|Year : 2015 | Volume
| Issue : 1 | Page : 32-36
Delayed reconstruction with free flap: answer to postelectric burn complex wounds: a 3-year experience
Aakash Sarangal, Pradeep Goil, Sunil Srivastava
Department of Plastic Surgery and Burns, SMS Medical College and Hospital, Jaipur, Rajasthan, India
|Date of Web Publication||11-Dec-2015|
Dr. Aakash Sarangal
Department of Plastic Surgery and Burns, SMS Medical College and Hospital, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
Background and Purpose : High voltage electric burn patients generally present with complex/composite defects requiring flap cover. Due to physiological factors as well as local factors involved in electric burns, there is high reluctance in performing free flaps in these burns patients. Our study comprised patients who were managed with free flap cover in last 3 years in the absence of local options. Comparison of acute/subacute and delayed (>6 weeks) reconstruction cases were done. Materials and Methods: It is a prospective study of data of 36 patients (32 male, 4 female) who required various free flap cover for the complex defects due to electric burns during January 2012 to December 2014 in Plastic Surgery Department, SMS Hospital, Jaipur. Eighteen patients (50%) underwent delayed reconstruction (>6 weeks) and equal number underwent surgery in acute/subacute settings. Data comprised the complications, causes of exploration and salvage rates in both groups that included various types of free flaps performed during the period. Results : Overall 5 flaps (13.8%) failed out of 36 flaps. Only one flap in delayed (5%) and 4 flaps in acute/subacute (22.2%) setting failed. Overall complication rate was 27.7% (10 patients). Conclusions : Considering low failure rate of 5% in delayed cases, as compared to 22.2% in acute/subacute cases, we propose free flap cover in a delayed manner in post electric contact burn complex defects as a better choice.
Keywords: Acute/subacute and delayed reconstruction, electric burn
|How to cite this article:|
Sarangal A, Goil P, Srivastava S. Delayed reconstruction with free flap: answer to postelectric burn complex wounds: a 3-year experience. Indian J Burns 2015;23:32-6
|How to cite this URL:|
Sarangal A, Goil P, Srivastava S. Delayed reconstruction with free flap: answer to postelectric burn complex wounds: a 3-year experience. Indian J Burns [serial online] 2015 [cited 2019 Aug 22];23:32-6. Available from: http://www.ijburns.com/text.asp?2015/23/1/32/171646
| Introduction|| |
Electric contact burn injury requires special attention among all the emergency patients because of the associated high morbidity and mortality rates. Although these occur in lesser number than flame burns cause long standing morbidities in variable manner. Damage occurs by heat produced in tissues as well as cell membrane disruption by passing an electric current through the tissues. The variable spectrum of wounds in these patients occurs because damage itself depends on number of factors such as the type of current, the resistance of tissues, voltage of current, the duration of the contact, pathway taken by current and the individual susceptibility.  The higher the water content of the tissue more is the damage because of the better conduction of electric current through them. Devitalization of the tissue occurs because of the thrombosis of vessels of the involved tissue. , Damage occurs more in distal than proximal regions in high voltage injuries (>1000 v). Some patients experience extensive damage to tissue creating deficiencies in the region of head and neck, upper and lower limbs. It is not an easy task to address these complex wounds created in these regions because of lack of surrounding normal scar less supple tissue thus cutting off the option of local tissue flaps. Free flap cover in these complex wounds is the only rescue option. Although with growing experience in free flaps, the failure rates have drastically decreased they remain to be on the higher side in cases of burn injury. In our study, we have studied free flap cover cases in burn complex defects over 3 years period and looked for the answer to better outcomes in these patients.
| Materials and Methods|| |
Prospective study was conducted in Department of Plastic Surgery and Burns, SMS Medical College and Hospital, Jaipur over a period of 3 years from January 2012 to December 2014. Data of the patients operated for complex wounds in electric contact burn patients with free flap cover was collected and observed. Overall 36 patients were operated during this period in which 32 patients were male and 4 patients were female. Average age of patients was 34.4 years. Half (n = 18) of the patients were operated in acute settings i.e., within 1 week and subacute period 2 nd to 6 th week while another half of patients were operated in delayed settings i.e., after 6 weeks. Reconstruction with fasciocutaneous flaps was preferred method in upper limb and facial defects. Patients covered in delayed settings either had undergone skin grafting or local flaps earlier which had resulted in variable success. Some patients did not have any graft take or had local flap failure. Some patients who did have some graft take had reduced tissue area to be covered or had only unstable area in functional important places such as wrist, perineum, lips, etc.
