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The inframammary extending lateral intercostal artery perforator flap for reconstruction of axillary contractures: a case report
Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, e7ee11
CASE REPORT
The inframammary extending lateral intercostal artery perforator flap for reconstruction of axillary contractures: a case report F.B. Stillaert*, B. Casaer, N. Roche, K. Van Landuyt, M. Hamdi, P.N. Blondeel, S. Monstrey Department of Plastic and Reconstructive Surgery, University Hospital Gent, Belgium Received 22 March 2008; accepted 30 March 2008
KEYWORDS Axillary contracture; LICAP; Burn injury
Summary Release and reconstruction of axillary scar contractures can be challenging due to the specific anatomic site and contouring of the axillary region. Pliable and unscarred skin coverage of resulting defects after scar release is needed which enhances the postoperative recovery and revalidation. When traditional donor regions of fasciocutaneous flaps are involved in the scarred area, options are few. We describe the design and versatility of an inframammary extended lateral intercostal artery perforator (LICAP) flap to reconstruct an axillary defect after wide scar release and debridement. The postoperative recovery was uneventful with restoration of the range of motion of the shoulder joint. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Of all burn-related contractures, the axilla is the most commonly involved. The position of least pain at the shoulder joint e the most mobile joint in the human body e is the one of adduction and internal rotation along with protraction of the scapula. Burn injury to the shoulder resulting in a severe restriction of shoulder mobility is a frequently observed debilitating deformity known for its high recurrence rate. Axillary contractures are anatomically classified into three main types.1 Type 1 is a contracture involving either the * Corresponding author. Address: University Hospital Gent, Department of Plastic and Reconstructive Surgery, De Pintelaan 185, 9000 Gent, Belgium. Tel.: þ32 93324653; fax: þ32 93323899. E-mail address: [email protected] (F.B. Stillaert).
anterior or the posterior axillary fold. Types 2 and 3 involve both axillary folds. Type 3 is also described as a panaxillary contracture and involves the intervening skin of the axillary dome. Toet and Bosse added upper arm and lateral trunk involvement to the type 3 axillary contracture. The type of contracture will dictate the feasibility or necessity of a reconstructive procedure and the degree of postoperative physical therapy. The goal of the reconstructive procedure is maximal contraction release with minimal anatomic distortion and maximal restoration of the abduction range of the shoulder joint. Surgical correction of axillary contractures remains challenging in the acute phase, as skin resurfacing of the axillary region is difficult due to its unfavourable concave contour, and immobilising the
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.03.070
e8
F.B. Stillaert et al.
Figure 1 Full-thickness burn injury involving the scapular and upper arm region extending into the posterior axillary fold (A). During the recovery period the patient developed an axillary scar contracture (B).
shoulder joint for a prolonged period is difficult, required to avoid shearing and loss of the grafts. Local transposition flaps for mild axillary contractures and autografting were first proposed by John Staige Davis in 1924.1 Local flap techniques such as Z-plasties and their modifications, VYor VM-advancement techniques and random fasciocutaneous flaps with supplemental skin grafts have traditionally been used for type 1 or 2 contractures. The feasibility of a particular surgical technique depends on the specific anatomical area which is involved and there is usually no possibility of local flap reconstruction in type 3 contractures. The problem in this severe type of contracture is the scarred and distorted anatomy of the posterior axillary fold, together with the periaxillary area which precludes the elevation of local unscarred donor tissue. Mobilisation of this scarred tissue could question flap survival and donor-site morbidity. The scar-releasing incision should extend beyond the axillary fat into the pectoralis fascia anteriorly and the latissimus dorsi fascia posteriorly. The
resulting defect is often prohibitive in size and will require large sheets of skin for coverage. The decision on which technique to use depends on each individual presentation and can be difficult.
