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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 22  |  Issue : 1  |  Page : 67-71

Free parascapular flap reconstruction of post burn neck contracture


Department of Plastic and Reconstructive Surgery, Armed Forces Medical College, Pune, Maharashtra, India

Date of Web Publication15-Dec-2014

Correspondence Address:
Rahul Dalal
Flat No. K-302, Queen's Tower, New D. P. Road, Aundh, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.147011

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  Abstract 

Neck reconstruction for cervical scar contracture after burn injuries often takes priority over other areas. The ideal material for coverage of defects created by neck contracture release is thin, supple, large well vascularized healthy tissue. We present here our experience of seven cases of postburn neck scar contracture release and reconstruction with free parascapular flap cover. Patients and Methods: Seven adult females, 18-44 year age group, 6-15 months postburn, total body surface area 20-60% burns, moderate to severe contractures limited to the most visible anterior aspect of the neck were reconstructed with free parascapular flap. Results: All flaps survived with good aesthetic and functional mobility. Donor sites were closed primarily in all patients. Conclusion: Parascapular free flap reconstruction of postburn neck contracture is reliable and effective method. It provides large supple skin flap with good color match for esthetic and functional reconstruction of postburn neck scar contracture.

Keywords: Contracture release, parascapular free flap, postburn neck contractures


How to cite this article:
Parwaz M A, Dalal R, Chakravarty B, Malik A. Free parascapular flap reconstruction of post burn neck contracture. Indian J Burns 2014;22:67-71

How to cite this URL:
Parwaz M A, Dalal R, Chakravarty B, Malik A. Free parascapular flap reconstruction of post burn neck contracture. Indian J Burns [serial online] 2014 [cited 2019 Jul 19];22:67-71. Available from: http://www.ijburns.com/text.asp?2014/22/1/67/147011


  Introduction Top


Postburn neck scar contracture is a major complication that still represents a major challenge for reconstruction. The basic goals of reconstruction are restoration of appearance (symmetry, contour, color and texture match) and functional mobility.

Methods available for release are plenty that is, Z-plasties, split-thickness skin grafts, full thickness skin grafts, local or pedicled skin flaps with or without tissue expanders, pedicled or free musculocutaneous flaps, and free cutaneous flaps. Parascapular flap has been used as a pedicled or island flap for axillary contractures. [1],[2] It was also used, with many modifications, as a free flap for neck reconstruction. [3],[4]

The parascapular flap is easily accessible, and its dissection is moderately difficult. The vascular system is constant, and the pedicle is long (up to 14 cm) and with a large diameter (up to 4.5 mm in diameter at the origin of the Subscapular artery). The intradermal network is rich, the skin is usually hairless, and the flap contains a reasonable amount of subcutaneous tissue. The flap has no functional morbidity and leaves the muscular anatomy of the donor area undisturbed. The donor site is closed primarily, even for large flaps. [5],[6] The flap can be as wide as 15 cm and as long as 25 cm. [7],[8]

The purpose of this article is to provide indications, methods and outcomes for free tissue transfer in severe neck scar contractures.


  Patients and methods Top


Seven adult females were included in the study of age group 18-44 years, who presented to us 6-15 months postburn period. They had total body surface area 25-60% burns, incurred during domestic fire accidents. They had moderate to severe neck contractures with associated abdomen, chest, upper and lower extremity burns.

Evaluation of the patient for consideration of parascapular donor site included an examination of the back and shoulder to rule out significant shoulder morbidity or scarring of the skin in the region, and any signs of vascular insufficiency. Patients with previous axillary lymph node dissection were excluded from this study.

These patients underwent free parascapular flap neck reconstruction during the period from January 2010 to September 2011. All patients were followed up for a period of 24 months. Written, informed consent was taken from each patient, and the work was carried out as per ethical guidelines.

Surgical technique

The procedure was performed first with the patient in the supine position. The procedure was started by performing full release of the neck contracture. After full release the measurements of the defect created were taken, and the site of emergence of the vessel from triangular space was taken into consideration while designing the flap. The landmark for the point of emergence of the pedicle was from the omotricipital space and the lateral edge of the scapula. This space, limited by the teres minor above, teres major below, and long head of the triceps laterally, was felt as a depressed area with finger palpation. The main axis was constituted by the lateral border of the scapula. We divided the flap vessels at the level of the circumflex scapular artery or subscapular artery depending upon the factors like requirement of pedicle length and the caliber of recipient vessels.

