|Year : 2013 | Volume
| Issue : 1 | Page : 42-47
Our experience in reconstructing the burn neck contracture with free flaps: Are free flaps an optimum approach?
Divya Narain Upadhyaya1, Vaibhav Khanna2, Adarsh Kumar3, Romesh Kohli4
1 Department of Plastic Surgery and Burns, Sanjay Gandhi PostGraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Plastic, Craniofacial and Microsurgery, Vivekananda Polyclinic and Institute of Medical Sciences; Department of Plastic, Reconstructive and Aesthetic Surgery, Sahara Hospital, Lucknow, Uttar Pradesh, India
3 Department of Plastic, Craniofacial and Microsurgery, Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
4 Department of Plastic, Reconstructive and Aesthetic Surgery, Sahara Hospital, Lucknow, Uttar Pradesh, India
|Date of Web Publication||22-Nov-2013|
Divya Narain Upadhyaya
B-2/128, Sector-F, Janakipuram, Lucknow-226021, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The aim of the reconstructive burn surgeon is to remove all the scar tissue in the affected area and resurface the area with supple tissue, which allows proper movement of the neck and is esthetically pleasing. We present our series of 10 patients of burn neck contracture, primary and recurrent, who were treated with free flap reconstruction. Patients and Methods: A retrospective review of all the data of the patients was done and the demographic data, preoperative and postoperative examination findings, surgery offered, results and follow-up details were tabulated and analyzed. Results: All the flaps survived completely. Two flaps showed postoperative congestion on day 1 and were taken to the operating room to be reexplored. All patients showed marked improvement in the degree of neck extension, lateral flexion, and rotation which remained unchanged with successive follow-ups. Conclusion: The results of free flap reconstruction of the burn neck contracture area appear to be better than other methods in terms of functional and esthetic restoration of the normal anatomy. The postoperative morbidities for the patient are also reduced and patient comfort is enhanced. The authors feel that in centers where microsurgical expertise is available, the patients of burn neck contractures may be offered the option of complete scar excision and free flap reconstruction as a primary option instead of scar release and split skin grafting.
Keywords: Free flaps, neck contracture, reconstruction
|How to cite this article:|
Upadhyaya DN, Khanna V, Kumar A, Kohli R. Our experience in reconstructing the burn neck contracture with free flaps: Are free flaps an optimum approach?. Indian J Burns 2013;21:42-7
|How to cite this URL:|
Upadhyaya DN, Khanna V, Kumar A, Kohli R. Our experience in reconstructing the burn neck contracture with free flaps: Are free flaps an optimum approach?. Indian J Burns [serial online] 2013 [cited 2019 Dec 9];21:42-7. Available from: http://www.ijburns.com/text.asp?2013/21/1/42/121881
| Introduction|| |
Severe burn neck contracture is a debilitating condition for the patient physically, esthetically, and also psychologically. It is not only severely disfiguring but also leads to compromise in neck movements and other functions like deglutition. Secondary effects of anterior cervical contractures include lip and eye ectropions, drooling due to inability to close mouth, difficulty in breathing, and mandibular growth inhibition in children. Exposed regions such as the face and neck are most commonly involved in severe burns; especially in patients who work in hazardous environment and do not use protective gear.  In the Indian scenario, however, the most common victims are the housewives working with kitchen fires or those playing with firecrackers, though it is difficult to substantiate this as there are no figures available for India due to lack of a burn registry. Release and resurfacing of extensive burn contractures of the neck is a daunting task for any reconstructive surgeon. The aim of the reconstructive burn surgeon is to remove all the scar tissue in the affected area and resurface the area with supple tissue, which allows proper movement of the neck and is esthetically pleasing. Sequel like contractures of the neck most commonly arise in those patients who suffer severe burns and are treated conservatively or with split skin grafting, which still remains the most common modality of treatment. , The other options for resurfacing the wound after release of the neck contracture besides split skin grafting include full thickness skin grafts, local flaps with or without tissue expansion  and free flaps. ,,, The frequency and severity of recontracture as well as the poor esthetics of the result following management of anterior cervical contractures by split skin grafting as well as the increasing availability of facilities for microsurgery have seen a shift in the routine treatment of neck contractures from simple contracture release and skin grafting to radical scar excision and free flap cover. We present our series of 10 patients of burn neck contracture, primary and recurrent, who were treated with free flap reconstruction.
| Patients and Methods|| |
Between March 2009 and March 2012, 10 patients with burn neck contractures, primary and recurrent, underwent complete burn contracture excision and reconstruction with free flaps at our hospital. A retrospective review of all the data of the patients was done and the demographic data, preoperative and postoperative examination findings, surgery offered, results and follow-up details were tabulated and analyzed.