Preoperative computed tomography angiography of the concerned part of body were done in each case to look for the status of the vessels available, their wall status, any contrast leaks, abrupt cut offs in continuity. Decisions of types of free flaps were based on the length of the pedicle required for anastomosis with vessels away from trauma zone, requirement of the tissue type and size of the defect. In acute/subacute settings number and type of free flap covers for various regions are as follows: 4 for lower limbs (3 lattismus dorsi muscle [LD] free flap, 1 anterolateral thigh [ALT] free flap), 4 for upper limb (1 LD, 3 radial artery forearm free flap [RAFFF]), 6 for face and neck region (4 RAFFF, 1 parascapular [PS], 1 ALT) and 4 for scalp region (1 ALT, 3 RAFFF). In cases of delayed reconstruction; 8 for lower limb (3 RAFFF, 3 LD, 2 ALT), 4 for upper limb (2 RAFFF, 1 LD, 1 osteocutaneous free fibula flap [OCFFF]), 2 for face (2 RAFFF), 3 for penile reconstruction (3 RAFFF), 1 for vascularized urethra reconstruction by free dorsalis pedis artery free flap. In postoperative course, a total of 10 patients developed complications, and all of them were explored (27.7%). In these only 2 were of the delayed reconstruction and rest 8 were done in acute settings. Of 8 acute cases, only 3 could be salvaged and 5 flaps failed. In delayed cases, one out of 2 was salvaged. Re-explored cases had vein blockage in 6 and artery block in 2 cases. Of the five failed free flaps; 4 were because of the vein and one due to artery block. Thus, overall total failure rate was 13.8%. Only 5% and significant 22.2% was failure rate among free flap reconstruction done in delayed and acute/subacute settings, respectively. As the sample size of the cases in our study is small (18 in each group), the statistical study does not show a significant difference in both groups using Fischer test (P = 0.104) [Table 1], [Table 2], [Table 3]. Photographs of some of delayed reconstruction cases can be cited in [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5].
|Figure 1: (a) Free osseocutaneous free fibula flap in patient with forearm defact with radial bone loss. (b) Donor site in same patient|
Click here to view
|Figure 2: (a) Postelectric burn defect in which patient underwent split skin graft in first stage. (b) Lattismus dorsi flap cover given in delayed stage|
Click here to view
|Figure 3: (a) Postelectric burn defect of nose, upper lip. (b) Reconstruction with radial artery forearm free flap done in subacute setting|
Click here to view
|Figure 4: (a) Postelectric burn facial defect in patient. (b) Split skin graft applied in acute phase. (c) Radial artery forearm free flap done and eye lid reconstruction after 6 months|
Click here to view
|Figure 5: (a) Patient with post electric burn penile necrosis. (b) Delayed reconstruction with radial artery forearm free flap|
Click here to view
|Table 1: Types of flaps done delayed and subacute cover according to site of defect|
Click here to view
|Table 2: Types of complication in delayed and subacute group and number of salvaged flaps|
Click here to view
| Results|| |
In delayed group, one free LD flap cover for lower limb defect developed venous block and one RAFFF done for penile reconstruction developed arterial block. RAFFF could not be salvaged accounting for one flap failure in this group. Whereas in acute/subacute setting group, more flaps developed complications that included 6 venous blockage and 2 arterial blockages. One free LD for lower limb, 1 free ALT for scalp, 2 RAFFF for upper limb, 1 RAFFF for face, 1 RAFFF for scalp defects developed venous blockage. Out of these only two were salvaged despite meticulous exploration and redoing the anastmosis. One ALT done for lower limb and 1 RAFFF for upper limb defect developed arterial blockage in which alt flap was salvaged after exploration. Salvage rates were less in flaps developing venous blockage as compared to arterial blockage.
