burns 41 (2015) 624–630
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Neck burn reconstruction with pre-expanded scapular free flaps Baoqiang Song a,1,*, Bo Xiao a,1, Chaohua Liu a, Lin He a, Yang Li a, Feng Sun a, Kia M. Washington b, Yalan Hu c, Dongyue Hao a, Juan Zhang a, Shuzhong Guo a,** a
Department of Plastic Surgery, Xijing Hospital, University of The Fourth Military Medical University, Xi’an, China Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA c Department of Plastic Surgery, 260th Hospital of PLA, Shijiazhuang, China b
article info
abstract
Article history:
Background: The reconstruction of neck contracture deformities after severe burns is chal-
Accepted 25 August 2014
lenging. This is due to insufficient tissue to resurface the large defect after local flap transfer
Keywords:
grafting. We employed free transfer of pre-expanded scapular flaps to reconstruct postburn
as well as the poor functional and cosmetic results after traditional methods such as skin Scapular flap
neck deformities.
Tissue expansion
Methods: In the first stage, skin expansion was performed with tissue expanders ranging
Burn reconstruction
from 400 to 800 mL according to the neck defect size and expanders were filled to their end volumes. In the second stage, the contracture in the neck was released and the unstable scar was resected. The pre-expanded scapular flap was then harvested and transferred to the neck defect. Flap revisions were performed 3–12 months after flap transfer. Results: A total of 12 flaps (100%) were successful. The contour, colour, and texture of flaps matched well to the nearby skin. The range of motion of the neck was significantly improved. The donor defects were closed directly except for one case, which required skin grafting. Conclusions: The free tissue transfer of pre-expanded scapular flap is a valuable tool in neck burn reconstruction. It can be used safely and effectively with minimal morbidity in selected patients. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Postburn neck scar contracture is a major sequela of burn that presents a pressing challenge for plastic surgeons. The
contracture causes not only cosmetic but also functional problems. The goals of treatment for neck contractures are to release the contractures thoroughly; to regain the natural profile, contour, and colour match; and to restore the normal mobility. Although skin grafting is a commonly used
* Corresponding author at: Department of Plastic Surgery, Xijing Hospital, The Fourth Military Medical University, Xi’an 710032, China. Tel.: +86 29 84775305; fax: +86 29 84775305. ** Corresponding author at: Department of Plastic Surgery, Xijing Hospital, The Fourth Military Medical University, Xi’an 710032, China. Tel.: +86 29 84775301; fax: +86 29 84775301. E-mail addresses: [email protected] (B. Song), [email protected] (S. Guo). 1 These authors contributed equally to this article. http://dx.doi.org/10.1016/j.burns.2014.08.015 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
burns 41 (2015) 624–630
treatment, its major disadvantages are hyperpigmentation and contracture. Local flaps such as the deltopectoral flap [1] and transverse cervical artery perforator flap [2] can be advanced into burn defects. These local flaps are able to obtain contour and colour match with the nearby tissue. However, it can cause a large unaesthetic donor defect that many patients, especially females, are reluctant to accept. Free scapular fasciocutaneous flaps can be used to resurface defects in the neck [3]. However, the bulkiness and size limitation of the flaps hinder their further application. Several second-stage debulking procedures are usually needed to obtain a better appearance. Furthermore, the usage of a skin graft at the donor site is usually unavoidable. The use of pre-expanded scapular free flaps is a viable option to improve the final aesthetic appearance and functional result and to reduce donor-site morbidity. In this article, we present a series of 12 patients who underwent neck reconstruction with preexpanded scapular free flaps. The indications, methods, and outcomes for these cases are provided, and the advantages and drawbacks of this technique are discussed.
2.
Patients and method
The authors retrospectively reviewed 12 pre-expanded free scapular flaps for neck burn reconstruction. Patient profiles and operative procedures were reviewed. The age and defect size were recorded for each case. The assessments of outcomes with at least 1-year follow-up included flap failures, infections, partial necrosis, donor-site complications, and the need for future revisions.
3.
Surgical technique
3.1.
First operation
The selection of expander volume is based on the size of the defect. The neck defect size was evaluated by comparing the contracted side with the normal side of the neck or with the normal neck of a person with a similar body type. A major portion of the skin expansion was performed with elliptical tissue expanders with volume ranging between 600 and 800 mL with the exception of one 400-mL expander for a 9-year-old patient who had a small back. With the patient in the lateral decubitus position, a longitudinal incision (6–10 cm) was made at the midaxillary line. The expander was inserted below the deep fascia and above the tunica muscularis. Great attention was paid when a dissection was made at the superior border of the teres major in order to prevent possible injury of the circumflex scapular artery. After good wound healing (14–21 days), expanders were filled twice a week until the targeted volumes were achieved. Annuliform pressure bandages were used (encircling entire body) at the inferior border of the expander to prevent gravitation-induced descent during expansion.
