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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 20  |  Issue : 1  |  Page : 75-78

Successful correction of postburn mentosternal contracture and kyphosis of thoracic spine with thoracodorsal artery perforator flap: A case report and review of literature


1 Department of Plastic Surgery, B.J. Medical College and Sassoon Hospital, Pune, Maharashtra, India
2 Department of Physical Medicine and Rehabilitation, B.J. Medical College and Sassoon Hospital, Pune, Maharashtra, India

Date of Web Publication13-May-2013

Correspondence Address:
Nikhil Panse
Vimal Niwas, Sudarshan Society, Near Model Colony Post Office, Shivajinagar, Pune 16
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.111794

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  Abstract 

Postburn kyphosis is extremely rare. Literature on this subject is lacking. We successfully managed a case of postburn mentosternal contracture with kyphosis of thoracic spine by a pedicled thoracodorsal artery perforator (TDAP) flap, postoperative postural bracing and physiotherapy. We had good functional and aesthetic outcomes with a satisfied patient and possible surgery for the spine was avoided. We would like to highlight this rare occurrence of a postburn kyphosis and present a detailed study of this case.

Keywords: Mentosternal contracture, postburn kyphosis, thoracodorsal artery perforator flap


How to cite this article:
Panse N, Sahasrabudhe P, Pande G. Successful correction of postburn mentosternal contracture and kyphosis of thoracic spine with thoracodorsal artery perforator flap: A case report and review of literature. Indian J Burns 2012;20:75-8

How to cite this URL:
Panse N, Sahasrabudhe P, Pande G. Successful correction of postburn mentosternal contracture and kyphosis of thoracic spine with thoracodorsal artery perforator flap: A case report and review of literature. Indian J Burns [serial online] 2012 [cited 2019 Oct 18];20:75-8. Available from: http://www.ijburns.com/text.asp?2012/20/1/75/111794


  Introduction Top


Postburn neck contractures are common after deep thermal burns to the upper body in the developing world. These are primarily because of inadequate primary management of the acute burn wound.

Postburn neck contractures can result in gross aesthetic and functional deformity and can accentuate the social miseries of these individuals. In a growing child, it may result in bony abnormalities.

We present an extremely rare case of postburn mentosternal contracture resulting in kyphosis of the thoracic spine in a young girl. The case was effectively managed by contracture release and coverage by a pedicled TDAP flap. Postoperative physiotherapy and use of a custom made positional brace resulted in the correction of spinal deformity. The patient was satisfied with the functional and aesthetic outcome of the surgery.


  Case Report Top


A previously nonkyphotic 7-year-old female child presented to us with postburn mentosternal contracture and progressive thoracic kyphosis. She had history of flame burns before one year, and was managed with dressings at a primary health care centre. The neck movements were severely restricted. The entire anterior chest wall was scarred.

The chin and the lower lip were restrained down to the anterior chest wall. The constant pull resulted in an anterior open bite deformity [Figure 1]. The mentosternal contracture was so severe that it resulted in kyphosis of the thoracic spine [Figure 2].
Figure 1: Postburn mentosternal contracture with scarring of anterior chest wall

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Figure 2: Lateral view - Post burn kyphosis

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Contracture release and flap coverage was planned. After a fiberoptic assisted intubation the mento-sternal contracture was released right up to the level of the muscles and the defect of around 15 × 10 cm thus produced was covered by a TDAP flap.

An anterior exploratory incision was made on the anterior border of the Latisimus dorsi muscle, and dissection was performed in the loose avascular plane overlying the Latisimus dorsi muscle to identify a reliable and robust perforator. The position of the perforator was around 13 cm from the dome of the axilla, and 2.5 cm from the anterior border of the Latisimus dorsi. Once the perforator was identified, it was dissected intramuscularly to the sub scapular vessel by ligating the branches. It gave us a pedicle length of around 18 cm. The perforator was of adequate size (approximately 0.5-0.6 mm), and pulsated well. Considering the pivot point and defect dimensions, the flap was planned in reverse and distal and posterior incisions of the flap were committed, and the flap was harvested. The entire flap was harvested taking care that there was no traction on the perforator. Due care was taken to prevent drying and spasm of the perforator by constant irrigation by a 2% lignocaine solution. [1],[2],[3] All the fibrous strands surrounding the perforator were dissected as is routinely recommended for all perforator flaps. [1],[2],[3] After the flap was harvested, the intervening area was incised to carry the pedicle and the flap inset was made. The donor site was split skin grafted [Figure 3].
Figure 3: Donor site of the TDAP flap skin grafted

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Postoperatively, the patient was provided with a custom made posture correction brace with a neck extension after the flap settled [Figure 4]. The patient was advised using the brace for maximum amount of time tolerated by the patient. The brace was continued for a period of six months. Physiotherapy involved exercises, stretches, strengthening, mobilizations as well as continual postural corrections. Deep breathing exercises were also initiated to strengthen the intercostals muscles.
Figure 4: Postoperative image with postural bracing

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Two lateral bands were formed, which were managed by a bilateral z plasty after a period of 8 weeks.

