrence. A cohort of 26 children with post-traumatic or post-burn contractures producing an equinus deformity was followed up for a minimum of 2 years after skeletal maturity. Cases with a bony deformity and/or nerve injury were excluded from this study. All patients were managed by a percutaneous tendo-Achilles lengthening followed by application of an Ilizarov external fixator. Post-operative treatment was in the form of gradual correction at a rate of 0.5 mm per day. Correction started from the second postoperative day until an over-correction of 15 degrees dorsiflexion was achieved. Ankle range of movement was encouraged 4 weeks prior to removal of the external fixator. On removal of the fixator, a posterior splint was applied until substituted by an ankle foot orthoses (AFO). The AFO was used continuously during the first 2–3 months and at nighttime thereafter until skeletal maturity. Fifteen children were compliant with the use of the AFO until skeletal maturity and 11 non-compliant. We compared the recurrence and the size of deformity between the two groups. The rate of recurrence, degree of equinus at recurrence and number of episodes of external fixation surgery showed statistical significant differences (P < 0.01) between the groups. The Ilizarov technique for treatment of acquired equinus deformity secondary to soft tissue scarring is a safe and effective technique. The use of an AFO until skeletal maturity can decrease the risk and degree of recurrence.

Reverse flow flap use in upper extremity burn contractures

Upper extremity contractures still happen and constitute one of the most trying challenges in burn patients. This series comprised of 4 radial forearm flaps, 14 dorsoulnar artery flaps, and 4 medial arm flaps, all of which were used in a reverse pattern for upper extremity postburn contractures. The reverse flow radial forearm flap (RRFF) was chosen for reconstruction of extensive palmar contractures after burn. The reverse flow dorsoulnar flap (RDUF) was used particularly for reconstruction of the hypothenar aspect of the hand which requires moderate size tissue transfer. The reverse medial arm flap (RMAF) was used for elbow contractures after burn. In the first RMAF, venous congestion occured and was finaly resolved with minimal flap loss, which was managed with STSG later. In the following 3 cases the flap was supercharged with anastomosis of the brachial vein into the antebrachial vein. Both RRFF and RDUF may provide a smooth and efficient solution. However, RMAF has a significant venous problem, which may result in flap loss, therefore, this flap should not be considered as a first option in the elbow area.

Are Reverse Flow Fasciocutaneous Flaps an Appropriate Option for the Reconstruction of Severe Postburn Lower Extremity Contractures?

Full thickness burns involving the lower extremity can result in severe contractures, which impair extremity functions if they are not managed with proper treatment and rehabilitation. After release of postburn contracture of the knee, ankle, and metatarsophalangeal joints, defects often require coverage by flaps. Twelve distally based reverse flow flaps were performed for lower-extremity reconstruction after release of postburn flexion contractures. All of the patients were male and their age ranged from 20 to 23 years, with a mean age of 21. After the release of the contractures, 3 flaps were used based on the location of the contractures. The reverse flow anterolateral thigh flap was used for knee reconstruction (n = 4, 33%). The reverse flow sural flap was used for ankle reconstruction (n = 4, 33%), and the reverse flow medial plantar flap was used for metatarsophalangeal reconstruction (n = 4, 33%). The sizes of the flap varied from 2 to 17 cm wide and 3 to 18 cm in length. All defects were covered successfully. Reverse fasciocutaneous tissue transfer to reconstruct the soft tissue defects provide early motion. Sufficient contracture release is achieved without displacement of anatomic landmarks. The reverse-flow flap is a reasonable and reliable choice for each joint level in the lower extremity.

Full-Thickness Skin Grafts: Maximizing Graft Take Using Negative Pressure Dressings to Prepare the Graft Bed

