- Email: [email protected]
Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps
ARTICLE IN PRESS
JID: JINJ
[m5G;March 5, 2020;13:35]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps ✩,✩✩,★,★★,✞,✞✞,✝ Tahsin Og˘ uz Acartürk∗, Fuat Barıs¸ Bengür University of Pittsburgh, Department of Plastic Surgery, 3550 Terrace Street/6B Scaife Hall, Pittsburgh, PA 15261, USA
a r t i c l e
i n f o
Article history: Accepted 21 February 2020 Available online xxx Keywords: Tissue expansion Aesthetic reconstruction Burn Neck Contracture Anterolateral thigh flap Free flap Perforator flap
a b s t r a c t Burn contractures of the anterior neck result in severe functional and aesthetic deformities. The release of wide contractures leads to defects that cannot be closed with local flaps. In these cases, tissue expansion of local tissues may be a solution. However, when local tissues are also burned or inadequate, microsurgical free tissue transfer may be necessary. In order to increase the surface are of the transferred flap, pre-expansion of the donor site can be combined with the procedure. Five patients with burn contractures of the anterior neck were treated using pre-expanded free anterolateral thigh (ALT) perforator flaps. The anterolateral thigh was dissected on top of the fascia lata in an avascular plane. The borders of the dissection were kept 2 cm lateral to the pre-identified perforators. A 10 0 0cc rectangular tissue expander was placed. The time of expansion ranged from 4–11 months with a final over expanded volume of 1200cc. The defect sizes ranged from 10 × 21 cm to 20 × 27 cm. There were either one or two perforators included in the flaps. All flaps survived completely with good functional and aesthetic outcomes. Donor areas were closed primarily in one patient and with various amounts of skin grafts in five patients. Overall, pre-expansion decreased the amount of total skin grafted area in the donor site. Preexpanded ALT perforator flap can be a good option in extensive burns with wide contractures where the regional donor areas are also affected. This technique has several advantages: 1) large flaps can be safely harvested, 2) the expanded skin thins out making it more aesthetically appropriate to resurface superficial defects, 3) expansion period of the thigh is well tolerated by the patients, 4) two teams can work simultaneously, decreasing the operating time, 5) the donor area can be closed either primarily or with minimal skin graft application, and 6) there is no functional loss in the donor area and the donor scar stays under the clothes. © 2020 Elsevier Ltd. All rights reserved.
Introduction Burn contractures of the neck create one of the most devastating functional and aesthetic deformities. Typically, the deformity
✩
This work was presented at: 31st National Congress of the Turkish Society of Plastic, Reconstructive and Aesthetic Surgeons, October 2009, Adana, Turkey. ★ 4th Congress of the Turkish Society for Reconstructive Microsurgery, December 2009, Antalya, Turkey. ★★ 10th Congress of the European Federation of Societies for Microsurgery, May 2010, Genova, Italy. ✞ Annual Meeting of the American Society of Reconstructive Microsurgery, January 2013, Naples, Florida. ✞✞ 17th International Confederation of Plastic, Reconstructive and Aesthetic Surgery World Congress, February, 2013, Santiago, Chile. ✝ This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM). ∗ Corresponding author. E-mail address: [email protected] (T.O. Acartürk). ✩✩
will result in varying degrees of limited neck range of motion, obtunded cervico-mental angle, stooped posture, neck pain and insomnia. Secondary vision problems, persistent upward gaze and headache are not uncommon. In addition, distortion of the unburned surrounding skin result in accompanying deformities; best exemplified by the inferior pulling of the mandible, unable to close the mouth, extroversion of the lips and even micrognathia. In its most severe form, the surrounding tissues beyond the neck subunit are also burned, leading to a major reconstructive challenge. All these are paramounted by the depression and social problems experienced by the burned patient. Based on recent algorithms, local tissue expansion and advancement or tissue expanded local perforator flaps are the most ideal treatment in terms of simplicity and using similar quality tissue [1–3]. However, in challenging burns, lack of local viable tissues in wide areas of contractures and accompanying upper body burns often preclude these methods due to limitations in harvesting and spatially orienting large flaps. Free flaps from unburned distant ar-
https://doi.org/10.1016/j.injury.2020.02.112 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112
ARTICLE IN PRESS
JID: JINJ 2
[m5G;March 5, 2020;13:35]
T.O. Acartürk and F.B. Bengür / Injury xxx (xxxx) xxx Table 1 Patient demographics, details of defects and reconstructions. Patient no. Age
Gender Defect location
Defect size (cm)
Time of expansion (months)
Number of perforators
Flap size (cm)
Complication
Donor site closure
1 2 3
17 15 20
M M M
10 × 21 18 × 22 20 × 27
11 10 4.5
1 2 2
8 × 20 17 × 20 18 × 26
None None None
Primary 10% STSG 20% STSG
4
14
M
18 × 25
4
1
16 × 24
None
10% STSG
5
30
F
20 × 24
4
2
19 × 23
None
10% STSG
Neck Neck Neck-Chin-Lower Lip Neck-Chin-Lower Lip Neck-Lower Chin-Sternum