3.2.
Second operation
The patient was initially placed supine with the neck and shoulder hyperextended. Thorough release of the contracture
625
was achieved by incising scar tissues in the subcutaneous, platysmal, and subplatysmal layers according to the depth of scarring. The shape of the incision along the neck should be perpendicular and curvilinear to avoid future contracture. The size and shape of the defect were evaluated and measured. For flap elevation, patients were placed in the lateral decubitus position with the ipsilateral arm free. Using the template of the neck wound made after release, marking in the expanded region was carried out based on the size and shape of the defect and on the location of the recipient blood vessels. The expander was then removed and the flap was elevated from the distal to the proximal end. After effective hemostasis and insertion of the drain tube, the donor site was closed directly in most patients after suitable undermining except one case, which needed a skin graft. In this case, the defect was 24 cm 16 cm and it could not be closed directly. Microsurgical vessel anastomosis was performed in an endto-end fashion, between the circumflex scapular artery and the facial artery and between the circumflex scapular vein and the facial vein. Gradient debulking in the distal portion of the flaps was performed in two-thirds of the flaps to diminish the thickness of the flaps. Usually, only 3–5 mm of subcutaneous tissue in the distal portion of the flaps was preserved. The flaps were then positioned and inset between the edges of the skin in the remaining defect. The average operative time was about 6.5 h. Three weeks after the operation, pressure bandages were initiated for 1 year to restrict incisional scars and to keep the neck contour.
3.3.
Third operation
The third stage was performed 3–12 months after the second stage. Debulking was performed if the flap was still bulky and Z-plasty was carried out if scar contracture occurred.
4.
Case reports
4.1.
Case 1
A 14-year-old boy sustained a burn extending to the deep dermis at the age of 8 years involving the juncture of his neck and upper chest. He was presented to our clinic with a neck contracture extending around the clavicular region that caused a decrease in the cervicomental angle and functional limitation of neck movements (Fig. 1). In the first stage of the reconstruction, an 800-mL elliptical tissue expander was inserted through a 7-cm horizontal incision on the left side. A serial expansion on a twice-weekly basis was performed for 8 weeks. In the second stage of the reconstruction, the contracture in the neck was released and resected in a fullthickness excision. With the neck in full extension, the size of the defect was determined to be 27 cm 14 cm. By means of a template, a free scapular flap (29 cm 16 cm) was outlined on the pre-expanded skin at the donor site (Fig. 2). The expander was then removed and the pre-expanded scapular flap was harvested. After microsurgical vessel anastomosis, the flap was positioned and inset between the edges of the wound. The flap donor site was closed directly. The early postoperative
626
burns 41 (2015) 624–630
Fig. 1 – Preoperative (left) frontal and (right) lateral views demonstrating the severe neck contracture deformity in a 14-yearold boy.
course was uneventful. Six months after the initial reconstruction, a minor defatting procedure was performed. The long-term results at the 1-year follow-up demonstrated full neck extension with no secondary contractures and good adaptation of the flap with regard to thickness, texture, colour, and consistency (Fig. 3).
4.2.
Case 2
A 9-year-old girl sustained a burn at the age of 6 years involving her neck and upper chest. She was presented to our clinic with a severe neck contracture extending from the right upper neck to the upper chest region that caused a functional
limitation of neck movements (Fig. 4). A 400-mL tissue expander was inserted through a 6-cm longitudinal incision that was made to correspond subsequently to the lower border of the scapular flap on the right side. A serial expansion on a twice-weekly basis was performed for 8 weeks. In the second stage, after the contracture in the neck was released, fullthickness platysma transection was also required to obtain full release of the contracture and full extension of the neck. The size of the defect was determined to be 16 cm 10 cm. By means of a template, a free scapular flap (18 cm 12 cm) was outlined on the pre-expanded skin at the donor site. The expander was then removed and the pre-expanded scapular flap was harvested. After microsurgical vessel anastomosis,
Fig. 2 – Design before operation (left) and free flap harvest (right).
burns 41 (2015) 624–630
627
Fig. 3 – Postoperative (left) frontal and (right) lateral views of the patient, 1 year after neck reconstruction with a preexpanded scapular flap.
the flap was then positioned and inset between the edges of the wound. The flap donor site was closed directly. The early postoperative course was uneventful. One year after the initial reconstruction, a Z-plasty procedure was performed at the edge of the flap to release a contracture from the incision (Fig. 5). At this time, the patient had obtained a significant increase in extension and a normal cervicomental angle.
5.
Results
Twelve patients were included in this study (five males and seven females). Their ages ranged from 9 to 44 years (mean, 18.75 years). All presented with severe postburn neck contractures. All patients underwent clinical follow-up for 12 months (Table 1). Long-term follow-up demonstrated
Fig. 4 – Preoperative (left) frontal and (right) lateral views demonstrating the severe neck contracture deformity in a 9-yearold girl.