Full thickness skin grafts (FTSGs) remain a good option for resurfacing defects of the face, neck, and dorsum of the feet. It results in soft, pliable, functional skin with minimal contraction. However, FTSG may result in patchy or irregular "take" resulting in recurrent contractures and pigmentary discrepancies. This study examines the use of a negative pressure dressing (NPD) to increase FTSG take. Wounds resulting from trauma, postburn contracture release, and an excision of a congenital nevus were included in the study. The wounds were prepared by surgical excision or debridement. A NPD was then applied for a period of 7 days, at which time the wounds were inspected and, if there was sufficient granulation tissue, covered with a FTSG. If the wound had not yet granulated sufficiently another NPD was placed and reassessed in 7 days. The FTSGs were harvested from the groin and abdominal area exactly to the size of the defect. A sponge bolster dressing was then applied. The take of the FTSG was judged using a grid of 1 x 1-cm squares. The wounds were measured and the amount of graft take was calculated as a percentage of the wound size. Complications in both the wound as well as the donor sites were noted. Twenty-four patients were included in the study. The mean age was 6 years (range 1-14 years), including 9 burn contracture excisions, 14 road traffic accident-related injuries, and 1 excision of a congenital nevus. The site involved was the foot (6 patients), ankle (9 patients), axilla (2 patients), forearm (4 patients), face (2 patients), and the neck (1 patient). The average surface area of the defect was 78 cm2 (range 18-264 cm2). Groin skin was harvested in all the cases. The NPD was applied on average for 8 days (range 7-15 days). The mean graft take was 95% (range 70%-100%). Only 1 patient had significant graft loss of 30%. Donor site morbidity was low, attaining primary closure in all but 2. Mean follow-up was 9 months. The results of this study confirm that the use of NPD enhances FTSG take.

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

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

A New Flap for the Treatment of Postburn Contractures of the Hand

Sir: Postburn contractures are still a challenging problem. Various local and distant flaps have been used to reconstruct hand contractures. However, distant flaps are more complicated and are mostly not suitable for the thin skin of the hand. We have used dorsolateral proximally pedicled ulnar skin flaps to cover a patient’s flexion contracture defects. A 7-year-old boy sustained a burn on the right hand that caused severe flexion scar contractures on the metacarpophalangeal joints of fingers 3, 4, and 5. First, the contractures were released and scar tissues were excised to obtain complete extension of the metacarpophalangeal joints. The flexor tendons were exposed after release of the contractures. Dorsolateral proximally pedicled local flaps were raised from the ulnar sides of fingers 3, 4, and 5 (Fig. 1). The flaps were rotated to cover the flexion defects. The donor sites were closed primarily. The hand was splinted for 2 weeks. Passive motion was started after 1 week. After 3 weeks, physical therapy was started to move the metacarpophalangeal joints.Fig. 1.: Preoperative view of the patient’s hand. Dorsolateral flaps were planned on the ulnar sides of fingers 3, 4, and 5.In postburn contractures of the hand, surgical treatment is often necessary when splinting has failed to improve the functional or aesthetic outcome. In our experience, there are several major types of postburn contracture involving the volar and dorsal sides of the hand: flexion contracture of the metacarpophalangeal joint, flexion contracture of the proximal interphalangeal joint, adduction contracture of the thumb, and extension dorsal contracture.1 Postburn contractures of the hand require appropriate surgical treatment whenever conservative approaches have failed. Kalliainen and Schubert1 stated that multiple reconstructive options exist for the web space contracture: skin grafts, local flaps, and distant flaps have all been used to release the contracture and resurface the resultant defect. Local flaps, however, are frequently more suited to web contractures between the fingers.1 Katsaros used free flaps in selected cases and stated that it is a modern reminder that there are many ways to treat defects of the upper limb and that the responsibility of the surgeon is to be both imaginative and wise in securing the best possible result for the patient.2 However, microsurgery is a more complex and expensive method, so free flaps may be indicated in selected cases. Innocenti and Felli reported some distant flaps for reconstruction of the first interdigital commissure,3 but distant flaps require multiple sessions, so they are not superior to local flaps. Furnas used Z-plasties to treat hand contractures.4 Z-plasties are especially useful in treating the web contractures, but they may be insufficient to cover large flexion defects. Our new flap has a secure blood supply that is very suitable for the palmar defect because it is thin. Cross-finger flaps have been used to cover palmar defects, but donor-site morbidity is one of the major drawbacks of this method.5 Our flap is prepared from the ulnar sides of the finger, which are not involved in opposition, so donor-site morbidity is minimal (Fig. 2).Fig. 2.: At 1 year postoperatively, the fingers have full extension and no recurrence is seen.Asuman Sevin, M.D. Plastic Surgery Department Ankara Numune Research and Training Hospital Ankara, Turkey Kutlu Sevin, M.D. Plastic and Reconstructive Surgery Department Ankara University Ankara Medical Faculty Ankara, Turkey