The primary principle in managing scar contractures is to address the loss of skin that results from releasing the contracted area, which is commonly restored using flaps or skin grafts. However, the unique attributes of scar contractures—including their location, configuration, and extent—differ substantially across patients, making preoperative planning complex. To achieve more predictable and effective outcomes, we formulated a three-dimensional classification framework for these lesions. This framework divides contractures into four groups: type 1 (shallow, linear scars), type 2-d (deep linear), type 2-s (planar but restricted to superficial layers), and type 3 (planar with deep involvement—thus, three-dimensional). When designing a surgical plan, three major parameters should be evaluated: (1) the size of the defect after release, (2) the amount of surrounding healthy tissue, and (3) the vascularity of the wound bed. Type 1 and type 2-d lesions are linear in shape; therefore, treatment usually involves direct excision and straight-line closure, using Z-plasty or modified versions to restore movement. In type 2-s lesions, following release, local flaps are preferred for small areas, pedicled perforator flaps for medium defects, and distant or free flaps for larger losses. Because type 2-s defects have well-perfused wound beds, full-thickness skin grafts remain an acceptable alternative regardless of the defect’s scale. In type 3 contractures, release exposes deep structures—such as tendons, joints, or bone—with limited blood supply, making flap reconstruction preferable to grafting. Currently, there is no universally accepted grading system or therapeutic algorithm for such contractures. We suggest that objective dimensional classification and quantitative assessment can enhance both functional recovery and aesthetic results.
