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Page 8 of 10 Madiedo et al. Plast Aesthet Res 2018;5:40 I http://dx.doi.org/10.20517/2347-9264.2018.40

joint contractures following deep burns have been widely reported. In a multicenter study involving 1865
[27]
patients, Goverman et al. described as risk factors and predictors of contracture development male sex,
Hispanic ethnicity, medical problems, neuropathy, total body surface area (TBSA) affected by partial-thickness
burns, TBSA grafted with split-thickness grafts, and prolonged hospital stay. According to their findings,
the most common postburn morbidity was joint contracture, which occurred despite aggressive therapeutic
interventions at both occupational and physical levels (positioning and splinting), affecting quality of life and
ADLs. Their surgical management required skin grafts, as well as local and distant flaps. The most frequently
contracted joint was the shoulder with 23.0%, followed by the elbow (19.9%), the ankle (13.6%), and the knee
[4]
(13.4%). Schneider et al. reported among 985 patients a joint contracture prevalence of 39% (n = 381), with
the shoulder, the elbow, and the knee being the most frequently contracted joints. In total, 39% of all cases
[28]
developed at least one joint contracture. In 2003, Kowalske et al. in a study involving 1478 patients with
[29]
major burns reported a joint contracture prevalence of 43% (n = 641). Furthermore, in 2016 Oosterwijk et al.
presented a systematic review according to which the prevalence of postburn contractures is different among
studies, ranging from 38% to 54%, and contractures were most likely to develop in deep and extensive burns,
as well as in the neck and upper limbs.

In this study, we found that the transverse placement of grafts may lead to clear changes in terms of
functionality and esthetics. The study sample revealed a very low incidence of contractures, adhesions,
hypertrophic scars, and keloids (4/138, 2.9%), particularly in limbs, which according to the literature constitute
the most commonly affected areas by scarring sequelae. We consider that the transverse placement of grafts
benefits scarring by reducing both tension of muscle contraction in grafted areas and resting skin tension,
as the muscle action generated by Kraissl’s lines correspond to the relaxed skin tension lines, which follow
wrinkles and skin movement during muscle contraction, mainly in the neck, trunk, and limbs. In this way,
[27]
such lines should be considered during the planning and placement of grafts. Unlike Goverman et al. ,
we believe that a multidisciplinary treatment with rehabilitation upon patient admission greatly influences
prevention control of functional and scarring disorders. These observations are preliminary, and therefore, not
conclusive, as they require further studies allowing comparisons with a control group.

Nevertheless, surgeons usually determine how to place split-thickness skin grafts on exposed areas, relying on
the orientation that will allow the operator to cover the greatest exposed tissue area with the obtained graft. In
this sense, the orientation of those forces resulting in the underlying muscle tissue contraction of the area to be
grafted are not taken into consideration. Generally, the skin is under constant tension, which varies depending
on the area. This static tension follows predictable patterns, and it is defined by Kraissl’s lines. The movement
of joints and muscles causes dynamic tension, and so placing grafts perpendicular to Kraissl’s lines creates
more tension, resulting in wider and hypertrophic scars that may even progress to severe contractures and
functional impairments, especially in the limbs and neck.

Infection processes in burn patients continue to be a great public health problem associated primarily with
an increase in mortality and morbidity, hospital stay, procedures, and costs. In our study, the occurrence
of infection caused full or partial graft failure, thereby increasing the number of surgical procedures and
prolonging hospital stay, as exposed areas required new grafts. Four of these patients obtained a score of ≥ 8
in the VSS, attributable to a more active inflammatory process, increased fibrosis, prompted formation of
hypertrophic scars, and some degree of contracture with functional limitations of the limbs. This sample
includes patients of all ages, ranging from 1 to 80 years, having extensions of 3-66. Nevertheless, results did
not vary based on age or extension.

Although not part of this study’s objectives, we noted that placing grafts transversely enables their
rationalization, since they are applied from both edges at the exact size of the defect, preventing the loss