The group consisted of 10 patients, 2 males and 8 females with an average age of 26.3 years (range: 18-35 years). The etiology of burn in these patients was flame burns in eight patients, electric burn in one patient and scald in one patient. Of this group, six patients were primary contractures and had not received any surgical treatment before hand, while four patients were recurrent contractures [Figure 1], [Figure 2], [Figure 3], [Figure 4] after split skin grafting. The average extent of burn in these patients was 34% (range: 20%-50%). The average interval between injury and definitive treatment (free flap at our institution) was 19.3 months with a range of 10 months to 28 months [Table 1]. The examination findings with regards to neck extension, rotation and lateral flexion were recorded and tabulated to compare with the improvement in the postoperative period [Table 2].
|Figure 1: Clinical photograph showing pre-operative anterior view of a patient with recurrent burn neck contracture following initial treatment of the contracture with release and split skin grafting|
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|Figure 2: Complete excision of previous split skin grafted area as well as the surrounding burn scar of the same patient as in Figure 1|
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|Figure 3: Photograph showing the harvested scapular flap ready to be inset|
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|Figure 4: Follow-up photographs of the same patient as in Figure 1 to Figure 3 showing well inset and supple flap at the chin-neck area. Notice the aesthetic cervico-mental angle|
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All patients underwent routine presurgical investigation and a preanesthesia evaluation before definitive surgery was planned. Routine counselling given to the patients included discussion of anesthesia and surgical risks and the choice of flaps offered. Importance of follow-up and need for further corrective surgeries was stressed. All patients were operated under general anesthesia with endotracheal intubation. In cases of severe neck contractures, flexible endoscope assisted endotracheal intubation was done. The burn scar was completely excised from the menton to the sternum. Full on-table extension was achieved. A second team harvested the flap simultaneously except in cases where the position had to be changed to harvest the flap from the scapular area (n=5). Other flaps offered included the free groin flap (n=3) and the radial artery forearm free flap (n=2) [Table 1].
Factors influencing the choice of flaps included flap anatomy, donor area cosmesis issues, and areas involved in burn injury. The scapular flap was our first choice as it has a predictable vascular anatomy, does not require the sacrifice of any major blood vessel, the donor scar is well-concealed, especially in women, and the color match is also excellent. However, it has the disadvantage that neck release and flap harvest cannot usually proceed simultaneously, thus, extending the operative time. Reasons for not being able to harvest the scapular flap in five cases included involvement of the area in the burn pathology or previous surgical intervention in the area. In such cases either the groin flap or the radial artery was chosen. The free groin flap gives a large quantity of hairless skin and is usually spared from burns except in very severe cases. Unfortunately, the vascular anatomy is less predictable than either the scapular or the radial artery flap and the area is often used for venous canulations in severely burn injured patients, thereby damaging the local vasculature but the donor area cosmesis is far superior to both. A reason for not being able to harvest the free groin flap in two cases was use of the area previously for harvesting full thickness skin grafts. The radial artery forearm free flap was harvested in only two cases and while it has a reliable vascular anatomy and is relatively easier and faster to harvest and, if harvested under tourniquet control, also involves less blood loss, the donor area deformity leaves a lot to be desired and the harvest of this flap involves sacrificing a major blood vessels of the limb. The color match of both the groin flap as well as the radial artery flap is not as good as that of the scapular flap.
The recipient vessels included the superior thyroid or facial vessels. The flaps were inset over suction drains and light compressive dressings were given. Postoperatively, the flaps were monitored closely for the first 72 h for any congestion, bleeding, or anastomotic failure.
| Results|| |
All the flaps survived completely. Two flaps showed postoperative congestion on day 1 and were taken to the operating room to be reexplored. Evacuation of hematoma was done in one patient and in another the venous anastomosis had to be redone. Rest eight patients had uneventful recovery. Average hospital stay of the patients was 7.4 days with a range of 6-15 days. After discharge, the patients were followed-up at regular intervals with an average follow-up of 10 months and a range of 3-20 months [Table 3]. Flap thinning was offered in five patients and ancillary procedures like dermabrasion and thin split thickness graft (SSG), Z-plasties, full thickness skin grafts and contracture release, and local flaps were done in all the patients for other areas affected by the burn, either at the time of the primary procedure or later. All patients showed marked improvement in the degree of neck extension, lateral flexion, and rotation which remained unchanged with successive follow-ups [Table 2].
| Discussion|| |
Burn neck contracture is a debilitating condition which arises most commonly in those patients with face/neck burns who are either treated conservatively or with split skin grafting. Traditionally, burn neck contractures have been treated with release and split skin grafting. Skin grafting of the resulting raw area after contracture release precludes radical excision of the burn scar and, sometimes, even adequate release of the burn contracture for fear of exposing the vital structures thus making flap cover necessary. Postoperative splintage after skin grafting of the released contracture is usually done by either hard cervical collar or plaster of Paris casts, which are both cumbersome and extremely uncomfortable for the patient. Recontracture of the bed begins almost immediately; to counteract which splintage of the neck in extreme extension has to be maintained by the above means for a period of 6 months to 1 year. In most cases, however, this proves inadequate to prevent recontracture which inevitably results. The dressings are cumbersome and the postoperative regimen of massage, pressure garment and splintage make running the complete course of treatment a nightmarish experience for the patient as well as the surgeon. Even if the patient adheres rigidly to the recommended postoperative regimen and a complete take of the skin graft is assured the esthetic result leaves a lot to be desired as the color match and the texture of the grafted skin never match the surrounding area. The cervicomental angle is almost always obliterated and neck movements are compromised due to the residual/recurrent fibrosis of the bed [Figure 1].