Case report A 63-year-old patient, suffering from dementia, was admitted to our department with a third degree burn of the back. The thermal injury involved the left scapular region extending into the posterior axillary fold and posterior aspect of the upper arm (Figure 1A). Initially she was debrided and skin grafted but during the postoperative period she developed a severe type 1 axillary contracture which involved part of the panaxillary area (Figure 1B). The lack of any adjacent area of suitable healthy donor tissue excluded the design of local (fascio)cutaneous flaps to release and reconstruct the contracture. The presence
Reconstruction of axillary contractures
e9
Figure 2 Status after axillary scar release with the design of an inframammary extending lateral intercostal artery perforator flap to cover the defect. Doppler ultrasound revealed a good intercostal perforator (marking).
of a bulk of unscarred inframammary skin tissue inspired us to design an inframammary fasciocutaneous perforator flap based on a lateral intercostal artery perforator (Figure 2). Preoperative Doppler ultrasound examination located a lateral perforator which emerges from the intersection of the anterior border of the latissimus dorsi muscle and the lower border of the fourth rib. The patient was positioned in the lateral decubitus position with the shoulder and elbow abducted at almost 90 . A posterior incision was made with anterior extension at its lower end to explore and confirm the feasibility of the intercostal perforator. The incision was deepened to expose the anterior border of the latissimus dorsi muscle and the lateral cutaneous branch was identified (Figure 3). The dissection was continued until enough pedicle length was obtained. With the perforator completely isolated, the superior border of
the flap was incised taking into consideration the dimensions of the residual axillary defect after debridement. The length of the flap reached the sternal border and as much skin tissue was included in this flap to permit primary closure of the donor site (Figure 3). The total harvest time was about 40 min. The postoperative recovery was uneventful with good recovery of the shoulder joint mobility (Figure 4).
Discussion The axillary region has multidirectional activity and postoperative scar contracture tends to recur easily. Skin grafts applied to the axillary region are not only more prone to failure or infection due to its unfavourable concave contour
Figure 3 The lateral intercostal artery perforator was identified emerging at the lateral border of the latissimus dorsi muscle and isolated to obtain good mobilisation of the perforator flap.
e10
F.B. Stillaert et al.
Figure 4
Postoperative result at 2 weeks with good range of motion of the shoulder joint.
but will also contract more easily due to the adducted postoperative position of the axilla. Local random or pedicled island flaps of adjacent non-traumatised tissue are able to cover only limited skin defects within the axillary region. Several reconstructive techniques that sought to avoid the morbidity of skin grafting have been introduced in the management of severe axillary contractures and most of them entail the use of vascularised flaps. The first were the regional myocutaneous flaps, such as the pectoralis major mycocutaneous flap and the latissimus dorsi myocutaneous flap. Fasciomyocutaneous flaps, such as the extended lower trapezius island flap, have also been described.2 The sacrifice of the muscle and the excessive bulk in the axilla, however, militated against their acceptability. The search for an alternative led to thinner fasciocutaneous flaps that avoided these problems. Fasciocutaneous flaps must be in proximity to the defect if a rotational flap is planned. The planned flap must be of sufficient size to reconstruct the defect and they are ideal for areas that do not require bulk such as the axillary region. Fasciocutaneous flaps include the axial-pattern scapular and parascapular fasciocutaneous flaps, the medial arm fasciocutaneous flap, and the random-pattern latissimus dorsi flap. The thoraco-dorsal perforator-based cutaneous island flap, the axial bilobed flap and the inframammary extended circumflex scapular flap3 have also been described. The advantages of using perforator flaps include less donor site morbidity, superior versatility in flap design, muscle sparing with less tissue bulk, and an improved postoperative recovery. Perforator flaps should have a predictable and consistent blood supply with at least one large perforating vessel of sufficient pedicle length, and the possibility to close the donor defect primarily. The vascular supply can easily be assessed preoperatively using Doppler sonography. When contractures extend into the axillary depressed area, the first choice should be a regional flap, and the second is the free flap. With the
