SURGICAL RECONSTRUCTION OF POST-BURN HAND CONTRACTURES IN CHILDREN: FLAPS VERSUS SKIN GRAFTS

Abstract

DOI: https://doi.org/10.46296/yc.v10i19.1002

Abstract

Introduction. Post-burn contractures of the hand in children can progress during growth, compromising range of motion, dexterity, pinch function, and activities of daily living. Following scar release, coverage can be achieved via skin grafts or flaps; the choice depends on defect depth, exposed structures, location, tissue availability, and functional goals. Objective. To compare outcomes of flaps versus skin grafts in the reconstruction of post-burn hand contractures in the pediatric population, focusing on function, recurrence/re-contracture, reoperation, complications, and reconstructive burden. Methods. A systematic review updated in accordance with PRISMA 2020 guidelines. Search strategies were structured for MEDLINE/PubMed, Scopus, Embase, Web of Science, CENTRAL, and LILACS/BVS, supplemented by Google Scholar and reference tracking. Synthesis relied on primary pediatric studies, comparative hand surgery evidence including pediatric subgroups, and two contemporary systematic reviews to ensure comprehensiveness. The updated focused search concluded on October 2, 2026. Critical appraisal was conducted using JBI criteria, and overall certainty was assessed via the GRADE approach. Due to clinical and methodological heterogeneity, a narrative synthesis was performed; as an exploratory analysis, relative risk was calculated based on the single pediatric study providing a clearly extractable direct comparison between flaps and grafts. Results. Direct comparative evidence is limited and predominantly observational. In a prospective pediatric study of 40 patients, 13 of 15 children treated with flaps achieved good or intermediate functional outcomes, compared to 3 of 13 treated with grafts—an exploratory relative risk of 3.76 (95% CI: 1.36–10.33)—though this finding carries a significant risk of confounding by indication. In the same study, grafts showed a higher proportion of poor functional outcomes. Full-thickness grafts exhibit better resistance to contraction than split-thickness grafts but remain prone to recurrence during growth. A pediatric cohort of 61 children reported in 2026 found that unplanned reoperation occurred in 18/61 cases (29.5%) following full-thickness grafting for severe digital contractures; defect size and the time elapsed between healing and the initial surgery were associated with the need for reoperation. Hand reconstruction literature indicates that flaps provide vascularized tissue and are particularly useful when tendons, joints, bone, or neurovascular bundles are exposed, whereas grafts are suitable for well-vascularized beds and large, superficial defects. Conclusions. Available evidence suggests a functional advantage for flaps in complex or deep pediatric contractures but does not demonstrate universal superiority over grafts due to low certainty and selection bias. When the wound bed allows for grafting, full-thickness grafts should be preferred over split-thickness grafts to minimize secondary contraction. The decision must be individualized based on depth, surface area, exposed structures, location, expected growth, and the feasibility of prolonged rehabilitation.

Keywords: burns; contracture; hand; child; surgical flaps; skin graft; reconstruction; plastic surgery.