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burns 41 (2015) 624–630
Fig. 5 – Postoperative (left) frontal and (right) lateral views of the patient, 1 year after the initial reconstruction, a Z-plasty procedure was performed at the edge of the flap to release a contracture from the incision.
improved appearance in all patients. The cervicomental angles and the maximum cervical spine hypsokinesis were measured by a Photo Measures software from the APP Store [15]. The cervicomental angle was significantly decreased (149.8 25.38 vs. 119.7 20.78, one-sample t-test, p < 0.01). The range of cervical motion for each patient was defined by the maximum cervical spine hypsokinesis. The mean angle of maximum cervical spine hypsokinesis was significantly increased (3.6 13.68 vs. 30.3 9.58, one-sample t-test, p < 0.01). Perfusion problems occurred in one flap. One flap with venous congestion was revised successfully. Overall, 12 of 12
free flaps survived (100%). One donor site became infected at 6 weeks after the expander insertion. The expander was removed instantaneously. After washout and drainage for 1 week, the free flap was harvested and transferred successfully. Eleven of 12 donor sites were closed directly. One donor site was closed by the skin graft. Two donor sites developed moderate scar and one donor site developed a hypertrophic scar. The hypertrophic scar also developed on the margin of the flap in one case. Six flaps required future debulking or sculpting. Two flaps required future Z-plasty to release incisional contractures.
Table 1 – Donor-site and reconstruction-site problems and secondary flap revisions associated with pre-expanded free scapular flaps used to reconstruct neck burn contractures in 12 patients. Patient 1 2 3 4 5 6 7 8 9 10 11 12
Age (years) 14 24 9 21 44 10 39 17 13 24 19 11
Sex
Defect size (cm cm)
M M F F M F M F F M F F
27 14 15 7 16 10 24 16 24 11 17 18 21 10 21 9 19 7 18 8 21 7 17 9
Donor-site problem Hypertrophic scar None Moderate scar Skin graft Infectiona Moderate scar None None None None None None
Reconstruction-site problem
Secondary flap procedure
Hypertrophic scar None None None None None Venous crisis None None None None None
Debulking None Z-plasty Debulking Debulking None Z-plasty Debulking None Debulking Debulking Z-plasty
a The expander was taken out instantaneously. After washout and drainage for 1 week, the free flap was harvested and transferred successfully.
burns 41 (2015) 624–630
6.
Discussion
The basic goals of neck reconstruction are the restoration of appearance including symmetry, contour, colour, texture match and function, mobility, and sensation in particular. There are several surgical options for resurfacing the neck after the release of contractures and each procedure has its own advantages, disadvantages, and limitations. Skin grafts are less time consuming and technically demanding. However, contracture and hyperpigmentation are the major drawbacks of skin graft. It is common for neck contractures to recur after skin grafting due to secondary skin graft contracture, even if a full-thickness skin graft is used. Another disadvantage of skin grafting is its inability to restore a natural colour and contour due to hyperpigmentation and lack of subcutaneous tissue. Tissue expansion of adjacent neck tissue is another method for the correction of neck postburn contracture [4,5]. However, it is not a reliable reconstructive technique. The expanded neck skin is more flexible than the skin in other areas of the body. The increase of surface area in neck expansion is mostly the result of the stretching phenomenon rather than newly regenerated tissue mass. As a result, the skin often shrinks in the long term. Pre-expanded local flaps such as deltopectoral flap [6], subclavicular flaps [7], and supraclavicular flaps [8] are able to obtain contour and colour match to the nearby tissue. The major disadvantage of these flaps is the morbidity of the donor site that always leads to a hypertrophic scar of the thorax. Such a resultant hypertrophic scar is unacceptable for many patients, especially female patients. Free tissue transfer for neck burn reconstruction is another choice [9]. Radial forearm flaps were proved to be reliable [10]. However, the disadvantage of this technique is the donor-site morbidity. The donor site needs skin grafting to cover the donor site. Free groin flaps have the less potential morbidity of the donor site [11]. However, the major disadvantages of this technique are the variability and shortness of the vascular pedicle [12]. Free anterolateral thigh flaps are reliable and large flaps with long pedicles. Yang et al. [13] reported that a good cervical contour was obtained by this flap. However, there can be a significant colour and contour mismatch. In addition, hair growth after flap transfer is another trouble. Free thin thoracodorsal artery perforator flaps are another choice to reconstruct neck contractures [14,15]. However, variations of perforators may exist and contribute to the difficulty of flap elevation. Moreover, two or more perforators have to be included if a large flap is harvested, which can further increase the complexity of the surgery. A free scapular flap is reliable in postburn neck reconstruction. However, a scapular flap has a small vertical dimension and it is unsuitable for reconstruction of large defects. Besides, several debulking procedures need to be performed after free flap transfer to obtain a better appearance. There are several advantages of our technique in neck burn reconstruction. Pre-expansion of the scapular area not only makes the flap thinner but also makes the flap more adequate for reconstruction. Expansion causes an increase in the surface area of flap and in the size of the capillary bed, which allows the surgeon to harvest more tissue, even beyond the anatomical boundaries of the known blood supply of the flap.