eas are the preferred alternatives in such cases, especially when they are compounded with tissue expansion [4]. Various donor sites have been previously utilized including back [3,5–8], groin [2,3], abdomen [1,9] and anterolateral thigh (ALT) [9–13]. Ironically, ALT perforator flap has been severely underutilized in the reconstruction of burn contractures of the neck although, although it has been suggested righteously as the universal donor site [11,13–15]. We report a series of patients with wide burn contractures of the neck that were reconstructed with pre-expanded free ALT perforator flaps. We describe our principles in approaching severe neck contractures, as well as a safe and easy technique of preexpanding the ALT region in preparation for neck reconstruction. Patients and methods Five patients (4 male, 1 female; age range 14–30 years) with severe burn contractures involving the anterior neck and surrounding structures were evaluated between 2007 and 2015 (Table 1). The time between the initial burn injury and reconstruction ranged between 1 and 10 years. All patients had severe debilitating functional disability with varying degrees of restricted lateral and upward movements, persistent open mouth, limited jaw motion, loss of the angle of the neck, drooling and had difficulty in eating. Patients 3, 4 and 5 also had severe contractures directly extending beyond the borders of the anterior neck into the chin, jaw line, lower lip, shoulder and chest wall (Figs. 1 and 2). Surgical technique Vastus lateralis muscle perforators of the descending branch of the lateral circumflex femoral artery were located on the thigh using a handheld Doppler. A 6-cm horizontal incision was made on the superolateral thigh at the inferior border of the tensor fascia lata muscle. The anterolateral thigh was dissected on top of the fascia lata in an avascular plane. The borders of the dissection was kept 2 cm lateral to the pre-identified perforators. A 10 0 0cc rectangular tissue expander was placed and the port was kept at least 5 cm away from the expander superior to the incision line in a separate pocket. Expanders were immediately expanded to 100– 200 cc. Serial expansions were started 2–3 weeks post-operatively using as much volume as possible without patient discomfort. The time of expansion ranged from 4–11 months with a final volume of 1200cc using 9–11 expansion visits (the variability of the time of expansion depended on the availability of the patients as some lived in remote rural areas). The contracted scars were excised as wide as possible together with all the subcutaneous tissue and parts of the contracted muscle fascia in order to achieve maximal release. Once the scars were removed the actual defects became larger and the tissue requirements were wider than initially anticipated. The defect in the patients 1 and 2 extended from the sterno-clavicular region to the lower rim of the mandible in a cranio-caudal direction and bilaterally as far as the trapezius muscles. In patients 3 and 4 the defect
also involved jaw line, chin, inferior lip, chest wall and/or medial shoulders. In patient 5 the sternum was also involved. Defect sizes ranged from 10 × 21 cm to 20 × 27 cm. The expanded tissue was harvested in whole to achieve maximal flap dimensions in all patients. Only a minimal non-expanded tissue was harvested, which was in the medial area where the perforators entered the flap. The flap dimensions ranged from 8 × 20 cm to 18 × 26 cm. The flaps had either one or two perforators depending on the availability. Flaps were elevated at the suprafascial plane and the capsules were neither removed nor scored and were kept completely intact with the flap. The recipient vein and artery was chosen depending on the availability, flap and pedicle orientation and matching of the vessel caliber. During the inset, the tough capsular layer underneath the subcutaneous tissue was not discarded. The edges of the capsule were sutured to the bilateral soft tissues in the fashion of a sling in order to 1) create the cervical angle, 2) prevent distortion and sagging of the flap and 3) maximally spread the flap to cover wider surface area. The technique was discussed in great detail in previous publications [13,16]. Results All flaps completely survived with good early and late functional and aesthetic outcomes. Part of the donor sites (10–20%) required skin grafting. No major or minor complications were observed. In four patients, the flaps shrunk within three to six months to the point that the underlying aesthetic anatomical landmarks such as the clavicle, sternal notch, sternoclaidomastoid muscle and thyroid cartilage were clearly visible. No secondary procedures were necessary in these patients. In patient 5, due to her preexisting obesity, a single session of liposuction for debulking of the transferred flap was performed to achieve the final aesthetic contours. Discussion Burn injuries to mobile areas result in debilitating contractures destroying form and function. Among them, anterior neck presents with varying of degrees severity depending on the depth of burn, width of the involved area as well as the exact location. Several classification systems and algorithms have been proposed in order to determine the appropriate treatment protocol [1,2,11]. There is no doubt that the areas that provide the best texture that matches the functional and aesthetic needs of the neck are the closest sites including the posterolateral thoracic area [3,6–8]. However, in severe cases, contractures may extend beyond the neck into the face, shoulders, back and anterior chest wall. When the neighboring areas are also affected, the most common donor areas cannot be utilized for the reconstruction even with tissue expansion techniques. In these cases, the functional and aesthetic challenge necessitate distant tissue transfer and increase the complexity of the reconstruction. In our practice, we also use pre-expanded posterolateral
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112
JID: JINJ
ARTICLE IN PRESS
[m5G;March 5, 2020;13:35]
T.O. Acartürk and F.B. Bengür / Injury xxx (xxxx) xxx
3
Fig. 1. Patient no 4. (A–B–C) Preoperative pictures of the patient at 14 years of age before surgery. Note hypertrophic scarring has reduced and contractures have matured in lines of movement and open wounds. The patient has difficulty closing the mouth. The scar is surrounding the whole subunits of the anterior and lateral neck. The angle of the neck is lost. (D–E–F) Early postoperative period where the pre-expanded anterolateral thigh flap is viable.
Fig. 2. Patient no 5. (A–B) Preoperative pictures of the patient at 30 years of age before surgery. The scar is surrounding the whole neck, shoulders bilaterally, sternum and anterior chest in total. There are no viable regional donor options. (C–D) Postoperative results after debulking of the flap is performed. Note that the aesthetic subunits of the neck is completely resurfaced and the cervical angle is created.