After 6 months of splintage and exercises, the entire kyphosis of the spine was corrected. The flap was well settled, and there was no need for cervical splintage/collars. The patient had complete range of movement of the neck, and was satisfied with the aesthetic outcome [Figure 5] and [Figure 6].
Figure 5: Frontal view postoperative correction of mentosternal contracture

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Figure 6: Lateral view postoperative correction of postburn kyphosis

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  Discussion Top


The cervicofacial area is one of the most important aesthetic and functional regions in burn patients. Due to gravity and weight of the head on the neck, the chronic flexion contracture is often seen in deep extensive cervical burns. The skin in this region is thin and pliable and contractures can result in abnormalities of lip competence, facial expression and decreased neck movements. In a growing child the growth and shape of the mandible can be affected. [4],[5]

We encountered a severe flexion deformity of the anterior neck resulting in a compensatory kyphosis of the dorsal spine in a young child. Kyphosis was possibly due to reflex bad posture on part of the patient. Postburn kyphosis is extremely rare, and few cases are reported in literature. Numerous methods have been used to reconstruct the normal contours in patients with postburn neck contracture. These include skin grafts, preexpanded axial and random flaps, free tissue transfer from the scapular and deltoid area, groin, forearm, anterolateral thigh, and tensor fascia lata. Preexpanded free flaps from these regions have also been reported. [6],[7],[8],[9],[10],[11],[12],[13],[14] The skin graft has the obvious disadvantage of color mismatch and postoperative graft contracture. For preexpanded local flaps the neighboring tissue is often itself badly scarred thus precluding the possibility of expansion. Furthermore, it is a two-stage procedure requiring repeated implant filling sessions. Free tissue transfer is an attractive option and when used as a superthin flap does provide excellent texture match. However, the color match is suboptimal and it also requires much longer operating time and microsurgical facilities. [8],[9],[10],[11],[12],[13],[14] Supraclavicular artery flap is a good option but may not be always possible in cases of extensive burns where the supraclavicular area is involved. [15] The head and neck region suffers from a lack of local tissues available for reconstruction. Reconstruction in this region is best achieved by a thin pliable flap with good color match.

The pedicled thoracodorsal artery perforator flap is one of the better options for resurfacing this area. To the best of our knowledge and literature search, use of TDAP flap has not yet been described for postburn neck contractures. Excluding the muscle makes it a thin and pliable flap resulting in better contour to the anterior neck. It employs tissue from the adjacent lateral chest wall and gives a decent texture and color match. When the perforator is dissected to the subscapular artery, it gives a good pedicle length to cover the anterior neck. No preexpansion is needed, and if the recipient defect is small, donor defect can possibly be closed primarily. No microvascular anastomosis is involved, and thus the associated risks are minimized.

Angrigiani first described the TDAP flap based on musculocutaneous perforators from LD muscle in 1985, and he then named the flap "latissimus dorsi musculocutaneous flap without muscle." [16] If there is no reason for harvesting muscle, the TDAP flap, either transferred pedicled or free, is an ideal choice for many soft-tissue defects. [17] Harvesting the skin without the underlying muscle provides thin pliable tissue for shallow soft-tissue defects. The long pedicle is one of the most predominant advantages of this flap. Guerra et al. reported the average pedicle length of the TDAP flap to be 20 cm, and the longest pedicle was 23 cm. [18] In pedicled transfers, this advantage offers a wider arc of rotation to cover a wide range of anatomical areas.

Robert et al. managed a case of postburn kyphosis using multiple z plasty and contracture release procedures, skin graft and a Milwaukee brace. Their patient mainly had a lateral band of the neck with other associated contractures. [19] Since we had a larger anterior cervical defect, we opted for a pedicled TDAP flap followed by bracing.