scarred or burned area involving the scapular, back and upper arm region, not that many options are left for (pan)axillary reconstruction, as flaps should be designed outside the contracted or scarred axillary area. However, when there is no normal skin around the axilla, Ogawa et al. even proposed the use of a scar flap.4 The lateral intercostal artery perforator (LICAP) flap has been described for defect coverage of different anatomical regions such as the back and sternal regions, or partial breast reconstruction or augmentation.5 We applied our knowledge of perforator flaps to a patient with a severely debilitating postburn axillary contracture type 1 with extensively cutaneous scarring extending into the panaxillary and scapularhumeral region. The aim of the reconstructive procedure is to provide a local flap consisting of non-scarred pliable skin with minimal donor site morbidity and a good aesthetic outcome. The inframammary extending LICAP flap was a practical and feasible option in this patient as the entire defect could be closed without any tension on the scarred wound margins with an attractive donor site scar hidden within the inframammary fold. This flap offers an anteriorly-located pedicle distant from the scarred and distorted axillary region with no residual tissue bulk at the recipient site. The mobility of the flap was optimal to cover the panaxillary region and provided durable wound coverage without unnecessary prolonged immobilisation of the shoulder. The point of rotation is based on the site of entrance of the dominant vascular pedicle into the fascia. In conclusion, this inframammary extending LICAP flap is devoid of the problem of bulk to reconstruct panaxillary contractures and combines good reach with width that allows primary closure of the donor site. There is decreased postoperative immobilisation, reduced postoperative therapy, decreased hospitalisation, and less likelihood of recurrence. This flap was
Reconstruction of axillary contractures particularly useful for this non-compliant patient who suffered from dementia.
References 1. Kurtzman LC, Stern PJ. Upper extremity burn contractures. Hand Clin 1990;6:261e79. 2. Elshaer WM. Extended lower trapezius island myocutaneous flap in the repair of postburn axillary contracture. Plast Reconstr Surg 2004;113:2076e81.
e11 3. Siebert JW, Longaker MT, Angrigiani C. The inframammary extended circumflex scapular flap: an aesthetic improvement of the parascapular flap. Plast Reconstr Surg. 1997; 99:70e7. 4. Ogawa R, Hyakusoku H, Murakami M, et al. Reconstruction of axillary scar contracturesdretrospective study of 124 cases over 25 years. Br J Plast Surg 2003;56:100e5. 5. Hamdi M, Van Landuyt K, De Frene B, et al. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg 2006;59:644e52.
CASE REPORT
The inframammary extending lateral intercostal artery perforator flap for reconstruction of axillary contractures: a case report F.B. Stillaert*, B. Casaer, N. Roche, K. Van Landuyt, M. Hamdi, P.N. Blondeel, S. Monstrey Department of Plastic and Reconstructive Surgery, University Hospital Gent, Belgium Received 22 March 2008; accepted 30 March 2008
KEYWORDS Axillary contracture; LICAP; Burn injury
Summary Release and reconstruction of axillary scar contractures can be challenging due to the specific anatomic site and contouring of the axillary region. Pliable and unscarred skin coverage of resulting defects after scar release is needed which enhances the postoperative recovery and revalidation. When traditional donor regions of fasciocutaneous flaps are involved in the scarred area, options are few. We describe the design and versatility of an inframammary extended lateral intercostal artery perforator (LICAP) flap to reconstruct an axillary defect after wide scar release and debridement. The postoperative recovery was uneventful with restoration of the range of motion of the shoulder joint. ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Of all burn-related contractures, the axilla is the most commonly involved. The position of least pain at the shoulder joint e the most mobile joint in the human body e is the one of adduction and internal rotation along with protraction of the scapula. Burn injury to the shoulder resulting in a severe restriction of shoulder mobility is a frequently observed debilitating deformity known for its high recurrence rate. Axillary contractures are anatomically classified into three main types.1 Type 1 is a contracture involving either the * Corresponding author. Address: University Hospital Gent, Department of Plastic and Reconstructive Surgery, De Pintelaan 185, 9000 Gent, Belgium. Tel.: þ32 93324653; fax: þ32 93323899. E-mail address: [email protected] (F.B. Stillaert).
anterior or the posterior axillary fold. Types 2 and 3 involve both axillary folds. Type 3 is also described as a panaxillary contracture and involves the intervening skin of the axillary dome. Toet and Bosse added upper arm and lateral trunk involvement to the type 3 axillary contracture. The type of contracture will dictate the feasibility or necessity of a reconstructive procedure and the degree of postoperative physical therapy. The goal of the reconstructive procedure is maximal contraction release with minimal anatomic distortion and maximal restoration of the abduction range of the shoulder joint. Surgical correction of axillary contractures remains challenging in the acute phase, as skin resurfacing of the axillary region is difficult due to its unfavourable concave contour, and immobilising the
1748-6815/$ - see front matter ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.03.070
e8
F.B. Stillaert et al.