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112
JID: JINJ 4
ARTICLE IN PRESS
[m5G;March 5, 2020;13:35]
T.O. Acartürk and F.B. Bengür / Injury xxx (xxxx) xxx
thoracic flaps for head and neck burn reconstruction [5]. However, in massive head and neck burns, we advocate the use of tissue expanded ALT for the whole neck subunit. ALT perforator flap has become the most widely used free flap worldwide, with its versatility, wide indications of use and decreased donor site morbidity [14]. However, the preexpansion of the ALT, although described more than a decade ago [10,11,13,15] did not gain popularity, as there are limited number of applications in the literature [2,9,12,16–20] and a recently proposed algorithm does not include it as an option in post-burn neck contractures [1]. The main advantage of the ALT flap is the ability to accommodate large volume tissue expanders and subsequent massive expansion due to the wide surface area and a relatively tight background made of the fascia lata. This is especially important in order to achieve large amounts of tissues required for resurfacing of large defects. We have consistently used 10 0 0 cc rectangular expanders (over expanded to 1200 cc), which were well tolerated by the patients and resulted in large tissue gains. In our experience, rectangular implants compared to round or elliptical implants yielded 1) greater expanded surface area along the whole length of the flap, 2) equal thinning of the subcutaneous tissue, as the whole length of the flap was compressed almost equally by the expander, 3) better planning and determination of the amount to be harvested as the tissue gained was easily calculated. We had various durations of tissue expansion in our patient group ranging from 4–11 months, although the final volumes were the same. Interestingly, patients with longer expansion durations had better tissue quality in the end, as the weight of the expander further thinned the flaps. This however, should be balanced between the patients’ desires, tolerability and comfort level for optimal patient satisfaction. The use of pre-expanded local perforator flaps, if possible, is highly advantageous due to similar texture and thinner tissues [1,3,6–8]. However, these leave a highly scarred donor site in commonly exposed areas (upper chest wall, shoulder), especially if a large flap is needed to resurface a wide defect. This will increase the “scar burden” resulting in an unsought aesthetic appearance, which may not be favored as patients often request the donor scar to be in unseen areas. In our experience, patients seem to tolerate leg scars better than scarring of the upper body. In addition, tissue expansion of the back, neck, chest wall or groin may cause a greater level of discomfort and interference with daily activities compared to expansion on the thigh area. Despite increased volumes, expansion of the ALT area is well tolerated in terms of general daily activities, movement and wearing of clothing. In some patients, the local donor areas were somewhat available but did not preferred due to these disadvantages. One other advantage is that when the ALT is used as the donor site, the patient does not have to be repositioned during the surgery and two teams can work simultaneously, decreasing the operating time. Therefore, the “universal donor site” is also an ideal donor site candidate for preexpanded free flaps. The maximal tissue expansion was achieved in each patient, regardless of the anticipated defect size. This serves two purposes 1) a large defect can be resurfaced in whole using the thinned flap and, 2) if the defect is slightly smaller, the extra tissue ensures maximal closure of the donor site primarily. Overall an expanded ALT had enough surface area to cover the whole anterior and bilateral neck subunits from the jawline to the sternal notch-upper clavicle. In addition chin and lower lip subunits can also be included. We aimed to remove the burn scar as a whole and resurface the defect maximally with the flap. Once the scar contracture is released the rest of the tissue receded back to its normal native position resulting in defects bigger than anticipated. One limitation of the study was that the degree of contractions and improvement were not measured objectively. However, since we aimed to
remove maximal amount of scar contracture on the anterior, lateral and the chin/lip subunit, and replaced the whole defect with an equally wide flap, it can be anticipated that the maximal release was already achieved. Pre-expansion of the free ALT flap have also been described by other authors for other indications. Hallock reports 3 cases that were used for lower extremity reconstructions. In contrast to our indication he mainly utilized it to prevent the donor site deformity rather than to produce a larger flap for the recipient site defect [12,15]. Hocaoglu et al. reported a case where a pre-expanded 18 × 8 cm flap was used to reconstruct a severe dorsal hand burn [17]. They also reported that the use of tissue expansion leads to increased caliber of the ALT perforators within the flap [21]. Preexpanded free flaps have multiple advantages in severe burn patients. During the tissue expansion the vascularity of the expanded skin increases, thus increasing the chance of survival as well as the effective surface area of the wide flaps [10]. Even more importantly, tissue expansion thins the subcutaneous elements, thus making the flap more pliable to cover complex contoured defects by facilitating the resurfacing of aesthetic