Besides flap failure complications included partial donor site graft loss (3 cases), partial margin loss of <1 cm of flap (2 cases) which were managed by conservative management. No formal long-term functional output follow-up of cases was done in our study as our main focus was regarding the timing of free flaps in electric burn cases. But the outcomes during follow-up in outpatient department in these cases have been satisfactory and encouraging.
| Discussion|| |
Initially, there was hesitation in doing free flap reconstruction in burn patients. First study concerning free flaps in burns was published by Sharzer et al.  and Harii et al. in 1975.  Initially microsurgery was used for secondary burn reconstruction that gradually has progressed in acute cases. , Despite that only <2% cases are managed with free flaps even in good burn management centers. , Primary aim for performing a free flap in acute cases is to reduce infection and early wound as well as salvaging limb in case of exposure of vital structure. Secondary or delayed reconstruction are generally carried after wound healing to improve functionality and aesthetics.
In our study, besides cases where salvaging limb or cover for the vital structure was an emergency, we had used modality to reduce the wound burden by applying vacuum-assisted closure (VAC) therapy or initially covering it with a split skin graft. Each case was selected according to individual need. We never used delayed reconstruction for exposed nerve, tendon without periosteum, vessel in subacute cases. These were treated as the acute case. We did grafting in cases of large raw areas involved in defects, tendons with intact paratenon, bone with intact periosteum. Usefulness of VAC was handy in cases of discharging wounds, for decreasing the size of the large wound, temporarily covering exposed bones with granulation tissue and skin grafts. Later on, delayed reconstruction was performed in such cases. In this way, we were able to reduce the infection, inflammation in the wound as well as the overall area of the wound was also reduced. Thus requirement of large flap covers in the extensive wound was also decreased, indirectly favoring flap survival.
Safety of microsurgical procedures in burn remains controversial. Damage to endothelium and media, vascular occlusion, thrombosis, arteritis, aneurysms, decreased nutrient vessels are the various abnormalities in vessels noticed after electric burns. , Despite this vascular anastomosis can be performed in region remote to necrosis. The reliable indicator for patency and the useful vessel is the intraoperative inspection under microscope.  The vessel should have normal elasticity, good bleeding, and intact endothelium. 
Site and timing of flaps influence the decision of the type of flap to be used in these defects. There has been general reluctance to carry out early free flap tissue transfer because of the concept of progressive tissue necrosis following electric burn.  In many studies, performing flaps within 5 days of burn had least failures, between 5 and 21 days there were higher failure rates that further decreased in 3 weeks after injury. ,, Only limiting factor in acute is the physiological instability in these patients. When functionally important structures such as nerve, vessels were exposed early flap was done and preferably a muscle flap was applied where wound infection was present. Larger areas are dealt with free LD flap whereas the face, scalp defects were preferentially covered with fasciocutaneous flap (RAFFF, ALT, PS). Only limitation in fasciocutaneous flaps is their higher susceptibility to infection because of their inferior vascular plexus.  Other studies have shown that after radical debridement fasciocutaneous flaps are a success even for covering bones. 
In our study, the foot and ankle region in lower limb; hand dorsum, wrist and elbow in upper limb; lip and periorbital region in the face; a penile region in perineum were the most common recipient sites requiring cover for the defects. Flaps like RAFFF was most commonly performed in reconstruction as it gave good pliable fasciocutaneous cover over joints in extremities as well as thin durable and esthetically better cover for facial defects. Moreover, it is easy to perform and has reliable anatomy. Free LD muscle cover was used in limb defects where cavity was created after debridement or where high chances of infection were suspected. One OCFFF was done in a delayed setting where forearm had a large segment of radial bone loss after debridement. Overall failure rate was 13.8% that are in tune with rates in other studies. 
Karabekmez et al.  conducted microvascular free flaps in early and late periods and found that most complications occurred between 12 and 19 day and no failure in delayed reconstruction. Their study also did not have statistically significant difference between early and delayed reconstruction regarding flap failure rates as in our case because of small sample size. They had flap survival rate of 69%. Our study had overall lower failure rates but was in agreement with the significant failure between 1 and 6 weeks. Herter et al. suggested that radical debridement and free flap cover within 24 h as the golden rule in his study. We also favor flaps in acute phases or otherwise delayed interventions.  However as patients do present late and the patient is thus not physiologically stable in the acute stage, many a times early intervention is not feasible in the Indian scenario. This leaves surgeon with delayed reconstruction if possible as better option in view of lesser failure. Baumeister et al.  showed that delayed reconstruction had lower failure rates.  Our study had almost similar failure rates as in this large study and it also shared our view of better results in delayed reconstruction.
