Keywords

1 Background

Local flaps are useful for reconstructing scar contractures on mobile areas such as the joints, the neck, the axilla, the digital web, and the mouth commissure. They are superior to skin grafts because the latter can contract, thereby leading to secondary contractures. Moreover, the color and texture match of local flaps is better than that of grafted skin. Consequently, local flaps generally provide superior aesthetic outcomes. Thus, if there is healthy skin adjacent to the scar contracture, local flaps should be the first choice. Based on the type of movement needed to place the flap, local flaps can be classified as advancement flaps, rotation flaps, and transposition flaps. A more recent advance is to design these flaps as perforator flaps. The inclusion of perforators in the flap provides great freedom in terms of flap shape and the movement and rotation arc of the flap: the propeller flap method is a particularly good example of such flaps. Moreover, flap combinations such as the bilobed flap and the square flap method can expand the possibilities offered by local flaps.

2 Selection of Local Flaps

Several approaches that elongate the scar and thereby release linear contractures have been reported. Z-plasty is one of the best-known options when it comes to releasing linear contractures [1]. The theoretical final scar length for the 60° angle z-plasty is approximately 1.73 times the original length of the scar. W-plasty also allows contracture release to some degree due to its so-called accordion effect: this reflects the fact that zigzag-shaped scars elongate in an accordion-like fashion over time [2]. However, these methods are mainly used for “linear” contractures. If the scar is wide, the scar cannot be removed and then sutured primarily. In this case, the scar should be divided by a local flap to obtain contracture release.

In terms of local flap selection, it is necessary to choose between a skin-pedicled flap and an island flap. We showed recently [3] that 6 months after surgery, skin-pedicled flaps associate with greater scar extension rates than island flaps (◘ Fig. 35.1). Notably, skin-pedicled and island flaps, respectively, extended the scar by 1.53- and 1.28-fold 6 months after surgery. Thus, local flaps, especially skin-pedicled flaps, elongate the scar as effectively as z-plasty. It should be noted that if the scar is large, it is effective only by dividing the scar with the local flap. However, the flap size can be slightly smaller than the deformity size (although how much smaller depends somewhat on how extensible the flap type is): it is not necessary that the flap is as big as the open wound after scar division or scar removal.

Fig. 35.1
figure 1

Comparison of skin-pedicled and island flaps in terms of extensibility. a Skin-pedicled flap . b Island flap . Skin-pedicled flaps have a greater extension rate than island flaps because they include healthy skin, which can expand after surgery. By contrast, the inelastic scar tissue all around the island flap limits its extensibility

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In the case of the local flap design, it can be affected not only by the ease of the technique but also by the geometry of the scar and open wound tissues. Thus, selecting between the skin-pedicled flap and the island flap should be performed on a case-by-case basis. However, the greater extensibility of the skin-pedicled flap means that it should be the primary choice in the case of scar contracture release [3]. This greater extensibility is probably because the entire perimeter of the island flap is surrounded by new scar, whereas the skin-pedicled flap maintains a connection with normal skin. Since normal skin is highly elastic (much more elastic than scar tissue), it may promote the elongation and enlargement of the skin-pedicled flap. Moreover, at a theoretical level, the circular shape of the island flap also limits its extensibility. However, it should be noted that island flaps have technical advantages over skin-pedicled flaps: they are relatively simple to transfer to the recipient site, and they can employ the remaining healthy skin around the scars without any waste.

3 Transposition Flaps

The transposition flap is one of the classical and most representative of the local flaps. Its contracture-releasing effect is very high because the flap has a skin pedicle. The healthy skin of the flap expands over time after surgery; as a result, the rectangular shape of the flap becomes triangular (◘ Figs. 35.2, 35.3, 35.4, and 35.5). This effect reflects the release of tension via the skin pedicle.

Fig. 35.2
figure 2

Transposition flap. Transposition flaps should be designed parallel to the contracture line. After surgery, the skin pedicle can expand over time

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Fig. 35.3
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Reconstruction of a scar contracture on the cubital fossa . a Preoperative view. b View immediately after the operation. c Two weeks after the operation. d Two months after the operation. e Ten months after the operation. Bilateral transposition flaps were harvested. No flap ischemia was observed. The contracture was released by about 10 cm

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Fig. 35.4
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Reconstruction of a scar contracture behind the knee. a Preoperative view. b Intraoperative view. c View immediately after the operation. d One year after the operation. e Two years after the operation. A transposition flap was designed next to the scar contracture behind the knee. The contracture was released completely

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Fig. 35.5
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Reconstruction of a scar contracture on the abdomen. a Preoperative view. b View immediately after the operation. c One year after the operation. A bilateral transposition flap was designed. The contracture sensation on the abdomen was relieved by the operation

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If the flap has to be large, perforators can be attached, and a supercharged transposition flap can be designed [4]. The perforator is then anastomosed to the recipient site. This perforator-supercharged transposition flap is especially useful for reconstructing anterior neck contractures (◘ Fig. 35.6).