subunits, such as in the cervical area [6,10,13]. This is especially important in pediatric patients with extensive burns, where there is a lack of healthy “total surface area”. Lastly, it ensures either full or partial primary closure of the donor site and decreases the need for skin grafting [12], although this should not be the primary aim of tissue expansion in severe deformities. The maximal dimension of the flap should be harvested with a goal to resurface an extended defect in a donor depleted patient, rather than utilizing it for the primary closure of the donor site [13,16]. Conclusion In conclusion, pre-expanded ALT perforator flap can be a good option in extensive burns with wide contractures where the regional donor areas are also affected. This technique has several advantages as 1) large flaps can be safely harvested, 2) the expanded skin thins out making it more aesthetically appropriate to resurface superficial defects, 3) expansion period of the thigh is well tolerated by the patients, 4) two teams can work simultaneously, decreasing the operating time, 5) the donor area can be closed either primarily or with minimal skin graft application, and 6) there is no functional loss in the donor area and the donor scar stays under the clothes. Declaration of Competing Interest None. References [1] Gao Y, Li H, Gu B, Xie F, Zhu H, Wang Z, et al. Postburn neck contracture: principles of reconstruction and a treatment algorithm. J Reconstr Microsurg 2018;34(7):514–21. doi:10.1055/s- 0038- 1641724. [2] Heidekrueger PI, Broer PN, Tanna N, Ninkovic M. Postburn head and neck reconstruction: an algorithmic approach. J Craniofac Surg 2016;27(1):150–5. doi:10.1097/SCS.0 0 0 0 0 0 0 0 0 0 0 02166. [3] Li H, Wang Z, Gu B, Gao Y, Xie F, Zhu H, et al. Postburn neck reconstruction with preexpanded upper back perforator flaps: free-Style design and an update of treatment strategies. Ann Plast Surg 2018;81(1):45–9. doi:10.1097/SAP. 0 0 0 0 0 0 0 0 0 0 0 01491. [4] Hocaoglu E. Pre-expanded free perforator flaps. Clin Plast Surg 2017;44(1):143– 52. doi:10.1016/j.cps.2016.08.011. [5] Acarturk TO, Glaser DP, Newton ED. Reconstruction of difficult wounds with tissue-expanded free flaps. Ann Plast Surg 2004;52(5):493–9 discussion 500. [6] Ninkovic M, Moser-Rumer A, Ninkovic M, Spanio S, Rainer C, Gurunluoglu R. Anterior neck reconstruction with pre-expanded free groin and scapular flaps. Plast Reconstr Surg 2004;113(1):61–8. doi:10.1097/01.PRS.0 0 0 0 090726.45594. 6B. [7] Wang AW, Zhang WF, Liang F, Li JY, Zhang XF, Niu XT. Pre-expanded thoracodorsal artery perforator-based flaps for repair of severe scarring in cervicofacial regions. J Reconstr Microsurg 2014;30(8):539–45. doi:10.1055/ s- 0033- 1361839.
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112
JID: JINJ
ARTICLE IN PRESS
[m5G;March 5, 2020;13:35]
T.O. Acartürk and F.B. Bengür / Injury xxx (xxxx) xxx [8] Song B, Xiao B, Liu C, He L, Li Y, Sun F, et al. Neck burn reconstruction with pre-expanded scapular free flaps. Burns 2015;41(3):624–30. doi:10.1016/ j.burns.2014.08.015. [9] Daugherty THF, Pribaz JJ, Neumeister MW. The use of prefabricated flaps in burn reconstruction. Clin Plast Surg 2017;44(4):813–21. doi:10.1016/j.cps.2017. 05.012. [10] Tsai F-C. A new method: perforator-based tissue expansion for a preexpanded free cutaneous perforator flap. Burns 2003;29(8):845–8. [11] Tsai FC, Mardini S, Chen DJ, Yang Jyung, Hsieh MS. The classification and treatment algorithm for post-burn cervical contractures reconstructed with free flaps. Burns 2006;32(5):626–33. doi:10.1016/j.burns.2005.12.009. [12] Hallock GG. Tissue expansion techniques to minimize morbidity of the anterolateral thigh perforator flap donor site. J Reconstr Microsurg 2013;29(9):565– 70. doi:10.1055/s- 0033- 1348035. [13] Acarturk TO. Aesthetic reconstruction of the postburn neck contracture with a preexpanded anterolateral thigh free flap. J Craniofac Surg 2014;25(1):e23–6. doi:10.1097/SCS.0b013e3182a2ed75. [14] Wei F, Jain V, Celik N, Chen H, Chuang DC-C, Lin C. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109(7):2219–30. [15] Hallock GG. The preexpanded anterolateral thigh free flap. Ann Plast Surg 2004;53(2):170–3.
5
[16] Acarturk TO, Bengur FB. Total aesthetic subunit reconstruction of the burned anterior abdomen using pre-expanded pedicled anterolateral thigh flap—a case report. Microsurgery 2019 (September):micr.30519. doi. doi:10.1002/micr. 30519. [17] Hocaoglu E, Arinci A, Berkoz O, Ozkan T. Free pre-expanded lateral circumflex femoral artery perforator flap for extensive resurfacing and reconstruction of the hand. J Plast Reconstr Aesthet Surg 2013;66(12):1788–91. doi:10.1016/j. bjps.2013.04.019. [18] Li Q, Zan T, Li H, Zhou S, Gu B, Liu K, et al. Flap prefabrication and stem cellassisted tissue expansion: how we acquire a monoblock flap for full face resurfacing. J Craniofac Surg 2014;25(1):21–5. doi:10.1097/01.scs.0 0 0 0436743.75289. 6b. [19] D’Arpa S, Colebunders B, Stillaert F, Monstrey S. Pre-expanded anterolateral thigh perforator flap for phalloplasty. Clin Plast Surg 2017;44(1):129–41. doi:10.1016/j.cps.2016.08.004. [20] De La Cruz Monroy MFI, Kalaskar DM, Rauf KG. Tissue expansion reconstruction of head and neck burn injuries in paediatric patients—a systematic review. JPRAS Open 2018;18:78–97. doi:10.1016/j.jpra.2018.10.004. [21] Hocaoglu E, Emekli U, Cizmeci O, Ucar A. Suprafascial pre-expansion of perforator flaps and the effect of pre-expansion on perforator artery diameter. Microsurgery 2014;34(3):188–96. doi:10.1002/micr.22184.
