About Dr. Chai Jiake
Dr. Chai Jiake is Chief of Burn and Plastic Surgery at Changhai Hospital, Naval Medical University — one of China's foremost burn and reconstructive surgery centres and a national reference institution for complex burn reconstruction, microsurgical flap repair, and scar management. He is one of China's most experienced reconstructive surgeons, recognised for his expertise in free flap microsurgery for post-burn hand reconstruction, scar contracture release, and the integration of surgical reconstruction with structured rehabilitation to achieve functional and aesthetic restoration in patients with complex traumatic and burn injuries. Dr. Chai's practice is defined by the philosophy that burn reconstruction is not a single operation — it is a longitudinal programme of surgical and rehabilitative interventions that must be planned from the moment of the acute injury, because the decisions made in the acute phase — the quality of the initial debridement, the choice of skin graft, the positioning during healing — determine the severity of the contracture that the reconstructive surgeon will face months later. His department at Changhai Hospital has established one of China's most comprehensive burn reconstruction programmes, integrating microsurgical free flap transfer, perforator flap design, scar management, and multidisciplinary hand rehabilitation into a unified care pathway for patients with complex post-burn functional and aesthetic deficits.
Case Overview
Mr. James O'Sullivan (pseudonym), a 32-year-old Irish factory worker based in Shanghai, presented three months after a workplace explosion that caused severe bilateral hand burns. Initial management at a local hospital included debridement and split-thickness skin grafting; wound closure was achieved but resulted in severe hypertrophic scarring and contracture. At presentation, both hands demonstrated dense dorsal and palmar scar contractures with fixed flexion deformities of the fingers, severely restricted metacarpophalangeal and interphalangeal joint range of motion, markedly reduced grip strength, inability to perform fine motor tasks, and significant sensory impairment in the scar territories. A multidisciplinary team led by Dr. Chai Jiake — including burn and plastic surgery and rehabilitation medicine — designed a staged reconstruction: free anterolateral thigh (ALT) flap for dorsal hand resurfacing with microsurgical anastomosis to the radial artery and cephalic vein; local rotation and transposition flaps for digital joint contracture release; and a structured post-operative hand rehabilitation programme commencing on day 3. All flaps survived completely. At one month, finger joint range of motion was significantly improved; at three months, the patient could dress and feed independently; at six months, fine motor tasks including writing and typing were restored; at one year, hand function was fully consolidated with no restriction on daily activities or work.
Patient Background
- Name / Nationality: Mr. James O'Sullivan (pseudonym) — Irish; 32-year-old factory worker based in Shanghai
- Age / Sex: 32-year-old male
- Chief Complaint: Bilateral severe post-burn hand scar contractures with functional impairment and aesthetic deformity; requesting reconstructive surgery to restore hand function and appearance
- Injury history: Workplace factory explosion 3 months prior; immediate transfer to local hospital; emergency debridement and split-thickness skin grafting; wound closure achieved; no systemic rehabilitation programme initiated after wound healing
- Current functional status: Unable to make a fist or grasp objects; unable to dress or feed independently; fine motor tasks impossible; severe psychological distress from functional loss and aesthetic deformity
- No systemic contraindications: No hypertension, diabetes, cardiac disease, haematological disorders, or infectious disease; no drug allergies; no smoking or alcohol
- Extraoral examination — bilateral hands: Large-area scar tissue on dorsal and palmar surfaces and around finger joints; dark red colour; hard consistency; irregular surface. Finger flexion deformities; markedly restricted MCP and IP joint range of motion. Grip strength severely reduced. Fine motor function absent. Sensory impairment in scar territories — reduced tactile and pain sensitivity
Diagnostic Workup
Plain Radiographs (Bilateral Hands)
- Skeletal integrity: No fracture, dislocation, or bony destruction; finger bone architecture intact
- Joint spaces: Narrowed at multiple MCP and IP joints secondary to scar contracture — confirming periarticular involvement but no primary bony pathology
Ultrasound of Scar Tissue
- Scar characteristics: Heterogeneous scar thickness; reduced internal vascularity — confirming poor blood supply within the scar tissue, consistent with mature hypertrophic scar; relevant for flap planning as poorly vascularised scar must be excised rather than incorporated into the reconstruction
Hand Function Assessment (DASH Scale)
- Disabilities of the Arm, Shoulder and Hand (DASH) score: Severely impaired — high DASH score confirming marked restriction of upper limb function and activities of daily living; baseline established for post-operative comparison
Dr. Chai's pre-operative assessment: The key decision in post-burn hand reconstruction is the flap selection. The dorsal hand is the dominant problem in this patient — the scar is thick, avascular, and adherent to the extensor tendons. When we excise it, we will expose the extensor mechanism over a large area. That exposed surface needs to be covered with tissue that is thin enough not to restrict tendon gliding, pliable enough to conform to the contours of the hand, and well-vascularised enough to survive in a scarred recipient bed. The anterolateral thigh flap meets all three criteria. It is thin in a lean patient, the vascular pedicle is long and the vessels are large — which makes the microsurgical anastomosis reliable — and we can harvest a flap of 15 by 10 centimetres from the thigh without significant donor site morbidity. The digital joint contractures are a separate problem — smaller, more localised, and amenable to local rotation flaps that avoid the complexity of a second free flap.