Figure 1 Full-thickness burn injury involving the scapular and upper arm region extending into the posterior axillary fold (A). During the recovery period the patient developed an axillary scar contracture (B).
shoulder joint for a prolonged period is difficult, required to avoid shearing and loss of the grafts. Local transposition flaps for mild axillary contractures and autografting were first proposed by John Staige Davis in 1924.1 Local flap techniques such as Z-plasties and their modifications, VYor VM-advancement techniques and random fasciocutaneous flaps with supplemental skin grafts have traditionally been used for type 1 or 2 contractures. The feasibility of a particular surgical technique depends on the specific anatomical area which is involved and there is usually no possibility of local flap reconstruction in type 3 contractures. The problem in this severe type of contracture is the scarred and distorted anatomy of the posterior axillary fold, together with the periaxillary area which precludes the elevation of local unscarred donor tissue. Mobilisation of this scarred tissue could question flap survival and donor-site morbidity. The scar-releasing incision should extend beyond the axillary fat into the pectoralis fascia anteriorly and the latissimus dorsi fascia posteriorly. The
resulting defect is often prohibitive in size and will require large sheets of skin for coverage. The decision on which technique to use depends on each individual presentation and can be difficult.
Case report A 63-year-old patient, suffering from dementia, was admitted to our department with a third degree burn of the back. The thermal injury involved the left scapular region extending into the posterior axillary fold and posterior aspect of the upper arm (Figure 1A). Initially she was debrided and skin grafted but during the postoperative period she developed a severe type 1 axillary contracture which involved part of the panaxillary area (Figure 1B). The lack of any adjacent area of suitable healthy donor tissue excluded the design of local (fascio)cutaneous flaps to release and reconstruct the contracture. The presence
Reconstruction of axillary contractures
e9
Figure 2 Status after axillary scar release with the design of an inframammary extending lateral intercostal artery perforator flap to cover the defect. Doppler ultrasound revealed a good intercostal perforator (marking).
of a bulk of unscarred inframammary skin tissue inspired us to design an inframammary fasciocutaneous perforator flap based on a lateral intercostal artery perforator (Figure 2). Preoperative Doppler ultrasound examination located a lateral perforator which emerges from the intersection of the anterior border of the latissimus dorsi muscle and the lower border of the fourth rib. The patient was positioned in the lateral decubitus position with the shoulder and elbow abducted at almost 90 . A posterior incision was made with anterior extension at its lower end to explore and confirm the feasibility of the intercostal perforator. The incision was deepened to expose the anterior border of the latissimus dorsi muscle and the lateral cutaneous branch was identified (Figure 3). The dissection was continued until enough pedicle length was obtained. With the perforator completely isolated, the superior border of
the flap was incised taking into consideration the dimensions of the residual axillary defect after debridement. The length of the flap reached the sternal border and as much skin tissue was included in this flap to permit primary closure of the donor site (Figure 3). The total harvest time was about 40 min. The postoperative recovery was uneventful with good recovery of the shoulder joint mobility (Figure 4).
Discussion The axillary region has multidirectional activity and postoperative scar contracture tends to recur easily. Skin grafts applied to the axillary region are not only more prone to failure or infection due to its unfavourable concave contour
Figure 3 The lateral intercostal artery perforator was identified emerging at the lateral border of the latissimus dorsi muscle and isolated to obtain good mobilisation of the perforator flap.
e10
F.B. Stillaert et al.