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112
JID: JINJ
[m5G;March 5, 2020;13:35]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps ✩,✩✩,★,★★,✞,✞✞,✝ Tahsin Og˘ uz Acartürk∗, Fuat Barıs¸ Bengür University of Pittsburgh, Department of Plastic Surgery, 3550 Terrace Street/6B Scaife Hall, Pittsburgh, PA 15261, USA
a r t i c l e
i n f o
Article history: Accepted 21 February 2020 Available online xxx Keywords: Tissue expansion Aesthetic reconstruction Burn Neck Contracture Anterolateral thigh flap Free flap Perforator flap
a b s t r a c t Burn contractures of the anterior neck result in severe functional and aesthetic deformities. The release of wide contractures leads to defects that cannot be closed with local flaps. In these cases, tissue expansion of local tissues may be a solution. However, when local tissues are also burned or inadequate, microsurgical free tissue transfer may be necessary. In order to increase the surface are of the transferred flap, pre-expansion of the donor site can be combined with the procedure. Five patients with burn contractures of the anterior neck were treated using pre-expanded free anterolateral thigh (ALT) perforator flaps. The anterolateral thigh was dissected on top of the fascia lata in an avascular plane. The borders of the dissection were kept 2 cm lateral to the pre-identified perforators. A 10 0 0cc rectangular tissue expander was placed. The time of expansion ranged from 4–11 months with a final over expanded volume of 1200cc. The defect sizes ranged from 10 × 21 cm to 20 × 27 cm. There were either one or two perforators included in the flaps. All flaps survived completely with good functional and aesthetic outcomes. Donor areas were closed primarily in one patient and with various amounts of skin grafts in five patients. Overall, pre-expansion decreased the amount of total skin grafted area in the donor site. Preexpanded ALT perforator flap can be a good option in extensive burns with wide contractures where the regional donor areas are also affected. This technique has several advantages: 1) large flaps can be safely harvested, 2) the expanded skin thins out making it more aesthetically appropriate to resurface superficial defects, 3) expansion period of the thigh is well tolerated by the patients, 4) two teams can work simultaneously, decreasing the operating time, 5) the donor area can be closed either primarily or with minimal skin graft application, and 6) there is no functional loss in the donor area and the donor scar stays under the clothes. © 2020 Elsevier Ltd. All rights reserved.
Introduction Burn contractures of the neck create one of the most devastating functional and aesthetic deformities. Typically, the deformity
✩
This work was presented at: 31st National Congress of the Turkish Society of Plastic, Reconstructive and Aesthetic Surgeons, October 2009, Adana, Turkey. ★ 4th Congress of the Turkish Society for Reconstructive Microsurgery, December 2009, Antalya, Turkey. ★★ 10th Congress of the European Federation of Societies for Microsurgery, May 2010, Genova, Italy. ✞ Annual Meeting of the American Society of Reconstructive Microsurgery, January 2013, Naples, Florida. ✞✞ 17th International Confederation of Plastic, Reconstructive and Aesthetic Surgery World Congress, February, 2013, Santiago, Chile. ✝ This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM). ∗ Corresponding author. E-mail address: [email protected] (T.O. Acartürk). ✩✩
will result in varying degrees of limited neck range of motion, obtunded cervico-mental angle, stooped posture, neck pain and insomnia. Secondary vision problems, persistent upward gaze and headache are not uncommon. In addition, distortion of the unburned surrounding skin result in accompanying deformities; best exemplified by the inferior pulling of the mandible, unable to close the mouth, extroversion of the lips and even micrognathia. In its most severe form, the surrounding tissues beyond the neck subunit are also burned, leading to a major reconstructive challenge. All these are paramounted by the depression and social problems experienced by the burned patient. Based on recent algorithms, local tissue expansion and advancement or tissue expanded local perforator flaps are the most ideal treatment in terms of simplicity and using similar quality tissue [1–3]. However, in challenging burns, lack of local viable tissues in wide areas of contractures and accompanying upper body burns often preclude these methods due to limitations in harvesting and spatially orienting large flaps. Free flaps from unburned distant ar-
https://doi.org/10.1016/j.injury.2020.02.112 0020-1383/© 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112
ARTICLE IN PRESS
JID: JINJ 2
[m5G;March 5, 2020;13:35]
T.O. Acartürk and F.B. Bengür / Injury xxx (xxxx) xxx Table 1 Patient demographics, details of defects and reconstructions. Patient no. Age
Gender Defect location
Defect size (cm)
Time of expansion (months)
Number of perforators
Flap size (cm)
Complication
Donor site closure
1 2 3
17 15 20
M M M
10 × 21 18 × 22 20 × 27
11 10 4.5
1 2 2
8 × 20 17 × 20 18 × 26
None None None
Primary 10% STSG 20% STSG
4
14
M
18 × 25
4
1
16 × 24
None
10% STSG
5
30
F
20 × 24
4
2
19 × 23
None
10% STSG
Neck Neck Neck-Chin-Lower Lip Neck-Chin-Lower Lip Neck-Lower Chin-Sternum