Multidisciplinary Team Discussion and Treatment Strategy
The MDT convened by Dr. Chai Jiake included burn and plastic surgery and rehabilitation medicine. The treatment strategy addressed the biological and functional prerequisites for reconstruction before proceeding to surgery.
Pre-operative preparation: Full pre-operative workup; psychological support to address the patient's anxiety and restore confidence; one week of pre-operative hand rehabilitation — passive joint mobilisation and massage — to improve baseline joint range of motion before surgery.
Surgical strategy — dorsal hand: Free anterolateral thigh (ALT) flap for dorsal hand resurfacing. The ALT flap — based on perforators from the descending branch of the lateral circumflex femoral artery — provides a large, thin, pliable skin paddle with a long vascular pedicle, suitable for covering large dorsal hand defects after scar excision. Microsurgical anastomosis to the radial artery (end-to-side) and cephalic vein at the wrist.
Surgical strategy — digital joints: Local rotation flaps and transposition flaps for contracture release at the finger joint level — using adjacent non-scarred or less-scarred tissue to resurface the released contracture defects, minimising donor site morbidity and preserving the digital architecture.
Post-operative management: ICU-level flap monitoring for 24 hours; antibiotic prophylaxis; low-molecular-weight heparin anticoagulation; papaverine antispasm therapy; structured hand rehabilitation commencing on post-operative day 3.
Rehabilitation strategy: Passive joint mobilisation from day 3; progressive active muscle contraction training as flap healing advances; fine motor and sensory retraining from week 2; functional task training (chopsticks, buttons, shoelaces) to restore coordination and sensory acuity.
Operative Procedure
Free Anterolateral Thigh Flap — Dorsal Hand Resurfacing
Flap design and harvest: Patient positioned supine; both the donor thigh and recipient hand prepared simultaneously by two surgical teams to minimise operative time. ALT flap designed on the left anterolateral thigh based on the dominant perforator from the descending branch of the lateral circumflex femoral artery, identified pre-operatively with handheld Doppler. Flap dimensions 15 cm × 10 cm — sized to cover the dorsal hand defect after scar excision with adequate margin. Flap harvested with the perforator and vascular pedicle under loupe magnification; pedicle length approximately 8 cm; artery diameter approximately 2.0 mm; venae comitantes diameter approximately 2.0 mm. Donor site closed primarily.
Recipient site preparation: Dorsal hand scar excised to the level of the extensor paratenon — complete excision of the avascular scar tissue to expose a well-vascularised recipient bed. Extensor tendons inspected — intact and gliding. Radial artery and cephalic vein at the wrist identified and prepared as recipient vessels.
Microsurgical anastomosis: Flap inset into the dorsal hand defect; vascular pedicle routed to the wrist. Arterial anastomosis: ALT perforator artery to radial artery, end-to-side, under operating microscope at 10× magnification, 9-0 nylon interrupted sutures. Venous anastomosis: ALT venae comitantes to cephalic vein, end-to-end, 9-0 nylon interrupted sutures. Clamps released; immediate flap perfusion confirmed — flap colour pink, capillary refill time less than 2 seconds, Doppler signal present at the anastomosis site.
Flap inset and closure: Flap trimmed and inset to conform to the dorsal hand contour; edges sutured with interrupted absorbable sutures; non-adherent dressing applied; hand splinted in the position of safe immobilisation (wrist extended, MCPs flexed, IPs extended).
Dr. Chai's operative note: The microsurgical anastomosis is the moment of maximum technical demand in free flap surgery. The radial artery at the wrist is a reliable recipient vessel — it is superficial, accessible, and large enough for a reliable end-to-side anastomosis without compromising the hand circulation. The end-to-side configuration preserves the radial artery flow to the hand while providing inflow to the flap. We use 9-0 nylon under the operating microscope at 10 times magnification. The sutures are placed 1 millimetre apart, 1 millimetre from the vessel edge. When the clamps come off, you watch the flap. If it turns pink within 30 seconds, the anastomosis is patent. If it stays pale, you have a problem with the arterial inflow. If it turns blue and congested, you have a venous problem. In this patient, the flap turned pink within 20 seconds of clamp release. That is the moment the operation succeeds.