629
Larger free scapular flaps make it possible to resurface larger neck defects after resection of scars. While a scapular flap is located in a well-concealed area, expansion further minimizes donor-site morbidity. Most donor sites can be closed directly without excessive tension. Patients typically are willing to accept scars in the region of the back where the flap is harvested. Our results proved the merits of Ninkovic’s method in which the reconstructed neck defect was also reconstructed by a pre-expanded free scapular flap [12]. The process of expansion leads to the formation of a capsule. We observed a moderate capsule formation in all preexpanded free flaps. The capsule is regarded by some authors as untouchable because of the risk of damaging the vascular network [16,17]. However, several authors introduced the concept of the ‘‘super-thin flap,’’ in which only a minimal fat layer and the subdermal vascular network are included [18]. The pre-expanded ‘‘super-thin flap’’ is regarded to be able to survive after the depletion of the capsule [19]. In our technique, we preserved the capsule in the proximal one-third of the flap and excised the capsule in the distal two-thirds of the flap. Furthermore, the distal one-third of the flap was thinned down to the layer in which the subdermal vascular network was seen through the minimal fat layer. By our technique, the blood supply through the proximal capsule of the flap was preserved and the distal two-thirds of the flap was thinned. All flaps survived completely. By this technique, the blood supply of the flap was maintained and at the same time debulking was only needed one time after free flap transfer. We experienced a change in the timing of performing the second stage surgery through the course of our study. At the beginning, the second stage was performed 1 week after the last injection. Although a major portion of the donor area can be closed directly, the high tension caused by retraction of the expanded tissues led to wide scars when the donor site width was >12 cm. The retraction of expanded tissues were closely related to time interval from the last expansion. We extended this time to 2 weeks, which led to reduction of tissue retraction and better donor outcome. Nevertheless, several disadvantages came with this surgical method including extra-operative procedures, the prolongation of hospital stay, the repeated follow-up visits, and the potential complications during tissue expansion period. Tissue loss may be caused by infection, overexpansion, and inadvertent flap thinning. Moreover, the pre-expanded free scapular flap procedure requires greater surgical skills than traditional microsurgery. Generally, the usage of the pre-expanded free-scapular flap is an effective way of reconstructing postburn neck contracture. It provides a large good-quality skin flap that can cover the defect after contracture release. We concluded that the expansion of the flap facilitates blood supply, improves the quality, increases the size of free scapular flap, and minimizes the donor-site morbidity.
Conflict of interest statement None of the authors has any commercial associations or financial disclosures that might pose or create a conflict of interest with the information presented in this article.
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references
[1] Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructive surgery of the head and neck. Br J Plast Surg 1971;24(2):174–83. [2] Chen WL, Zhang DM, Yang ZH, Huang ZQ, Wang JG, Zhang B, et al. Extended supraclavicular fasciocutaneous island flap based on the transverse cervical artery for head and neck reconstruction after cancer ablation. J Oral Maxillofac Surg 2010;68(10):2422–30. [3] Sullivan MJ, Carroll WR, Baker SR, Crompton PT, SmithWheelock M. The free scapular flap for head and neck reconstruction. Am J Otolaryngol 1990;11(5):318–27. [4] MacLennan SE, Corcoran JF, Neale HW. Tissue expansion in head and neck burn reconstruction. Clin Plast Surg 2000;27(1):121–32. [5] Rashid M, Zia-Ul-Islam M, Sarwar SU, Bhatti AM. The ‘expansile’ supraclavicular artery flap for release of postburn neck contractures. J Plast Reconstr Aesthet Surg 2006;59(10):1094–101. [6] Ma XJ, Peng P, Zheng Y, Guo SZ, Han Y, Lu KH. Expanded deltopectoral flaps for treatment of cervical cicatricial contracture. Zhonghua Zheng Xing Wai Ke Za Zhi 2010;26(1):21–3. [7] Xie F, Wang J, Li Q, Zhou S, Zan T, Gu B, et al. Resurfacing large skin defects of the face and neck with expanded subclavicular flaps pedicled by the thoracic branch of the supraclavicular artery. Burns 2012;38(6):924–30. [8] Vinh VQ, Ogawa R, Van Anh T, Hyakusoku H. Reconstruction of neck scar contractures using supraclavicular flaps: retrospective study of 30 cases. Plast Reconstr Surg 2007;119(1):130–5. [9] Parrett BM, Pomahac B, Orgill DP, Pribaz JJ. The role of freetissue transfer for head and neck burn reconstruction. Plast Reconstr Surg 2007;120(7):1871–8.