eas are the preferred alternatives in such cases, especially when they are compounded with tissue expansion [4]. Various donor sites have been previously utilized including back [3,5–8], groin [2,3], abdomen [1,9] and anterolateral thigh (ALT) [9–13]. Ironically, ALT perforator flap has been severely underutilized in the reconstruction of burn contractures of the neck although, although it has been suggested righteously as the universal donor site [11,13–15]. We report a series of patients with wide burn contractures of the neck that were reconstructed with pre-expanded free ALT perforator flaps. We describe our principles in approaching severe neck contractures, as well as a safe and easy technique of preexpanding the ALT region in preparation for neck reconstruction. Patients and methods Five patients (4 male, 1 female; age range 14–30 years) with severe burn contractures involving the anterior neck and surrounding structures were evaluated between 2007 and 2015 (Table 1). The time between the initial burn injury and reconstruction ranged between 1 and 10 years. All patients had severe debilitating functional disability with varying degrees of restricted lateral and upward movements, persistent open mouth, limited jaw motion, loss of the angle of the neck, drooling and had difficulty in eating. Patients 3, 4 and 5 also had severe contractures directly extending beyond the borders of the anterior neck into the chin, jaw line, lower lip, shoulder and chest wall (Figs. 1 and 2). Surgical technique Vastus lateralis muscle perforators of the descending branch of the lateral circumflex femoral artery were located on the thigh using a handheld Doppler. A 6-cm horizontal incision was made on the superolateral thigh at the inferior border of the tensor fascia lata muscle. The anterolateral thigh was dissected on top of the fascia lata in an avascular plane. The borders of the dissection was kept 2 cm lateral to the pre-identified perforators. A 10 0 0cc rectangular tissue expander was placed and the port was kept at least 5 cm away from the expander superior to the incision line in a separate pocket. Expanders were immediately expanded to 100– 200 cc. Serial expansions were started 2–3 weeks post-operatively using as much volume as possible without patient discomfort. The time of expansion ranged from 4–11 months with a final volume of 1200cc using 9–11 expansion visits (the variability of the time of expansion depended on the availability of the patients as some lived in remote rural areas). The contracted scars were excised as wide as possible together with all the subcutaneous tissue and parts of the contracted muscle fascia in order to achieve maximal release. Once the scars were removed the actual defects became larger and the tissue requirements were wider than initially anticipated. The defect in the patients 1 and 2 extended from the sterno-clavicular region to the lower rim of the mandible in a cranio-caudal direction and bilaterally as far as the trapezius muscles. In patients 3 and 4 the defect
also involved jaw line, chin, inferior lip, chest wall and/or medial shoulders. In patient 5 the sternum was also involved. Defect sizes ranged from 10 × 21 cm to 20 × 27 cm. The expanded tissue was harvested in whole to achieve maximal flap dimensions in all patients. Only a minimal non-expanded tissue was harvested, which was in the medial area where the perforators entered the flap. The flap dimensions ranged from 8 × 20 cm to 18 × 26 cm. The flaps had either one or two perforators depending on the availability. Flaps were elevated at the suprafascial plane and the capsules were neither removed nor scored and were kept completely intact with the flap. The recipient vein and artery was chosen depending on the availability, flap and pedicle orientation and matching of the vessel caliber. During the inset, the tough capsular layer underneath the subcutaneous tissue was not discarded. The edges of the capsule were sutured to the bilateral soft tissues in the fashion of a sling in order to 1) create the cervical angle, 2) prevent distortion and sagging of the flap and 3) maximally spread the flap to cover wider surface area. The technique was discussed in great detail in previous publications [13,16]. Results All flaps completely survived with good early and late functional and aesthetic outcomes. Part of the donor sites (10–20%) required skin grafting. No major or minor complications were observed. In four patients, the flaps shrunk within three to six months to the point that the underlying aesthetic anatomical landmarks such as the clavicle, sternal notch, sternoclaidomastoid muscle and thyroid cartilage were clearly visible. No secondary procedures were necessary in these patients. In patient 5, due to her preexisting obesity, a single session of liposuction for debulking of the transferred flap was performed to achieve the final aesthetic contours. Discussion Burn injuries to mobile areas result in debilitating contractures destroying form and function. Among them, anterior neck presents with varying of degrees severity depending on the depth of burn, width of the involved area as well as the exact location. Several classification systems and algorithms have been proposed in order to determine the appropriate treatment protocol [1,2,11]. There is no doubt that the areas that provide the best texture that matches the functional and aesthetic needs of the neck are the closest sites including the posterolateral thoracic area [3,6–8]. However, in severe cases, contractures may extend beyond the neck into the face, shoulders, back and anterior chest wall. When the neighboring areas are also affected, the most common donor areas cannot be utilized for the reconstruction even with tissue expansion techniques. In these cases, the functional and aesthetic challenge necessitate distant tissue transfer and increase the complexity of the reconstruction. In our practice, we also use pre-expanded posterolateral
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112
JID: JINJ
ARTICLE IN PRESS
[m5G;March 5, 2020;13:35]
T.O. Acartürk and F.B. Bengür / Injury xxx (xxxx) xxx
3
Fig. 1. Patient no 4. (A–B–C) Preoperative pictures of the patient at 14 years of age before surgery. Note hypertrophic scarring has reduced and contractures have matured in lines of movement and open wounds. The patient has difficulty closing the mouth. The scar is surrounding the whole subunits of the anterior and lateral neck. The angle of the neck is lost. (D–E–F) Early postoperative period where the pre-expanded anterolateral thigh flap is viable.
Fig. 2. Patient no 5. (A–B) Preoperative pictures of the patient at 30 years of age before surgery. The scar is surrounding the whole neck, shoulders bilaterally, sternum and anterior chest in total. There are no viable regional donor options. (C–D) Postoperative results after debulking of the flap is performed. Note that the aesthetic subunits of the neck is completely resurfaced and the cervical angle is created.