Pre-operatively, all patients had a hand held Doppler examination to identify the donor vessel. Flap harvest was performed with the patient in the lateral decubitus position. As the parascapular branch of the circumflex scapular artery was constant in its presence and location in all cases we started our dissection from below upwards. We first performed the cutaneous incision of the lower end of the flap and the medial border of the flap down to the fascia but not including fascia.

The dissection was carried out at the same plane till we reached the lower border of the scapula. Careful dissection was carried out as the plane here is usually not very well-defined. Transillumination of the flap was very helpful in identifying the pedicle. Once the pedicle was identified dissection was carried out to the site of emergence of the vessels from the triangular space. The required thinning of flap was done on table. 5000 I Units of heparin was given IV 5 min prior to the division of the pedicle.

The anastomosis of donor and recipient vessels was done under microscope magnification, with 10-0 nylon intermittent sutures. Recipient vessels used were mostly facial artery and the internal jugular vein tributaries. Multiple tube drains were used to prevent hematoma or seroma formation under the flap. The donor site was closed primarily in two layers over a suction drain.

Postoperative management

The donor arm was immobilized in an arm sling for 5 days. Regular postoperative monitoring of the flap vascular flow was carried out with serial examination and pinprick. Minimal dressing given for the neck. Physiotherapy to improve shoulder strength commenced 3 weeks after surgery.


  Results Top


We did not have any total flap loss in all our seven patients [Table 1] and [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]. We experienced congestion and subsequent sloughing of the distal 1 cm of one flap. The width of this flap that proved consistent with direct closure of the donor defect in our series was 11 cm.
Figure 1: Preoperative (a) postoperative (b)

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Figure 2: Preoperative (a) postoperative (b)

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Figure 3: Preoperative (a) postoperative (b)

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Figure 4: Preoperative defect after scar release and excision Intraoperative flap raising harvested flap final flap inset postoperative

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Figure 5: One patient with donor site complication, split skin grafting well consolidated

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Table 1: Results

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Full range of movement was restored in all patients after postoperative physiotherapy.

We have experienced one case of minimal donor site infection, which was easily managed by frequent dressings and topical antibacterial agents.

There was no incidence of hematoma or seroma formation either at the donor site or under the flap, as meticulous hemostasis and good suction drainage were insured in every case. Two patients underwent flap thinning by liposuction, and one patient had liposuction with scar revision surgery [Figure 6].
Figure 6: Secondary revision surgery-liposuction and scar revision

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  Discussion Top


The reconstruction of head and neck burns is challenging and traditionally involves skin grafting and local flaps. Free flaps have improved in versatility and variability in recent years and are now among the established techniques used in burn reconstruction.

The first free flap for burn care was performed in 1974 [9] and in 1997, a total face reconstruction was performed with bilateral free scapular mega flap. [10] Flap choice depends on defect size and available donor sites. It is important to respect facial esthetic units and reconstruct the entire unit when possible. [9],[11]

Defects greater than two-thirds of the anterior neck require distant tissue and are usually not amenable to local flaps. Skin grafting can work well but often requires prolonged immobilization and pressure and is often not aesthetically pleasing. [12] Skin grafting of the resulting raw area after contracture release needs radical excision of the burn scar. In-adequate release of the burn contracture may result for fear of exposing the vital structures thus making flap cover necessary. The split skin grafted bed begins to contract almost immediately in the postoperative period. Splintage of the neck in extreme extension has to be maintained for a period of 6 months to 1 year. In many cases, however, this proves inadequate to prevent a recontracture. The increasing availability of facilities for microsurgery has seen a shift in the management of neck contractures from simple contracture release and skin grafting to radical scar excision and free flap cover. [13]

Free flaps provide full thickness skin and subcutaneous tissue with improved aesthetics and better resurfacing than skin grafts. [14],[15] The neck mobility is greatly enhanced with free flap reconstruction. However, their thickness can blunt the cervicomental angle, and they routinely require thinning procedures. The flap of choice is a thin flap that covers the entire exposed neck when the shirt is worn. The parascapular flap easily fits into these criteria. The other indications are failure of skin grafting in patients with continued contraction, hypertrophic scarring or wound breakdown.

Both aesthetic and functional results are important for surgery of post-burn neck contracture, and the functional outcome is always considered first.