Local Rotation and Transposition Flaps — Digital Joint Contracture Release
Contracture release: Scar contractures at the MCP and IP joint levels released by longitudinal incision through the scar; joints mobilised to confirm full passive range of motion achievable after release.
Flap design and inset: Local rotation flaps and Z-plasty transposition flaps designed from adjacent less-scarred tissue at each digital joint level; flaps rotated or transposed to cover the released contracture defects; donor sites closed primarily or with small split-thickness skin grafts where primary closure not achievable without tension.
Operative data: Total operative time approximately 6 hours (both hands, simultaneous two-team approach); blood loss managed with cell salvage; no allogeneic transfusion required; all flaps and local flaps with satisfactory perfusion at end of procedure.
Post-operative Management and Outcomes
Flap Monitoring and Early Recovery
- ICU (24 hours): Hourly flap observation — colour, temperature, capillary refill time, and Doppler signal; antibiotic prophylaxis; low-molecular-weight heparin; papaverine infusion for antispasm; hand maintained in position of safe immobilisation
- Day 3: Flap blood supply stable; no vascular compromise; passive hand rehabilitation commenced by physiotherapy team
- Week 1: Sutures removed; flap healing confirmed; no infection, haematoma, or partial necrosis; transferred from ICU monitoring to ward-based care
Rehabilitation Progression
- Day 3 — week 2: Passive MCP and IP joint flexion and extension, 15–20 minutes, 3–4 times daily; oedema management with elevation and compression; scar massage initiated around flap margins
- Week 2 — month 1: Progressive active muscle contraction training; fine motor retraining initiated — pinch, grasp, and release tasks; sensory retraining with graded texture discrimination
- Month 1–3: Functional task training — dressing, feeding, using chopsticks, writing; grip strength exercises with progressive resistance; patient able to dress and feed independently by month 3
- Month 3–6: Fine motor consolidation — writing, typing, tool use; grip strength approaching normal; DASH score improving progressively
Follow-up Outcomes
- 1 month: All flaps fully viable; finger joint range of motion significantly increased; partial grasp function restored
- 3 months: Independent dressing and feeding achieved; grip strength markedly improved; DASH score significantly reduced from baseline
- 6 months: Fine motor function restored — writing and typing possible; near-normal hand function; flap colour and texture blending with surrounding skin
- 1 year: Hand function fully consolidated; no restriction on daily activities or work; patient returned to employment; no flap complications; no contracture recurrence; patient satisfaction high — functional and aesthetic outcomes exceeded expectations
Expert Commentary — Dr. Chai Jiake
1. The Anterolateral Thigh Flap: Why It Has Become the Workhorse of Hand Reconstruction
The free anterolateral thigh flap has become the most widely used free flap for large dorsal hand defects because it combines the properties that hand reconstruction demands: a large skin paddle (up to 25 cm × 15 cm), a long vascular pedicle (8–12 cm), large-calibre vessels (2–3 mm artery, 2–3 mm vein) that facilitate reliable microsurgical anastomosis, and a tissue thickness that — in lean patients — is appropriate for dorsal hand coverage without restricting extensor tendon gliding. The donor site on the anterolateral thigh can be closed primarily for flaps up to approximately 8 cm wide, and the donor scar is concealed under clothing. The perforator anatomy is consistent enough to be reliably identified with handheld Doppler pre-operatively in the majority of patients. No other free flap combines all of these properties in a single donor site. The ALT flap has replaced the radial forearm flap as the preferred choice for large dorsal hand defects at most high-volume centres, because it avoids sacrificing the radial artery — a major vessel of the hand — as the donor pedicle.
2. Microsurgical Anastomosis: The Technical Foundation of Free Flap Surgery
A free flap is a block of tissue that has been completely detached from its blood supply and reattached to a new blood supply at the recipient site through microsurgical anastomosis of vessels typically 1–3 mm in diameter. The anastomosis is performed under the operating microscope at 6–10 times magnification using sutures of 8-0 to 10-0 nylon — finer than a human hair. The technical requirements are absolute: the vessel ends must be cleanly cut without crush injury, the adventitia must be trimmed from the anastomotic zone to prevent intraluminal contamination, the sutures must be placed with consistent spacing and depth, and the knots must be tied with sufficient tension to achieve a watertight seal without constricting the lumen. A single technical error — a suture placed too close to the vessel edge, a knot tied too tightly, a twist in the pedicle — can cause thrombosis and flap loss within hours of the operation. The learning curve for microsurgery is measured in hundreds of anastomoses performed in the laboratory before the first clinical case. At Changhai Hospital, our microsurgical team performs more than 200 free flap procedures annually — the volume that maintains the technical precision that free flap surgery demands.