Figure 4
Postoperative result at 2 weeks with good range of motion of the shoulder joint.
but will also contract more easily due to the adducted postoperative position of the axilla. Local random or pedicled island flaps of adjacent non-traumatised tissue are able to cover only limited skin defects within the axillary region. Several reconstructive techniques that sought to avoid the morbidity of skin grafting have been introduced in the management of severe axillary contractures and most of them entail the use of vascularised flaps. The first were the regional myocutaneous flaps, such as the pectoralis major mycocutaneous flap and the latissimus dorsi myocutaneous flap. Fasciomyocutaneous flaps, such as the extended lower trapezius island flap, have also been described.2 The sacrifice of the muscle and the excessive bulk in the axilla, however, militated against their acceptability. The search for an alternative led to thinner fasciocutaneous flaps that avoided these problems. Fasciocutaneous flaps must be in proximity to the defect if a rotational flap is planned. The planned flap must be of sufficient size to reconstruct the defect and they are ideal for areas that do not require bulk such as the axillary region. Fasciocutaneous flaps include the axial-pattern scapular and parascapular fasciocutaneous flaps, the medial arm fasciocutaneous flap, and the random-pattern latissimus dorsi flap. The thoraco-dorsal perforator-based cutaneous island flap, the axial bilobed flap and the inframammary extended circumflex scapular flap3 have also been described. The advantages of using perforator flaps include less donor site morbidity, superior versatility in flap design, muscle sparing with less tissue bulk, and an improved postoperative recovery. Perforator flaps should have a predictable and consistent blood supply with at least one large perforating vessel of sufficient pedicle length, and the possibility to close the donor defect primarily. The vascular supply can easily be assessed preoperatively using Doppler sonography. When contractures extend into the axillary depressed area, the first choice should be a regional flap, and the second is the free flap. With the
scarred or burned area involving the scapular, back and upper arm region, not that many options are left for (pan)axillary reconstruction, as flaps should be designed outside the contracted or scarred axillary area. However, when there is no normal skin around the axilla, Ogawa et al. even proposed the use of a scar flap.4 The lateral intercostal artery perforator (LICAP) flap has been described for defect coverage of different anatomical regions such as the back and sternal regions, or partial breast reconstruction or augmentation.5 We applied our knowledge of perforator flaps to a patient with a severely debilitating postburn axillary contracture type 1 with extensively cutaneous scarring extending into the panaxillary and scapularhumeral region. The aim of the reconstructive procedure is to provide a local flap consisting of non-scarred pliable skin with minimal donor site morbidity and a good aesthetic outcome. The inframammary extending LICAP flap was a practical and feasible option in this patient as the entire defect could be closed without any tension on the scarred wound margins with an attractive donor site scar hidden within the inframammary fold. This flap offers an anteriorly-located pedicle distant from the scarred and distorted axillary region with no residual tissue bulk at the recipient site. The mobility of the flap was optimal to cover the panaxillary region and provided durable wound coverage without unnecessary prolonged immobilisation of the shoulder. The point of rotation is based on the site of entrance of the dominant vascular pedicle into the fascia. In conclusion, this inframammary extending LICAP flap is devoid of the problem of bulk to reconstruct panaxillary contractures and combines good reach with width that allows primary closure of the donor site. There is decreased postoperative immobilisation, reduced postoperative therapy, decreased hospitalisation, and less likelihood of recurrence. This flap was
Reconstruction of axillary contractures particularly useful for this non-compliant patient who suffered from dementia.
References 1. Kurtzman LC, Stern PJ. Upper extremity burn contractures. Hand Clin 1990;6:261e79. 2. Elshaer WM. Extended lower trapezius island myocutaneous flap in the repair of postburn axillary contracture. Plast Reconstr Surg 2004;113:2076e81.
e11 3. Siebert JW, Longaker MT, Angrigiani C. The inframammary extended circumflex scapular flap: an aesthetic improvement of the parascapular flap. Plast Reconstr Surg. 1997; 99:70e7. 4. Ogawa R, Hyakusoku H, Murakami M, et al. Reconstruction of axillary scar contracturesdretrospective study of 124 cases over 25 years. Br J Plast Surg 2003;56:100e5. 5. Hamdi M, Van Landuyt K, De Frene B, et al. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg 2006;59:644e52.