[10] Hung KF, Liu YT, Tsai YC. Clinical experience of free forearm flap in head and neck surgery. Changgeng Yi Xue Za Zhi 1990;13(1):24–30. [11] Ohkubo E, Kobayashi S, Sekiguchi J, Ohmuri K. Restoration of the anterior neck surface in the burned patient by free groin flap. Plast Reconstr Surg 1991;87(2):276–84. [12] Ninkovic M, Moser-Rumer A, Ninkovic M, Spanio S, Rainer C, Gurunluoglu R. Anterior neck reconstruction with preexpanded free groin and scapular flaps. Plast Reconstr Surg 2004;113(1):61–8. [13] Yang JY, Tsai FC, Chana JS, Chuang SS, Chang SY, Huang WC. Use of free thin anterolateral thigh flaps combined with cervicoplasty for reconstruction of postburn anterior cervical contractures. Plast Reconstr Surg 2002;110(1): 39–46. [14] Mun GH, Jeon BJ, Lim SY, Hyon WS, Bang SI, Oh KS. Reconstruction of postburn neck contractures using free thin thoracodorsal artery perforator flaps with cervicoplasty. Plast Reconstr Surg 2007;120(6): 1524–32. [15] Wang AW, Zhang WF, Liang F, Li JY, Zhang XF, Niu XT. Preexpanded thoracodorsal artery perforator-based flaps for repair of severe scarring in cervicofacial regions. J Reconstr Microsurg 2014 [Epub ahead of print]. [16] Marks MW, Burney RE, Mackenzie JR, Knight PR. Enhanced capillary blood flow in rapidly expanded random pattern flaps. J Trauma 1986;26(10):913–5. [17] Cherry GW, Austad E, Pasyk K, McClatchey K, Rohrich RJ. Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin. Plast Reconstr Surg 1983;72(5):680–7. [18] Ogawa R, Hyakusoku H. Survival area of super-thin flaps. Burns 2010;36(6):947. [19] Gao JH, Ogawa R, Hyakusoku H, Lu F, Hu ZQ, Jiang P, et al. Reconstruction of the face and neck scar contractures using staged transfer of expanded ‘‘Super-thin flaps’’. Burns 2007;33(6):760–3.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Neck burn reconstruction with pre-expanded scapular free flaps Baoqiang Song a,1,*, Bo Xiao a,1, Chaohua Liu a, Lin He a, Yang Li a, Feng Sun a, Kia M. Washington b, Yalan Hu c, Dongyue Hao a, Juan Zhang a, Shuzhong Guo a,** a
Department of Plastic Surgery, Xijing Hospital, University of The Fourth Military Medical University, Xi’an, China Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA, USA c Department of Plastic Surgery, 260th Hospital of PLA, Shijiazhuang, China b
article info
abstract
Article history:
Background: The reconstruction of neck contracture deformities after severe burns is chal-
Accepted 25 August 2014
lenging. This is due to insufficient tissue to resurface the large defect after local flap transfer
Keywords:
grafting. We employed free transfer of pre-expanded scapular flaps to reconstruct postburn
as well as the poor functional and cosmetic results after traditional methods such as skin Scapular flap
neck deformities.
Tissue expansion
Methods: In the first stage, skin expansion was performed with tissue expanders ranging
Burn reconstruction
from 400 to 800 mL according to the neck defect size and expanders were filled to their end volumes. In the second stage, the contracture in the neck was released and the unstable scar was resected. The pre-expanded scapular flap was then harvested and transferred to the neck defect. Flap revisions were performed 3–12 months after flap transfer. Results: A total of 12 flaps (100%) were successful. The contour, colour, and texture of flaps matched well to the nearby skin. The range of motion of the neck was significantly improved. The donor defects were closed directly except for one case, which required skin grafting. Conclusions: The free tissue transfer of pre-expanded scapular flap is a valuable tool in neck burn reconstruction. It can be used safely and effectively with minimal morbidity in selected patients. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Postburn neck scar contracture is a major sequela of burn that presents a pressing challenge for plastic surgeons. The
contracture causes not only cosmetic but also functional problems. The goals of treatment for neck contractures are to release the contractures thoroughly; to regain the natural profile, contour, and colour match; and to restore the normal mobility. Although skin grafting is a commonly used
* Corresponding author at: Department of Plastic Surgery, Xijing Hospital, The Fourth Military Medical University, Xi’an 710032, China. Tel.: +86 29 84775305; fax: +86 29 84775305. ** Corresponding author at: Department of Plastic Surgery, Xijing Hospital, The Fourth Military Medical University, Xi’an 710032, China. Tel.: +86 29 84775301; fax: +86 29 84775301. E-mail addresses: [email protected] (B. Song), [email protected] (S. Guo). 1 These authors contributed equally to this article. http://dx.doi.org/10.1016/j.burns.2014.08.015 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
burns 41 (2015) 624–630
treatment, its major disadvantages are hyperpigmentation and contracture. Local flaps such as the deltopectoral flap [1] and transverse cervical artery perforator flap [2] can be advanced into burn defects. These local flaps are able to obtain contour and colour match with the nearby tissue. However, it can cause a large unaesthetic donor defect that many patients, especially females, are reluctant to accept. Free scapular fasciocutaneous flaps can be used to resurface defects in the neck [3]. However, the bulkiness and size limitation of the flaps hinder their further application. Several second-stage debulking procedures are usually needed to obtain a better appearance. Furthermore, the usage of a skin graft at the donor site is usually unavoidable. The use of pre-expanded scapular free flaps is a viable option to improve the final aesthetic appearance and functional result and to reduce donor-site morbidity. In this article, we present a series of 12 patients who underwent neck reconstruction with preexpanded scapular free flaps. The indications, methods, and outcomes for these cases are provided, and the advantages and drawbacks of this technique are discussed.