Other options for resurfacing in cases of burn neck contractures are local flaps, with or without tissue expansion and full thickness skin grafts. In patients with extensive burns, the areas for harvesting of local flaps are usually also affected resulting in an unreliable vascular anatomy and poorer esthetic result. Local flaps (if unexpanded) are also disfiguring at the areas where the visibility is maximum. On the contrary, expanded full thickness grafts from the abdomen to cover the whole anterior neck can provide good results in burn contracture. However, there is evidence in literature which has shown that free flaps give superior functional results in the reconstruction of scar contractures, especially thin cutaneous perforator flaps. ,,
With the advent of microsurgery, the number of options for the burn surgeon has increased tremendously. The surgeon can now harvest a flap from an unburned or relatively less affected area which may also be an area which has low visibility (like the groin) and can ensure good esthetic as well as functional results [Figure 5], [Figure 6], [Figure 7], [Figure 8].Free flap cover ensures that the surgeon can radically excise all the scar tissue and give the resulting wound a good, healthy, and supple covering which ensures a recurrence free functional and esthetic restoration of the neck contour. The ideal microsurgical reconstruction is one that replaces the damaged scarred tissue with tissue of the same quality and quantity from donor sites which have minimal visibility, in a one-stage procedure and without sacrificing other types of tissues unnecessarily.  Microsurgical reconstruction of the burn neck contracture can be exhausting and time-consuming if a well-coordinated team approach is not put into place. Team work can ensure that burn scar excision and flap harvesting can proceed simultaneously and that the lead surgeon is not completely exhausted by the time he is needed for the actual vascular anastomosis. Team approach brings down operating time considerably and ensures good, predictable results in most of the cases. Apart from the initial surgery, the team is also ready for close postoperative monitoring of the flap and the patient and can carry out emergent explorations and salvage procedures should such a need arise. Free tissue transfer needs significantly less postoperative splintage and physical rehabilitation than either skin grafts or local flaps. The need for dressings is minimized and patient comfort is enhanced. A light compressive dressing is all that is needed for a couple of days, at the end of which dressing are dispensed with altogether.
|Figure 5: Clinical photograph showing primary post-burn anterior cervical contracture in a patient who was managed conservatively|
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|Figure 7: Clinical photograph showing complete excision of burn contracture and burn scar from the neck-chest area. The flap has been inset in the neck defect. Split skin graft has been used to resurface the anterior chest area|
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|Figure 8: Follow-up photographs of the same patient as in Figure 5 to figure 7 showing supple and lax flap in the cervical area. Notice the aesthetic cervico-mental angle|
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Flaps which are bulky may seem ungainly and not provide the expected increase in neck movement and, therefore, one has to be cautious while the flaps is being raised.The free flap maybe thinned for a better esthetic outcome and may also be contoured to give a pleasing cervicomental angle. Flaps that are not thinned in the first stage (to avoid increasing the complication rate) maybe thinned (surgically or by liposuction) later and also otherwise altered. When a limited amount of free flap tissue is available (unexpanded flap, large burns), priority should be given to the areas of maximum scarring, preferably the upper anterior neck as most of the neck extension occurs here. ,, A little postoperative stretching of the flap also occurs rendering the flap lax and making it amenable to secondary procedures to cover other adjacent small areas of contracture or unreconstructed wound. However reconstruction of the full anterior neck, whenever possible, should be attempted as it results in the most dramatic improvement in flexion contracture and return of neck extension. Free flap surgery does entail the risk of complete flap failure to the list of possible complications; however, once the team is past, the learning curve a reasonable rate of success can be expected and offered to the patient.
In this series of 10 patients, the authors have had to reexplore only two patients (20%) and redo the anastomosis (venous) in one patient (10%). There was no flap loss, partial or complete. The present sample size is too small to make definite recommendations, but the authors do believe that after a certain period of time (the ''learning curve'') the operative time and incidence of complications continues to plunge and a reasonable result with minimal morbidities, operative time, down time and costs can be expected. The results of free flap reconstruction of the burn neck contracture area far exceed other methods in terms of functional and esthetic restoration of the normal anatomy. The postoperative morbidities for the patient are also reduced and patient comfort is enhanced. The authors feel that the free flap is a valuable weapon in the burn reconstructive surgeon's armamentarium and should be considered on a priority if the facilities for microsurgery are available. It is the authors' belief that the days when we may see a paradigm shift toward recommending the primary use of free flaps in burn neck reconstruction may not be far off.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 1], [Table 2], [Table 3]