**Background:** Post-burn contractures are a common and debilitating complication, limiting joint range of motion (ROM) and quality of life. Optimal surgical treatment remains debated, with options including skin grafts and various local flaps. This study evaluates the efficacy of local flaps, particularly Z-plasty, for reconstructing burn contractures in the neck and extremities in a large cohort from southwestern Iran.
**Methods:** This retrospective study included 243 patients (314 joints) who underwent contracture release surgery at Taleghani Hospital (Khuzestan, Iran) between September 2011 and March 2020. Data collected included demographics, burn characteristics (etiology, total burn surface area [TBSA]), scar details, surgical procedures, and outcomes. The primary surgical method was local flap reconstruction, predominantly Z-plasty and its modifications. When necessary, Z-plasty was combined with skin grafts or skin grafts alone were used. Joint ROM was measured goniometrically and indexed as a percentage of normal ROM values. Outcomes assessed at 12 months included ROM improvement, complications (infection, flap necrosis, wound dehiscence, re-contracture), need for second-stage surgery, and patient satisfaction (functional and aesthetic scores on a 1-10 scale). Statistical analysis used paired t-tests and ANOVA.
**Key Results:** The cohort had a mean age of 19.2 ± 13.8 years, with 56.4% female. Flame burns (38.1%) and scalds (28.4%) were the most common causes. Mean TBSA was variable (1-70%), and mean time from injury to surgery was 546.1 ± 493.1 days. The most common contracture locations were the hand (45.9%), elbow (16.2%), neck (15.9%), and axilla (11.1%). After scar release, 70.4% of joints were covered with Z-plasty and similar local flaps, 26.1% with Z-plasty plus skin grafts, and 3.5% with skin grafts alone. Mean preoperative ROM was 47.2 ± 28.7% of normal; at 12 months, it improved to 93.0 ± 10.0% of normal, a mean improvement of 45.80% (p<0.001). The overall complication rate was 10.82% (34 joints). Specific complications included: surgical site infection in 7.3% (14 joints), re-contracture in 3.82% (12 joints), flap tip necrosis in 1.27% (4 joints), partial flap necrosis in 0.31% (1 joint), and wound dehiscence in 1.0% (3 joints). No complete flap necrosis or in-hospital mortality occurred. Mean functional satisfaction score was 9.45 ± 1.50 out of 10, and mean aesthetic satisfaction score was 7.61 ± 2.06 out of 10. Second-stage surgery was needed in 5.4% of patients.
**Clinical Implications:** This large, real-world study demonstrates that local flap reconstruction, particularly Z-plasty, is a safe and effective method for treating post-burn contractures in the neck and extremities. The significant improvement in ROM (45.80% of normal) and high functional satisfaction (9.45/10) highlight its clinical utility. The low re-contracture rate (3.82%) and overall complication rate (10.82%) compare favorably with other techniques, especially skin grafts, which often have higher recurrence rates. The procedure's simplicity, minimal facility requirements, and steep learning curve make it particularly suitable for low- and middle-income countries (LMICs), where most severe burns occur. The authors recommend Z-plasty as the primary technique for contracture release, emphasizing its ability to provide like-for-like tissue coverage and durable results. Limitations include the retrospective design, use of standard goniometry (which may not fully capture functional outcomes), and a debatable 50% ROM improvement threshold. Future prospective studies with standardized outcome measures are needed to confirm these findings.