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Brimh Journal of Plnsric Surgery (1994).

Q 1994 The British Association of Plastic Surgeons

The seven flap-plasty

N. Karacaoglan and A. Uysal

Division of Plastic and Reconstructive Surgery, Ondokuzmayis University, Samsun, Turkey

SUMMARY. A method of releasing skin contracture crossing a joint by seven flap-plasty is presented. The seven
flap-plasty consists of two half Z-plasties and one W-M plasty. We have obtained satisfactory results in the repair
of postburn contractures at elbow, axilla, fingers and interdigital webs using the technique.

Full-thickness and deep dermal burns are prone to then designed as shown in Figure 1. The length of all
develop contractures. These can be very severe and can the limbs must be equal. After the release of con-
produce functional and anatomical deformities. There tracture the a, b, c flaps are interdigitated as in V-M
are many methods of correction which include Z- plasty6 and flaps d, e, f, g are transposed. All of the
plasty (two flap),l square flap (three flap),’ double Z- flaps must be raised with underlying fascia in order to
plasty (four flap Z-plasty) (four flap), V-Y advance- enhance viability.
ment and Z-plasty (five flap) and six flap Z-plasty (six A variation in the design of seven flap-plasty is
flap).’ More recently X-plasty,3 propeller flap* and possible, where three 60 degree triangular flaps on the
multiple Y-V plasty5 have been introduced. In this same side and four 45 degree triangular flaps on the
paper we illustrate a new technique, which we have
named the seven flap-plasty, to release post-burn


The line of contracture is marked and measured (A-B)

and the centre of AB is defined (C point). Flaps are

’ a b \

D a I b E

A 0

Fig. 2
Figure 2-Another design of the seven flap-plasty.

Table 1 Site of contracture

Cubital contracture 6
Axillary contracture 5
Digital web contracture 1
Fig. 1 Digital contracture 2
Neck contracture 1
Figure l-Planning the seven flap-plasty.

The Seven Flap-plasty 373

Fig. 3

Figure 3-(A) Post-burn contracture of the cubital region, preoperative planning of the seven flap-plasty. (B) After release of the contracture
by seven flap-plasty.

Fig. 4
Figure &(A) Preoperative planning of the digital contracture. (B. C) After release of the contracture by seven flap-plasty

other side of the contracture line are designed. The Clinical applications
angles of the quadrangular flaps are changed to 120
degrees (Fig. 2). There are some advantages to this A total of 15 seven flap-plasties in 12 patients were
variation. First, it is possible to obtain wider flaps at performed in our clinic over a 20-month period in 7
their bases, so they have more adequate perfusion. males and 5 females, age range 6-26 years. All patients
Second, adaptation of flaps after transposition is were burned during childhood except one (case 1). For
easier. this reason contracture release was carried out on old
374 British Journal of Plastic Surgery

and mature scars. Table 1 shows the site of con- The geometry of the seven flap-plasty consists of
tractures. two half Z-plasties and one W-M plasty. The actual
gain in length depends on the angle of the half Z-
plasty, the length of the central member of the half Z-
plasty, and the angle of the c flap (Fig. 1). We have
measured the actual gain in length which was more
Case reports
than 180 %. This is better than that achieved by other
Case 1 methods. Theoretical gain in length in 30 degree angle
Z-plasty is 25 %, in 60 degree angle Z-plasty 75 %, in
A lo-year-old patient had a scar contracture of the left
90 degree angle Z-plasty 120 %, in four flap Z-plasty
antecubital region resulting from a flame burn 1 year before
(Fig. 3). A seven flap-plasty was performed. No distal flap
124 %, in six flap Z-plasty 180 % and in square flap
necrosis occurred and all flaps healed without problems. The (three flap Z-plasty) 180 %.ls2 Six flap Z-plasty pro-
measured gain in length was 180 % in this patient. vides a theoretical gain in length in the direction of the
central member in 180 % .l In the seven flap-plasty the
actual gain in length was measured as more than
180 %. Furnas and Fisher have shown in experimental
Case 2 studies of Z-plastics on the skin of the trunk in dogs
A 16-year-old patient had a digital scar limiting extension of that the actual gain in length is always less than the
the finger. It was released by seven flap-plasty; all flaps theoretical gain.’ For these reasons, seven flap Z-
healed without problems (Fig. 4). We splinted the finger for plasty has a practical advantage over the alternatives.
3 months during the day. After normal hand function was It has been shown that the viable length of flaps can be
achieved the splint was continued for 2 months at night. increased by including the underlying fascia.*-lo We
Measured gain in length was 200 %. raise our flaps beneath the fascia and have not had any
problem with distal flap necrosis.

Results 1. Jankauskas S, Cohen JK, Grabb WC. Basic techniques of
plastic surgery. In: Smith JW, Aston SJ, editors. Plastic
surgery. Liitle, Brown and Company, 1991: 71-8.
Twelve patients underwent 15 releases by seven flap- 2. Hvakosoku H. Fumiiri M. The sauare flao method. Br J Plast
plasty over a period of 20 months. All healed well; ‘Surg 1987; 40: 4&6.
there was no flap necrosis. The release was satisfactory 3. Vartak A, Keswani MH. X-plasty for repair of burn contrac-
in all patients, with no recurrence of contracture. tures. Burns 1992; 18: 32&8.
4. Hyakosoku H, Yamamoto T, Fumiiri M. The propeller flap
Splintage was not used after the initial postoperative method. Br J Plast Surg 1991; 44: 534.
period. 5. Cooper MACS. The multiple Y-V plasty in linear burn scar
contracture release. Br J Plast Surg 1990; 43: 145-9.
6. Karacaoglan N, Velidedeoglu H, Cicekci B, et al. Reverse W-M
plasty in the repair of congenital syndactyly: a new method.
Br J Plast Surg 1993; 46: 30@2.
Discussion 7. Furnas DW, Fischer GW. The Z-plasty : biomechanics and
mathematics. Br J Plast Surg 1971; 24: 144.
8. Ponten B. The fasciocutaneous flap: its use in soft tissue defects
The main disadvantage of the Z-plasty, when im- of the lower leg. Br J Plast Surg 1981; 34: 2 1520.
properly designed and placed, is that it enlarges the 9. Tolhurst DE, Haeseker B, Zeeman RJ. The development of the
area it occupies. It is possible to eliminate this problem fasciocutaneous flap and its clinical applications. Plast
by multiple Z-plasties and variations with smaller Reconstr Surg 1983; 71: 597-605.
10. Bas L, Numanoglu A, Celebiler 0. Application of fascio-
limbs. For this reason, multiple Z-plasties are preferred cutaneous Z plasty on old burn contractures. Eur J Plast Surg
to a single, large Z-plasty because the scar resulting 1990; 13: 112-4.
from a large Z-plasty is usually more noticeable than
the one resulting from a series of small Z-plasties. The Authors
Seven flap-plasty has the advantage of having smaller
Naci Karacao@an,MD, Assistant Professor
triangular limbs, which break up the scar into smaller Ata Uysal, MD, Associate Professor and Head
components that look better. Seven flap-plasty also
Division of Plastic and Reconstructive Surgery, Ondokuzmayis
has the advantage of using all of the available skin, as
University, Samsun. Turkey
it is possible to perform the seven flap-plasty without
excising the scar. Requests for reprints to: Dr N. Karacaoglan. P. K. 198. Samsun,
The old burn contractures can be released by direct Turkey 55000.
incision plus skin grafting but prolonged splinting is Paper received 29 December 1993.
always necessary to avoid recurrence of contracture. Accepted 17 March 1994, after revision.