2.
Patients and method
The authors retrospectively reviewed 12 pre-expanded free scapular flaps for neck burn reconstruction. Patient profiles and operative procedures were reviewed. The age and defect size were recorded for each case. The assessments of outcomes with at least 1-year follow-up included flap failures, infections, partial necrosis, donor-site complications, and the need for future revisions.
3.
Surgical technique
3.1.
First operation
The selection of expander volume is based on the size of the defect. The neck defect size was evaluated by comparing the contracted side with the normal side of the neck or with the normal neck of a person with a similar body type. A major portion of the skin expansion was performed with elliptical tissue expanders with volume ranging between 600 and 800 mL with the exception of one 400-mL expander for a 9-year-old patient who had a small back. With the patient in the lateral decubitus position, a longitudinal incision (6–10 cm) was made at the midaxillary line. The expander was inserted below the deep fascia and above the tunica muscularis. Great attention was paid when a dissection was made at the superior border of the teres major in order to prevent possible injury of the circumflex scapular artery. After good wound healing (14–21 days), expanders were filled twice a week until the targeted volumes were achieved. Annuliform pressure bandages were used (encircling entire body) at the inferior border of the expander to prevent gravitation-induced descent during expansion.
3.2.
Second operation
The patient was initially placed supine with the neck and shoulder hyperextended. Thorough release of the contracture
625
was achieved by incising scar tissues in the subcutaneous, platysmal, and subplatysmal layers according to the depth of scarring. The shape of the incision along the neck should be perpendicular and curvilinear to avoid future contracture. The size and shape of the defect were evaluated and measured. For flap elevation, patients were placed in the lateral decubitus position with the ipsilateral arm free. Using the template of the neck wound made after release, marking in the expanded region was carried out based on the size and shape of the defect and on the location of the recipient blood vessels. The expander was then removed and the flap was elevated from the distal to the proximal end. After effective hemostasis and insertion of the drain tube, the donor site was closed directly in most patients after suitable undermining except one case, which needed a skin graft. In this case, the defect was 24 cm 16 cm and it could not be closed directly. Microsurgical vessel anastomosis was performed in an endto-end fashion, between the circumflex scapular artery and the facial artery and between the circumflex scapular vein and the facial vein. Gradient debulking in the distal portion of the flaps was performed in two-thirds of the flaps to diminish the thickness of the flaps. Usually, only 3–5 mm of subcutaneous tissue in the distal portion of the flaps was preserved. The flaps were then positioned and inset between the edges of the skin in the remaining defect. The average operative time was about 6.5 h. Three weeks after the operation, pressure bandages were initiated for 1 year to restrict incisional scars and to keep the neck contour.
3.3.
Third operation
The third stage was performed 3–12 months after the second stage. Debulking was performed if the flap was still bulky and Z-plasty was carried out if scar contracture occurred.
4.
Case reports
4.1.
Case 1
A 14-year-old boy sustained a burn extending to the deep dermis at the age of 8 years involving the juncture of his neck and upper chest. He was presented to our clinic with a neck contracture extending around the clavicular region that caused a decrease in the cervicomental angle and functional limitation of neck movements (Fig. 1). In the first stage of the reconstruction, an 800-mL elliptical tissue expander was inserted through a 7-cm horizontal incision on the left side. A serial expansion on a twice-weekly basis was performed for 8 weeks. In the second stage of the reconstruction, the contracture in the neck was released and resected in a fullthickness excision. With the neck in full extension, the size of the defect was determined to be 27 cm 14 cm. By means of a template, a free scapular flap (29 cm 16 cm) was outlined on the pre-expanded skin at the donor site (Fig. 2). The expander was then removed and the pre-expanded scapular flap was harvested. After microsurgical vessel anastomosis, the flap was positioned and inset between the edges of the wound. The flap donor site was closed directly. The early postoperative
626
burns 41 (2015) 624–630
Fig. 1 – Preoperative (left) frontal and (right) lateral views demonstrating the severe neck contracture deformity in a 14-yearold boy.
course was uneventful. Six months after the initial reconstruction, a minor defatting procedure was performed. The long-term results at the 1-year follow-up demonstrated full neck extension with no secondary contractures and good adaptation of the flap with regard to thickness, texture, colour, and consistency (Fig. 3).