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112
JID: JINJ 4
ARTICLE IN PRESS
[m5G;March 5, 2020;13:35]
T.O. Acartürk and F.B. Bengür / Injury xxx (xxxx) xxx
thoracic flaps for head and neck burn reconstruction [5]. However, in massive head and neck burns, we advocate the use of tissue expanded ALT for the whole neck subunit. ALT perforator flap has become the most widely used free flap worldwide, with its versatility, wide indications of use and decreased donor site morbidity [14]. However, the preexpansion of the ALT, although described more than a decade ago [10,11,13,15] did not gain popularity, as there are limited number of applications in the literature [2,9,12,16–20] and a recently proposed algorithm does not include it as an option in post-burn neck contractures [1]. The main advantage of the ALT flap is the ability to accommodate large volume tissue expanders and subsequent massive expansion due to the wide surface area and a relatively tight background made of the fascia lata. This is especially important in order to achieve large amounts of tissues required for resurfacing of large defects. We have consistently used 10 0 0 cc rectangular expanders (over expanded to 1200 cc), which were well tolerated by the patients and resulted in large tissue gains. In our experience, rectangular implants compared to round or elliptical implants yielded 1) greater expanded surface area along the whole length of the flap, 2) equal thinning of the subcutaneous tissue, as the whole length of the flap was compressed almost equally by the expander, 3) better planning and determination of the amount to be harvested as the tissue gained was easily calculated. We had various durations of tissue expansion in our patient group ranging from 4–11 months, although the final volumes were the same. Interestingly, patients with longer expansion durations had better tissue quality in the end, as the weight of the expander further thinned the flaps. This however, should be balanced between the patients’ desires, tolerability and comfort level for optimal patient satisfaction. The use of pre-expanded local perforator flaps, if possible, is highly advantageous due to similar texture and thinner tissues [1,3,6–8]. However, these leave a highly scarred donor site in commonly exposed areas (upper chest wall, shoulder), especially if a large flap is needed to resurface a wide defect. This will increase the “scar burden” resulting in an unsought aesthetic appearance, which may not be favored as patients often request the donor scar to be in unseen areas. In our experience, patients seem to tolerate leg scars better than scarring of the upper body. In addition, tissue expansion of the back, neck, chest wall or groin may cause a greater level of discomfort and interference with daily activities compared to expansion on the thigh area. Despite increased volumes, expansion of the ALT area is well tolerated in terms of general daily activities, movement and wearing of clothing. In some patients, the local donor areas were somewhat available but did not preferred due to these disadvantages. One other advantage is that when the ALT is used as the donor site, the patient does not have to be repositioned during the surgery and two teams can work simultaneously, decreasing the operating time. Therefore, the “universal donor site” is also an ideal donor site candidate for preexpanded free flaps. The maximal tissue expansion was achieved in each patient, regardless of the anticipated defect size. This serves two purposes 1) a large defect can be resurfaced in whole using the thinned flap and, 2) if the defect is slightly smaller, the extra tissue ensures maximal closure of the donor site primarily. Overall an expanded ALT had enough surface area to cover the whole anterior and bilateral neck subunits from the jawline to the sternal notch-upper clavicle. In addition chin and lower lip subunits can also be included. We aimed to remove the burn scar as a whole and resurface the defect maximally with the flap. Once the scar contracture is released the rest of the tissue receded back to its normal native position resulting in defects bigger than anticipated. One limitation of the study was that the degree of contractions and improvement were not measured objectively. However, since we aimed to
remove maximal amount of scar contracture on the anterior, lateral and the chin/lip subunit, and replaced the whole defect with an equally wide flap, it can be anticipated that the maximal release was already achieved. Pre-expansion of the free ALT flap have also been described by other authors for other indications. Hallock reports 3 cases that were used for lower extremity reconstructions. In contrast to our indication he mainly utilized it to prevent the donor site deformity rather than to produce a larger flap for the recipient site defect [12,15]. Hocaoglu et al. reported a case where a pre-expanded 18 × 8 cm flap was used to reconstruct a severe dorsal hand burn [17]. They also reported that the use of tissue expansion leads to increased caliber of the ALT perforators within the flap [21]. Preexpanded free flaps have multiple advantages in severe burn patients. During the tissue expansion the vascularity of the expanded skin increases, thus increasing the chance of survival as well as the effective surface area of the wide flaps [10]. Even more importantly, tissue expansion thins the subcutaneous elements, thus making the flap more pliable to cover complex contoured defects by facilitating the resurfacing of aesthetic subunits, such as in the cervical area [6,10,13]. This is especially important in pediatric patients with