Functional and aesthetic reconstruction of digital flexion contractures with full‐thickness plantar skin grafts in children

Abstract

Hand burns are frequently seen in children, often resulting in digital flexion contractures. Traditional split-thickness or full-thickness skin grafts leave notably different skin texture and hyperpigmentation. The purpose of this study was to describe our operation for treating digital flexion contractures with full-thickness plantar skin grafts, and to evaluate the appearance and function outcomes. Hematoxylin and eosin staining, Masson trichrome staining and Melan A (marker of melanocyte) staining were used to evaluate palmar skin, plantar skin, groin skin and burn scars. Full-thickness plantar skin grafts were performed between 2008 and 2015 in 24 hand burn patients with digital flexion contracture. The average age at the time of surgery was 39.3 months and the average follow-up period was 5.5 years. The functional and cosmetic results were assessed. Plantar skin shared similar attributes with palmar skin histologically. Both plantar skin and palmar skin did not express melan A. All of the skin grafts survived well without hematoma, infection and necrosis. The grafts resembled the adjacent normal skin in regards to appearance and texture. The average TAM (total active movement) degree for the fingers was improved from 152.3 to 238.5. The average VSS (Vancouver Scar Scale) score decreased dramatically from 10.4 to 1.1. Twenty one of twenty four patients (21/24, 87.5%) were very satisfied with function and appearance, and three in twenty four (3/24, 12.5%) were somewhat satisfied. This study indicates that full-thickness plantar skin grafts can achieve a satisfactory appearance and good function for hand burn child patients with digital flexion contractures. K E Y W O R D S aesthetic reconstruction, digital flexion contracture, full-thickness skin graft, hand burn, plantar skin 1 | INTRODUCTION Digital flexion contractures are potential complications seen in children due to scar contractures on the palmar side of fingers following injuries such as burns and fires. After scars are released and resected, split-thickness skin grafts (STSGs) or full-thickness skin grafts (FTSGs) are usually applied to resurface the volar skin defects. Routine donor sites include the medial forearm, the medial upper arm, wrist creases, postauricular, thigh, groin region. 1-3 These traditional skin grafts often leave a notably unsightly skin texture, hyperpigmentation and donor sites morbidity, which are reminders of physical trauma in childhood and may leave psychological problems during adolescence. One of the basic principles in reconstructive and plastic surgery is to replace tissue with like tissue. The ideal donor site should provide good skin type match, easy access and minimal donor site morbidity.

Functional and aesthetic outcomes of abdominal full‐thickness skin grafts in paediatric postburn digital and palmar flexion contractures

“…Some scholars have demonstrated that FTSGs from routine donor sites, such as the post‐auricular, inguinal, and thigh areas are usually associated with poor skin texture, hyperpigmentation, and donor site morbidity 4,15,16 . The plantar skin could be the preferred choice for repairing skin defects on the volar side of fingers 3 . However, we do not share the same opinion.…”

“…Particularly, it may itch a lot when hypertrophic scars develop. In the treatment of paediatric digital flexion contracture post‐burn, the full‐thickness plantar skin graft could only be considered in the fingers of children where small defects after excision of scars needed to be coveraged 3 . However, when the scars that cause the digital and palmar flexion contractures are resected, the fingers and palms of children will be straightened, resulting in a larger defect that requires more full‐thickness skin to achieve coverage, but the amount of full‐thickness plantar skin is usually insufficient.…”

“…Reconstructive surgery is often indicated to improve organ function and life quality. The full‐thickness skin grafts (FTSGs) are frequently used to cover the defect surface in the paediatric hand after scar release 3 . Chandrasegaram et al 4 showed that, according to their experience in skin grafting for hand burns in children over the past 10 years, the contracture rate of full‐thickness skin grafting was lower than that of split‐thickness skin grafting.…”

Surgical excision and skin grafting combined with intralesional injection of triamcinolone for the treatment of keloids after syndactyly release

“…The skin in the lower abdominal region was harvested in cases where a large area of skin was required. In cases with a relatively small defect on the palmar side of the hand, the plantar skin from the foot was preferred because the skin in these regions is similar (Jiang et al., 2020). The original donor site used in the primary surgery was preferred to avoid adding new wounds and scars.…”

Engineering edgeless human skin with enhanced biomechanical properties

“…The current paradigm contemplates 3D skin constructs as rectangular or circular planar patches with open boundaries on all sides and disregards the fact that human skin is a fully enclosed organ and has complex geometries. While the conventional skin constructs can be successfully grafted onto flat body parts, such as the upper back ( 20 ), they typically fail to effectively cover irregular body parts, such as fingers or facial features, because of their generic geometry and limited mechanical properties ( 21 ). They have to be delicately placed as multiple patches (e.g., around each finger) on large wounds, requiring a high number of stitches in between each individual piece or excessive bandaging, substantially lengthening the surgery time and worsening the aesthetic and functional outcome of the procedure.…”