4.2.
Case 2
A 9-year-old girl sustained a burn at the age of 6 years involving her neck and upper chest. She was presented to our clinic with a severe neck contracture extending from the right upper neck to the upper chest region that caused a functional
limitation of neck movements (Fig. 4). A 400-mL tissue expander was inserted through a 6-cm longitudinal incision that was made to correspond subsequently to the lower border of the scapular flap on the right side. A serial expansion on a twice-weekly basis was performed for 8 weeks. In the second stage, after the contracture in the neck was released, fullthickness platysma transection was also required to obtain full release of the contracture and full extension of the neck. The size of the defect was determined to be 16 cm 10 cm. By means of a template, a free scapular flap (18 cm 12 cm) was outlined on the pre-expanded skin at the donor site. The expander was then removed and the pre-expanded scapular flap was harvested. After microsurgical vessel anastomosis,
Fig. 2 – Design before operation (left) and free flap harvest (right).
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Fig. 3 – Postoperative (left) frontal and (right) lateral views of the patient, 1 year after neck reconstruction with a preexpanded scapular flap.
the flap was then positioned and inset between the edges of the wound. The flap donor site was closed directly. The early postoperative course was uneventful. One year after the initial reconstruction, a Z-plasty procedure was performed at the edge of the flap to release a contracture from the incision (Fig. 5). At this time, the patient had obtained a significant increase in extension and a normal cervicomental angle.
5.
Results
Twelve patients were included in this study (five males and seven females). Their ages ranged from 9 to 44 years (mean, 18.75 years). All presented with severe postburn neck contractures. All patients underwent clinical follow-up for 12 months (Table 1). Long-term follow-up demonstrated
Fig. 4 – Preoperative (left) frontal and (right) lateral views demonstrating the severe neck contracture deformity in a 9-yearold girl.
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Fig. 5 – Postoperative (left) frontal and (right) lateral views of the patient, 1 year after the initial reconstruction, a Z-plasty procedure was performed at the edge of the flap to release a contracture from the incision.
improved appearance in all patients. The cervicomental angles and the maximum cervical spine hypsokinesis were measured by a Photo Measures software from the APP Store [15]. The cervicomental angle was significantly decreased (149.8 25.38 vs. 119.7 20.78, one-sample t-test, p < 0.01). The range of cervical motion for each patient was defined by the maximum cervical spine hypsokinesis. The mean angle of maximum cervical spine hypsokinesis was significantly increased (3.6 13.68 vs. 30.3 9.58, one-sample t-test, p < 0.01). Perfusion problems occurred in one flap. One flap with venous congestion was revised successfully. Overall, 12 of 12
free flaps survived (100%). One donor site became infected at 6 weeks after the expander insertion. The expander was removed instantaneously. After washout and drainage for 1 week, the free flap was harvested and transferred successfully. Eleven of 12 donor sites were closed directly. One donor site was closed by the skin graft. Two donor sites developed moderate scar and one donor site developed a hypertrophic scar. The hypertrophic scar also developed on the margin of the flap in one case. Six flaps required future debulking or sculpting. Two flaps required future Z-plasty to release incisional contractures.
Table 1 – Donor-site and reconstruction-site problems and secondary flap revisions associated with pre-expanded free scapular flaps used to reconstruct neck burn contractures in 12 patients. Patient 1 2 3 4 5 6 7 8 9 10 11 12
Age (years) 14 24 9 21 44 10 39 17 13 24 19 11
Sex
Defect size (cm cm)
M M F F M F M F F M F F
27 14 15 7 16 10 24 16 24 11 17 18 21 10 21 9 19 7 18 8 21 7 17 9
Donor-site problem Hypertrophic scar None Moderate scar Skin graft Infectiona Moderate scar None None None None None None
Reconstruction-site problem
Secondary flap procedure
Hypertrophic scar None None None None None Venous crisis None None None None None
Debulking None Z-plasty Debulking Debulking None Z-plasty Debulking None Debulking Debulking Z-plasty
a The expander was taken out instantaneously. After washout and drainage for 1 week, the free flap was harvested and transferred successfully.
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6.