Fig. 35.6
figure 6

Reconstruction of a scar contracture on the anterior neck by using a supercharged transposition flap. a Preoperative view. b Intraoperative view. c Two years after the operation. An anterior neck contracture of a 71-year-old man was reconstructed with a supercharged transposition flap. A perforator of the internal mammary artery in the first intercostal space was attached to the flap and anastomosed with the facial artery and vein. The flap allowed full extension of the neck

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4 The Square Flap Method

The square flap method was reported previously by Hyakusoku et al. [5] and is an effective way of elongating the skin, especially for scar contracture release (◘ Fig. 35.7). This method consists of a combination of a square flap, one 45° triangular flap, and one 90° triangular flap. The angle of the triangular flaps of Limberg’s original method is 30° [6]. However, in the case of scar surgery, the 30° triangular flap can lead to blood flow failure because, in some cases, part of the scar must be included in the flap. Thus, the angles of the triangular flaps in the square flap method should be wider: the combination of a 45° triangular flap and a 90° triangular flap is ideal. One option is to design a four-flap z-plasty and a five-flap z-plasty. However, it is safer to include one square flap. Moreover, the biggest advantage of the square flap method is that one of the flaps has a square shape. This square flap can advance downward and can make a suitably large and pliable floor over the joints and web space. Thus, the method results in three-dimensional reconstruction [7]. In addition, the skin pedicle of the square flap can effectively release tension over time after the operation. This method is particularly indicated for scars on the joints, the neck, the axilla, the digital web, and the mouth commissure (◘ Figs. 35.8, 35.9, and 35.10). Theoretically, this method increases the original scar length by 2.8-fold [7].

Fig. 35.7
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The square flap method. Theoretically, the method lengthens the original scar length by 2.8-fold

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Fig. 35.8
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Reconstruction of a scar contracture on the axilla. a Preoperative view. b Design of the flap. c Intraoperative view. d View immediately after the operation. e Three months after the operation. f Six months after the operation. g One year after the operation. The square flap method was used to reconstruct an axillary scar contracture. The square flap gained a triangular shape one year after operation. This indicates that the skin pedicle of the flap extended, thus effectively releasing the tension

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Fig. 35.9
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Reconstruction of a scar contracture on the digital web. a Design of the flap. b View immediately after the operation. c Two years after the operation. The square flap method was used to reconstruct a digital web scar contracture. The skin pedicle of the flap extended, thereby effectively releasing the tension

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Fig. 35.10
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Reconstruction of a scar contracture on the cubital fossa. a Design of the flap. b Intraoperative view. c View immediately after the operation. d Eighteen months after the operation. The square flap method was used to reconstruct a cubital fossa scar contracture. The skin pedicle of the flap extended, thereby effectively releasing the tension

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5 Propeller Flaps

It has been reported that an island flap that can be rotated 90° like a propeller is suitable for the reconstruction of the axilla and cubitus [8] (◘ Fig. 35.11). That was the first time this flap type was described. This original propeller flap was made by using the intact skin in a cubital fossa as a subcutaneous-pedicled island flap to release post-burn linear scar contractures that adjoined the fossa. The subcutaneous pedicle was located in the center of the flap. In the 20 years following this seminal advance, propeller flaps have been refined and modified, and various types of propeller flaps have been reported [9,10,11,12,13]. The most sophisticated of these is the perforator-pedicled propeller (PPP) flap [9]. This type of flap can be harvested from any site on the body that bears a perforator. It employs a skeletonized vascular pedicle that allows the flap to be rotated by up to 180°. Moreover , if the perforator pedicle is located at the edge of the flap, the flap can cover a defect that is a long distance away from the flap donor site. Depending on the case, the flap can be rotated in a clockwise or counterclockwise direction.

Fig. 35.11
figure 11

Propeller flap. The most sophisticated of the propeller flaps is the perforator-pedicled propeller (PPP) flap . However, its contracture-releasing effect is lower than that of skin- pedicled flaps. Thus, propeller flaps are most useful when the available healthy skin adjacent to the scar is limited and a skin-pedicled flap cannot be performed

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The PPP flap is now considered by many plastic surgeons to be a highly viable and particularly sophisticated perforator flap option. This largely reflects the fact that the human body has over 400 perforators whose diameters exceed 0.5 mm. Thus, at least 400 types of propeller flaps can theoretically be harvested. This broad availability means that custom-made PPP flaps can be used to reconstruct defects on many parts of the body. Indeed, PPP flaps are particularly suitable for scars on the trunk and limbs. However, donor site limitations may reduce the suitability of this method for reconstructing the head and neck region.

Since the course and territory of perforators differ for each region, it is advisable to perform a careful preoperative assessment with Doppler ultrasound, color Doppler ultrasonography, or multi-detector low computed tomography (MD-CT). This greatly facilitates the operation, thereby reducing the operative time [14].

It should be noted, however, that propeller flaps have one significant disadvantage: they are always island flaps. Thus, their contracture-releasing effect is lower than that of skin-pedicled flaps. Consequently, propeller flaps are generally only chosen when the available healthy skin adjacent to the defect is limited and a skin-pedicled flap is not possible (◘ Fig. 35.12).

Fig. 35.12
figure 12

Reconstruction of a scar contracture on the anterior chest wall. a Design of the flap. b, c Intraoperative view. d View immediately after the operation. e Eighteen months after the operation. The propeller flap was designed on the limited space between a scar contracture and an ulcer. Both open wounds were reconstructed by using a 90° rotated propeller flap

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6 Conclusion

Local flaps generally provide superior functional and aesthetic outcomes. In terms of local flap selection, it is necessary to choose between a skin-pedicled flap and an island flap. It was suggeested that skin-pedicled flaps associate with greater scar extension rates than island flaps. Moreover, it should be noted that if the scar is large, it is effective only by dividing the scar with the local flap.

Take Home Messages

  • Local flaps are superior to skin grafts because the latter can contract, thereby leading to secondary contractures.

  • The color and texture match of local flaps is better than that of grafted skin.

  • Local flaps, especially skin-pedicled flaps, elongate the scar as effectively as z-plasty.

  • It should be noted that if the scar is large, it is effective only by dividing the scar with the local flap.