3. Post-Burn Contracture: Why Early Rehabilitation After Acute Burns Prevents the Problem
The contractures that required reconstruction in this patient were not inevitable consequences of the burn injury — they were the consequence of inadequate rehabilitation after the acute burn. Scar contracture develops when healing tissue is allowed to shorten along the lines of tension during the proliferative phase of wound healing — typically weeks 2 through 12 after injury. Positioning, splinting, and active mobilisation during this period counteract the contractile forces of the healing scar and maintain joint range of motion. A hand that is splinted in the position of safe immobilisation — wrist extended, MCPs flexed to 70–90 degrees, IPs extended, thumb abducted — and mobilised daily during the healing phase will develop far less contracture than a hand that is allowed to rest in the position of comfort — wrist flexed, fingers extended — which is the position of maximum contracture. The tragedy of post-burn contracture is that it is largely preventable with appropriate acute-phase rehabilitation. The reconstructive surgery that this patient required — a six-hour free flap procedure with months of rehabilitation — could have been avoided or significantly reduced by two weeks of positioning and splinting in the acute phase.
4. Hand Rehabilitation After Flap Reconstruction: The Surgery Is the Beginning, Not the End
Free flap coverage of a post-burn hand contracture restores the skin envelope — it does not restore hand function. Function is restored by rehabilitation: the progressive mobilisation of joints that have been stiff for months, the retraining of muscles that have been inhibited by pain and disuse, and the re-education of sensory pathways that have been disrupted by the burn and the scar. The rehabilitation programme must begin as early as the flap biology allows — passive mobilisation from day 3, active training from week 2, functional task training from week 4 — because every day of immobilisation after flap surgery allows the periarticular fibrosis to progress and the muscle atrophy to deepen. The rehabilitation therapist is as important as the surgeon in the outcome of post-burn hand reconstruction. In this patient, the restoration of fine motor function — writing and typing at six months — was the product of four months of daily rehabilitation, not of the surgery alone. The surgery created the biological conditions for rehabilitation to succeed. The rehabilitation created the functional outcome.
How CMCS Shanghai Coordinated This Case
CMCS Shanghai supported Mr. O'Sullivan and his family from initial consultation through one-year follow-up, including: urgent coordination of burn and plastic surgery consultation with Dr. Chai Jiake at Changhai Hospital, Naval Medical University with priority appointment scheduling given the functional severity of the bilateral hand contractures; bilingual review of all prior burn treatment records, operative notes from the initial debridement and grafting, and wound healing photographs with clinical summary for the MDT; coordination of bilateral hand radiographs, scar ultrasound, and DASH functional assessment with bilingual results communication; bilingual interpretation throughout all MDT discussions involving burn and plastic surgery and rehabilitation medicine; pre-operative psychological support coordination — bilingual counselling sessions to address the patient's anxiety and restore confidence before surgery; pre-operative rehabilitation coordination including one week of physiotherapy-guided passive joint mobilisation with bilingual instruction; surgical consent coordination including bilingual explanation of the free ALT flap procedure, the microsurgical anastomosis, the local digital flaps, the donor site, and the expected recovery timeline; real-time updates to the patient's family and his GP in Dublin during the operative period and ICU monitoring phase; ICU flap monitoring support — bilingual hourly updates to the family on flap perfusion status during the critical 24-hour post-operative period; anticoagulation and antispasm medication coordination with bilingual pharmacy instructions; post-operative dressing and wound care coordination with bilingual nursing instruction; rehabilitation programme coordination — bilingual physiotherapy sessions from day 3, with weekly progress summaries communicated to the patient's occupational therapist in Ireland; functional milestone tracking — bilingual documentation of grip strength, joint range of motion, and DASH scores at each follow-up visit; one-year follow-up coordination with comprehensive functional assessment and results communicated to the patient's GP and occupational therapist overseas; and return-to-work coordination including bilingual medical report for the patient's employer and workers' compensation documentation support.
For international patients with post-burn contractures, complex traumatic hand injuries, or conditions requiring microsurgical reconstruction in Shanghai, Dr. Chai Jiake's team at Changhai Hospital, Naval Medical University represents reconstructive surgery expertise at the international frontier — combining free flap microsurgery, perforator flap design, scar contracture release, and structured hand rehabilitation to achieve functional and aesthetic restoration in patients with complex post-burn deficits. CMCS ensures that expertise is accessible: in the patient's language, with overseas physicians and families informed at every step, from the first reconstructive consultation through one-year functional follow-up.
This case report is de-identified and published for educational purposes. All clinical details have been anonymized in accordance with patient privacy standards. CMCS Shanghai is a medical concierge service and does not provide direct medical care.
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