The free anterolateral thigh (ALT) musculocutaneous flap is also useful in head and neck reconstructions when adequate bulk is required with obliteration of dead space as in post-malignancy defect reconstruction. The excessive bulk, color mismatch and thickness of subcutaneous tissue of the ALT are the main disadvantages of the ALT flap. Furthermore, donor site scars associated with the use of skin grafts sometimes make the ALT unfavorable for reconstruction of post-burn neck contractures. [16]

The use of the parascapular flap for reconstruction of severe contracted neck yielded an excellent functional restoration together with very good aesthetic results as the parascapular flaps provided ample amount of soft, pliable and relatively thin skin, together with minimal donor sites scars, which were closed primarily in all of our cases. However, the only limiting factor is the available width of the flap that can be closed primarily. This limits the use of this flap to those areas of the neck, which are vertically oriented, placed anteriorly and are not too wide.


  Conclusion Top


Free flaps are one of the many tools used in burn reconstruction and require long, complex and staged management with the need for future revisions. The surgeon and patient must be flexible and have realistic goals and expectations in facial burn reconstruction.

Parascapular flap is the author's method of choice for reconstruction of the post-burn neck when it is feasible owing to its reliable blood supply, large coverage area, and low donor-site morbidity to provide the desirable functional and aesthetic effect expected by both the patient and the surgeon.

 
  References Top

1.
Hallock GG, Okunski WJ. The parascapular fasciocutaneous flap for release of the axillary burn contracture. J Burn Care Rehabil 1987;8:387-90.  Back to cited text no. 1
    
2.
Yanai A, Nagata S, Hirabayashi S, Nakamura N. Inverted-U parascapular flap for the treatment of axillary burn scar contracture. Plast Reconstr Surg 1985;76:126-9.  Back to cited text no. 2
    
3.
Xu J, Li SK, Li YQ, Ma XB, Li SY. Superior extension of the parascapular free flap for cervical burn scar contracture. Plast Reconstr Surg 1995;96:58-62.  Back to cited text no. 3
    
4.
Siebert JW, Longaker MT, Angrigiani C. The inframammary extended circumflex scapular flap: An aesthetic improvement of the parascapular flap. Plast Reconstr Surg 1997;99:70-7.  Back to cited text no. 4
    
5.
Saijo M. The vascular territories of the dorsal trunk: A reappraisal for potential flap donor sites. Br J Plast Surg 1978;31:200-4.  Back to cited text no. 5
    
6.
Batchelor AG, Sully L. A multiple territory free tissue transfer for reconstruction of a large scalp defect. Br J Plast Surg 1984;37:76-9.  Back to cited text no. 6
    
7.
Nassif TM, Vidal L, Bovet JL, Baudet J. The parascapular flap: A new cutaneous microsurgical free flap. Plast Reconstr Surg 1982;69:591-600.  Back to cited text no. 7
    
8.
Baudet J, Guimberteau JC, Nascimento E. Successful clinical transfer of two free thoraco-dorsal axillary flaps. Plast Reconstr Surg 1976;58:680-8.  Back to cited text no. 8
    
9.
Harri K, Ohmori K, Ohmori S. Utilization of free composite tissue transfer by microvascular anastomosis for repair of burn deformities. Burns 1975;1:237.  Back to cited text no. 9
    
10.
Angrigiani C, Grilli D. Total face reconstruction with one free flap. Plast Reconstr Surg 1997;99:1566-75.  Back to cited text no. 10
    
11.
Neale HW, Billmire DA, Carey JP. Reconstruction following head and neck burns. Clin Plast Surg 1986;13:119-36.  Back to cited text no. 11
    
12.
Bunchman HH 2 nd , Huang TT, Larson DL, Lewis SR. Prevention and management of contractures in patients with burns of the neck. Am J Surg 1975;130:700-3.  Back to cited text no. 12
    
13.
Upadhyaya DN, Khanna V, Kumar A, Kohli R. Our experience in reconstructing the burn neck contracture with free fl aps: Are free fl aps an optimum approach? Indian J Burns 2013;21:43-5.  Back to cited text no. 13
    
14.
Angrigiani C. Aesthetic microsurgical reconstruction of anterior neck burn deformities. Plast Reconstr Surg 1994;93:507-18.  Back to cited text no. 14
    
15.
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. 15
    
16.
Bianchi B, Ferri A, Ferrari S, Copelli C, Boni P, Ferri T, et al. The free anterolateral thigh musculocutaneous flap for head and neck reconstruction: One surgeon's experience in 92 cases. Microsurgery 2012;32:87-95.  Back to cited text no. 16
    


    Figures

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

  [Table 1]



 

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