extensive burns, where there is a lack of healthy “total surface area”. Lastly, it ensures either full or partial primary closure of the donor site and decreases the need for skin grafting [12], although this should not be the primary aim of tissue expansion in severe deformities. The maximal dimension of the flap should be harvested with a goal to resurface an extended defect in a donor depleted patient, rather than utilizing it for the primary closure of the donor site [13,16]. Conclusion In conclusion, pre-expanded ALT perforator flap can be a good option in extensive burns with wide contractures where the regional donor areas are also affected. This technique has several advantages as 1) large flaps can be safely harvested, 2) the expanded skin thins out making it more aesthetically appropriate to resurface superficial defects, 3) expansion period of the thigh is well tolerated by the patients, 4) two teams can work simultaneously, decreasing the operating time, 5) the donor area can be closed either primarily or with minimal skin graft application, and 6) there is no functional loss in the donor area and the donor scar stays under the clothes. Declaration of Competing Interest None. References [1] Gao Y, Li H, Gu B, Xie F, Zhu H, Wang Z, et al. Postburn neck contracture: principles of reconstruction and a treatment algorithm. J Reconstr Microsurg 2018;34(7):514–21. doi:10.1055/s- 0038- 1641724. [2] Heidekrueger PI, Broer PN, Tanna N, Ninkovic M. Postburn head and neck reconstruction: an algorithmic approach. J Craniofac Surg 2016;27(1):150–5. doi:10.1097/SCS.0 0 0 0 0 0 0 0 0 0 0 02166. [3] Li H, Wang Z, Gu B, Gao Y, Xie F, Zhu H, et al. Postburn neck reconstruction with preexpanded upper back perforator flaps: free-Style design and an update of treatment strategies. Ann Plast Surg 2018;81(1):45–9. doi:10.1097/SAP. 0 0 0 0 0 0 0 0 0 0 0 01491. [4] Hocaoglu E. Pre-expanded free perforator flaps. Clin Plast Surg 2017;44(1):143– 52. doi:10.1016/j.cps.2016.08.011. [5] Acarturk TO, Glaser DP, Newton ED. Reconstruction of difficult wounds with tissue-expanded free flaps. Ann Plast Surg 2004;52(5):493–9 discussion 500. [6] Ninkovic M, Moser-Rumer A, Ninkovic M, Spanio S, Rainer C, Gurunluoglu R. Anterior neck reconstruction with pre-expanded free groin and scapular flaps. Plast Reconstr Surg 2004;113(1):61–8. doi:10.1097/01.PRS.0 0 0 0 090726.45594. 6B. [7] Wang AW, Zhang WF, Liang F, Li JY, Zhang XF, Niu XT. Pre-expanded thoracodorsal artery perforator-based flaps for repair of severe scarring in cervicofacial regions. J Reconstr Microsurg 2014;30(8):539–45. doi:10.1055/ s- 0033- 1361839.
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112
JID: JINJ
ARTICLE IN PRESS
[m5G;March 5, 2020;13:35]
T.O. Acartürk and F.B. Bengür / Injury xxx (xxxx) xxx [8] Song B, Xiao B, Liu C, He L, Li Y, Sun F, et al. Neck burn reconstruction with pre-expanded scapular free flaps. Burns 2015;41(3):624–30. doi:10.1016/ j.burns.2014.08.015. [9] Daugherty THF, Pribaz JJ, Neumeister MW. The use of prefabricated flaps in burn reconstruction. Clin Plast Surg 2017;44(4):813–21. doi:10.1016/j.cps.2017. 05.012. [10] Tsai F-C. A new method: perforator-based tissue expansion for a preexpanded free cutaneous perforator flap. Burns 2003;29(8):845–8. [11] Tsai FC, Mardini S, Chen DJ, Yang Jyung, Hsieh MS. The classification and treatment algorithm for post-burn cervical contractures reconstructed with free flaps. Burns 2006;32(5):626–33. doi:10.1016/j.burns.2005.12.009. [12] Hallock GG. Tissue expansion techniques to minimize morbidity of the anterolateral thigh perforator flap donor site. J Reconstr Microsurg 2013;29(9):565– 70. doi:10.1055/s- 0033- 1348035. [13] Acarturk TO. Aesthetic reconstruction of the postburn neck contracture with a preexpanded anterolateral thigh free flap. J Craniofac Surg 2014;25(1):e23–6. doi:10.1097/SCS.0b013e3182a2ed75. [14] Wei F, Jain V, Celik N, Chen H, Chuang DC-C, Lin C. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109(7):2219–30. [15] Hallock GG. The preexpanded anterolateral thigh free flap. Ann Plast Surg 2004;53(2):170–3.
5
[16] Acarturk TO, Bengur FB. Total aesthetic subunit reconstruction of the burned anterior abdomen using pre-expanded pedicled anterolateral thigh flap—a case report. Microsurgery 2019 (September):micr.30519. doi. doi:10.1002/micr. 30519. [17] Hocaoglu E, Arinci A, Berkoz O, Ozkan T. Free pre-expanded lateral circumflex femoral artery perforator flap for extensive resurfacing and reconstruction of the hand. J Plast Reconstr Aesthet Surg 2013;66(12):1788–91. doi:10.1016/j. bjps.2013.04.019. [18] Li Q, Zan T, Li H, Zhou S, Gu B, Liu K, et al. Flap prefabrication and stem cellassisted tissue expansion: how we acquire a monoblock flap for full face resurfacing. J Craniofac Surg 2014;25(1):21–5. doi:10.1097/01.scs.0 0 0 0436743.75289. 6b. [19] D’Arpa S, Colebunders B, Stillaert F, Monstrey S. Pre-expanded anterolateral thigh perforator flap for phalloplasty. Clin Plast Surg 2017;44(1):129–41. doi:10.1016/j.cps.2016.08.004. [20] De La Cruz Monroy MFI, Kalaskar DM, Rauf KG. Tissue expansion reconstruction of head and neck burn injuries in paediatric patients—a systematic review. JPRAS Open 2018;18:78–97. doi:10.1016/j.jpra.2018.10.004. [21] Hocaoglu E, Emekli U, Cizmeci O, Ucar A. Suprafascial pre-expansion of perforator flaps and the effect of pre-expansion on perforator artery diameter. Microsurgery 2014;34(3):188–96. doi:10.1002/micr.22184.
Please cite this article as: T.O. Acartürk and F.B. Bengür, Reconstruction of burn contractures of the anterior neck with pre-expanded free anterolateral thigh flaps, Injury, https://doi.org/10.1016/j.injury.2020.02.112