Discussion
The basic goals of neck reconstruction are the restoration of appearance including symmetry, contour, colour, texture match and function, mobility, and sensation in particular. There are several surgical options for resurfacing the neck after the release of contractures and each procedure has its own advantages, disadvantages, and limitations. Skin grafts are less time consuming and technically demanding. However, contracture and hyperpigmentation are the major drawbacks of skin graft. It is common for neck contractures to recur after skin grafting due to secondary skin graft contracture, even if a full-thickness skin graft is used. Another disadvantage of skin grafting is its inability to restore a natural colour and contour due to hyperpigmentation and lack of subcutaneous tissue. Tissue expansion of adjacent neck tissue is another method for the correction of neck postburn contracture [4,5]. However, it is not a reliable reconstructive technique. The expanded neck skin is more flexible than the skin in other areas of the body. The increase of surface area in neck expansion is mostly the result of the stretching phenomenon rather than newly regenerated tissue mass. As a result, the skin often shrinks in the long term. Pre-expanded local flaps such as deltopectoral flap [6], subclavicular flaps [7], and supraclavicular flaps [8] are able to obtain contour and colour match to the nearby tissue. The major disadvantage of these flaps is the morbidity of the donor site that always leads to a hypertrophic scar of the thorax. Such a resultant hypertrophic scar is unacceptable for many patients, especially female patients. Free tissue transfer for neck burn reconstruction is another choice [9]. Radial forearm flaps were proved to be reliable [10]. However, the disadvantage of this technique is the donor-site morbidity. The donor site needs skin grafting to cover the donor site. Free groin flaps have the less potential morbidity of the donor site [11]. However, the major disadvantages of this technique are the variability and shortness of the vascular pedicle [12]. Free anterolateral thigh flaps are reliable and large flaps with long pedicles. Yang et al. [13] reported that a good cervical contour was obtained by this flap. However, there can be a significant colour and contour mismatch. In addition, hair growth after flap transfer is another trouble. Free thin thoracodorsal artery perforator flaps are another choice to reconstruct neck contractures [14,15]. However, variations of perforators may exist and contribute to the difficulty of flap elevation. Moreover, two or more perforators have to be included if a large flap is harvested, which can further increase the complexity of the surgery. A free scapular flap is reliable in postburn neck reconstruction. However, a scapular flap has a small vertical dimension and it is unsuitable for reconstruction of large defects. Besides, several debulking procedures need to be performed after free flap transfer to obtain a better appearance. There are several advantages of our technique in neck burn reconstruction. Pre-expansion of the scapular area not only makes the flap thinner but also makes the flap more adequate for reconstruction. Expansion causes an increase in the surface area of flap and in the size of the capillary bed, which allows the surgeon to harvest more tissue, even beyond the anatomical boundaries of the known blood supply of the flap.
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Larger free scapular flaps make it possible to resurface larger neck defects after resection of scars. While a scapular flap is located in a well-concealed area, expansion further minimizes donor-site morbidity. Most donor sites can be closed directly without excessive tension. Patients typically are willing to accept scars in the region of the back where the flap is harvested. Our results proved the merits of Ninkovic’s method in which the reconstructed neck defect was also reconstructed by a pre-expanded free scapular flap [12]. The process of expansion leads to the formation of a capsule. We observed a moderate capsule formation in all preexpanded free flaps. The capsule is regarded by some authors as untouchable because of the risk of damaging the vascular network [16,17]. However, several authors introduced the concept of the ‘‘super-thin flap,’’ in which only a minimal fat layer and the subdermal vascular network are included [18]. The pre-expanded ‘‘super-thin flap’’ is regarded to be able to survive after the depletion of the capsule [19]. In our technique, we preserved the capsule in the proximal one-third of the flap and excised the capsule in the distal two-thirds of the flap. Furthermore, the distal one-third of the flap was thinned down to the layer in which the subdermal vascular network was seen through the minimal fat layer. By our technique, the blood supply through the proximal capsule of the flap was preserved and the distal two-thirds of the flap was thinned. All flaps survived completely. By this technique, the blood supply of the flap was maintained and at the same time debulking was only needed one time after free flap transfer. We experienced a change in the timing of performing the second stage surgery through the course of our study. At the beginning, the second stage was performed 1 week after the last injection. Although a major portion of the donor area can be closed directly, the high tension caused by retraction of the expanded tissues led to wide scars when the donor site width was >12 cm. The retraction of expanded tissues were closely related to time interval from the last expansion. We extended this time to 2 weeks, which led to reduction of tissue retraction and better donor outcome. Nevertheless, several disadvantages came with this surgical method including extra-operative procedures, the prolongation of hospital stay, the repeated follow-up visits, and the potential complications during tissue expansion period. Tissue loss may be caused by infection, overexpansion, and inadvertent flap thinning. Moreover, the pre-expanded free scapular flap procedure requires greater surgical skills than traditional microsurgery. Generally, the usage of the pre-expanded free-scapular flap is an effective way of reconstructing postburn neck contracture. It provides a large good-quality skin flap that can cover the defect after contracture release. We concluded that the expansion of the flap facilitates blood supply, improves the quality, increases the size of free scapular flap, and minimizes the donor-site morbidity.
Conflict of interest statement None of the authors has any commercial associations or financial disclosures that might pose or create a conflict of interest with the information presented in this article.
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references
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