Most of the burn injuries are preventable. Even if burn injury occurs, most of the burn deformities can be prevented or minimized to a great extent by proper primary management. In the unfortunate event of a cervical burn progressing to a mentosternal contracture and a compensatory kyphosis of the thoracic spine, a pedicled thoracodorsal artery perforator flap is one of the better options to resurface the defect. More number of cases are needed to establish the reach and reliability of this flap for resurfacing postburn mentosternal defects. By contracture release and flap cover, proper physiotherapy and bracing, postburn kyphosis can be corrected and possible surgery for the spine can be avoided.

 
  References Top

1.Panse N, Sahasrabudhe P. The ulnar digital artery perforator flap: A new flap for little finger reconstruction: A preliminary report. Indian J Plast Surg 2010;43:190-4.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.Panse NS, Bhatt YC, Tandale MS. What is safe limit of the perforator flap in lower extremity reconstruction? Do we have answers yet?, Plast Surg Int 2011;2011:349357.  Back to cited text no. 2
    
3.Panse N, Sahasrabudhe P, Bhatt Y. Use of Local Perforator Flaps for Post Burn Reconstruction. Word J Plast Surg 2012;1:22-9.  Back to cited text no. 3
    
4.Sinsel NK, Opdebeeck H, Lesaffre E, Wieland W, Guelinckx PJ. Maxillofacial growth after neck burn injury at a young age: An experimental study in the rabbit. Plast Reconstr Surg 1997;99:918.  Back to cited text no. 4
    
5.Uzunismail A, Iccen D. Long term effect of postburn neck contracture on mandibular growth. Plast Reconstr Surg 1995;96:1588e99.  Back to cited text no. 5
    
6.Iwuagwu FC, Wilson D, Bailie F. The use of skin grafts in postburn contracture release: A 10-year review. Plast Reconstr Surg 1999;103:1198e204.  Back to cited text no. 6
    
7.Wilson IF, Lokeh A, Schubert W, Benjamin CI. Latissimus dorsi myocutaneous flap reconstruction of neck and Axillary burn contractures. Plast Reconstr Surg 2000;105:27.  Back to cited text no. 7
    
8.Agarwal R, Chandra R. Latissimus dorsi myocutaneous flap reconstruction of neck and axillary burn contractures. Plast Reconstr Surg 2000;106:1216.  Back to cited text no. 8
    
9.Angrigiani C, Grilli D, Karanas YL, Longaker MT, Sharma S. The dorsal scapular island flap: An alternative for head, neck, and chest reconstruction. Plast Reconstr Surg 2003;111:67-78.  Back to cited text no. 9
    
10.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;113:61-8.  Back to cited text no. 10
    
11.Celikoz B, Sengezer M, Guler MM, Selmanpakoðlu N. Reconstruction of anterior neck contractures with sensate expanded radial forearm free flap. Burns 1996;22:320.  Back to cited text no. 11
    
12.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;110:39-46.  Back to cited text no. 12
    
13.Horch RE, Meyer-Marcotty M, Stark GB. Preexpansion of the tensor fasciae latae for free-flap transfer. Plast Reconstr Surg 1998;102:1188-92.  Back to cited text no. 13
    
14.Tsai FC, Yang J, Mardini S, Chuang SS, Wei FC. Free split-cutaneous perforator flaps procured using a three-dimensional harvest technique for the reconstruction of postburn contracture defects. Plast Reconstr Surg 2004;113:185-93.  Back to cited text no. 14
    
15.Lamberty BG. The supraclaricular axial patterned flap. Br J Plast Surg 1979;32:207-12.  Back to cited text no. 15
    
16.Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995;96:1608-14.  Back to cited text no. 16
    
17.Ayhan S, Tuncer S, Demir Y, Kandal S. Thoracodorsal artery perforator flap: A versatile alternative for various soft tissue defects. J Reconstr Microsurg 2008;24:285-93.  Back to cited text no. 17
    
18.Guerra AB, Metzinger SE, Lund KM, Cooper MM, Allen RJ, Dupin CL. The thoracodorsal artery perforator flap: Clinical experience and anatomic study with emphasis on harvest techniques. Plast Reconstr Surg 2004;114:32-41  Back to cited text no. 18
    
19.Winter RB, Pilney FT. Treatment of severe postburn kyphosis with combined plastic surgery and Milwaukee Bracing Spine. Lippincott Williams and Wilkins, Inc. vol. 27. No. 11. 2002. p. E288-90.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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