Our study had significantly more failure (22.2%) when flaps were done within 6 weeks (acute/subacute) cases whereas only 5% cases failed in delayed settings (after 6 weeks). Failure was more because of vein blockage rather than an arterial problem. Poor salvage rates were also evident in flaps with venous blockages. Only 5% cases in delayed reconstruction with free flap group developed failure, which is less than half the rate of overall free flap failure rate reported in most standard burn institutes. Our study is unique in the manner that other studies do not talk about the alternative methods used while waiting for delayed reconstruction. We in our study have judiciously managed patients alternatively while waiting for a favorable period of delayed reconstruction.
| Conclusion|| |
As the failure rates were significantly lower in delayed reconstruction with free flap than done in acute settings as well as standard overall free flaps failure rates. Failure rates significantly increased if initial 5-7 days pass without intervention that is normally the case in our settings while patient condition stabilizes. We propose that performing a reconstructive free flap surgery is better when done at least after 6 weeks of electric burn, i.e., in delayed settings. It is wise to see off the 1 st to 6 th week wound stage in electric burns by alternative wound management methods to get better results in quality and less failures.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Department of Plastic Surgery, SMS Medical College.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Haddad SY. Electrical burn - A four-year study. Ann Burns Fire Disasters 2008;21:78-80.
Babik J, Sandor S. Electric burn injuries. Ann Burns Fire Disasters 1998;11:153-5.
Sharzer LA, O′Brien BM, Horton CE, Adamson JE, Mladick RA, Carraway JH, et al. Clinical applications of free flap transfer in the burn patient. J Trauma 1975;15:766-71.
Harii K, Ohmori K, Ohmori S. Utilization of free composite tissue transfer by microvascular anastomosis for the repair of burn deformities. Burns 1975;1:237.
Stallings JO, Ban JL, Pandeya NK, Abramsohn L, Bergman RS. Secondary burn reconstruction: recent advances with microvascular free flaps, regional flaps, and specialized grafts. Am Surg 1982;48:505-13.
Shen TY, Sun YH, Cao DX, Wang NZ. The use of free flaps in burn patients: experiences with 70 flaps in 65 patients. Plast Reconstr Surg 1988;81:352-7.
Platt AJ, McKiernan MV, McLean NR. Free tissue transfer in the management of burns. Burns 1996;22:474-6.
De Lorenzi F, van der Hulst R, Boeckx W. Free flaps in burn reconstruction. Burns 2001;27:603-12.
Jaffe RH, Willis D, Bachem A. The effect of electrical current on the arteries: A histological study. Arch Pathol 1928;6:244.
Zelt RG, Daniel RK, Ballard PA, Brissette Y, Heroux P. High-voltage electrical injury: chronic wound evolution. Plast Reconstr Surg 1988;82:1027-41.
Kuo ET. Experimental study of free flap transplantation after debridement in early stage of electric burn. Zhonghua Zheng Xing Shao Shang Wai Ke Za Zhi 1990;6:285-7, 318.
Chick LR, Lister GD, Sowder L. Early free-flap coverage of electrical and thermal burns. Plast Reconstr Surg 1992;89:1013-9.
Sauerbier M, Ofer N, Germann G, Baumeister S. Microvascular reconstruction in burn and electrical burn injuries of the severely traumatized upper extremity. Plast Reconstr Surg 2007;119:605-15.
Ofer N, Baumeister S, Megerle K, Germann G, Sauerbier M. Current concepts of microvascular reconstruction for limb salvage in electrical burn injuries. J Plast Reconstr Aesthet Surg 2007;60:724-30.
Baumeister S, Köller M, Dragu A, Germann G, Sauerbier M. Principles of microvascular reconstruction in burn and electrical burn injuries. Burns 2005;31:92-8.
Hallock GG. Flap selection. In: Wie FC, Mardini S, editors. Flaps and Reconstructive Surgery. Philadelphia: Saunders (W. B) Co., Ltd.; 2009. p. 17-29.
Pan CH, Chuang SS, Yang JY. Thirty-eight free fasciocutaneous flap transfers in acute burned-hand injuries. Burns 2007;33:230-5.
Karabekmez FE, Duymaz A, Tosun Z, Keskin M, Savaci N. Early and late term microsurgical free flap reconstruction and risks in high voltage electric injury. Acta Med Mediterr 2013;29:711-6.
Herter F, Ninkovic M, Ninkovic M. Rational flap selection and timing for coverage of complex upper extremity trauma. J Plast Reconstr Aesthet Surg 2007;60:760-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]