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Use of Free Thin Anterolateral Thigh Flaps Combined with Cervicoplasty for Reconstruction of Postburn Anterior Cervical Contractures
Abstract
Free thin anterolateral thigh flaps combined with cervicoplasty were used in a series of seven patients undergoing reconstruction for previous burn injury from September of 2000 to May of 2001 at Chang Gung Memorial Hospital. This method uses a suprafascial dissection technique to provide a thin flap to improve cervical contour. Neck contractures had resulted from flame burns in six patients and from a chemical burn in one patient. The mean age was 32.7 years (range, 22 to 45 years). The size of excised scar ranged from 10 x 2 cm to 26 x 5 cm (mean, 19.7 x 3.3 cm). The size of flaps ranged from 11 x 5 cm to 26 x 8 cm (mean, 21.3 x 6.5 cm). Average operative time was 6 hours. Average hospital stay was 10 days. All flaps survived, with one flap sustaining partial marginal loss. The donor site was closed primarily in five cases and by using a split-thickness skin graft in two cases. At a mean follow-up time of 5 months, the functional improvement was measured as follows: a mean increase in extension of 30 degrees (preoperatively, 95 degrees; postoperatively, 125 degrees), a mean increase in rotation of 18 degrees (preoperatively, 59 degrees; postoperatively, 77 degrees), and a mean increase in lateral flexion of 12.5 degrees (preoperatively, 26.5 degrees; postoperatively, 39 degrees). The average cervicomandibular angle was improved by 25 degrees (preoperatively, 145 degrees; postoperatively, 120 degrees). This series demonstrates that the use of free thin anterolateral thigh flaps combined with cervicoplasty provides a one-stage reconstruction with a thin, pliable flap that achieves good cervical contour with low donor-site morbidity.
... It has been described to vary up to 8 inches wide by 15 cm long with primary closure of the donor area 5 . In the presence of major defects, grafting from the donor area may become necessary 1,3,4,6 . Another possibility is pre-expansion of the donor area with skin expanders aimed to create primary synthesis of the area after flap removal 4 . ...
... In the presence of major defects, grafting from the donor area may become necessary 1,3,4,6 . Another possibility is pre-expansion of the donor area with skin expanders aimed to create primary synthesis of the area after flap removal 4 . ...
... The major advantages of this flap are the possibility of lifting the flap while resecting the tumor, long vascular pedicle, moderately thick to thin flap thickness, simpler implementation than other flaps based on the musculocutaneous perforator vessels, lower donor area morbidity, and the possibility of reconstructing complex defects [1][2][3][4] . ...
Introduction
The anterolateral thigh (ALT) flap has become an important tool in the microsurgical reconstruction of cutaneous and subcutaneous defects. Since the ALT flap can be up to 35 cm long, it can be used in both, esophageal reconstruction and cervical skin defects.
Case Report
Patient C. S. M., a 57-year-old woman, presented with squamous cell carcinoma of the larynx and underwent radiotherapy and a total laryngectomy followed by reconstruction by primary closure. However, she developed a postoperative complication due to the formation of a cervical esophagocutaneous fistula that required four surgical procedures to ensure permanent closure. The latter procedure consisted of the creation of a microsurgical ALT flap to correct the esophagocutaneous fistula, the subject of this report.
Conclusions
The microsurgical ALT flap has extensive applications in various fields based on the following characteristics: reliable vascularization, long and broad vascular pedicle (at least 8 cm long), an extensive and easily delimited flap region, the possibility of reducing the primary flap thickness to 3-5 mm without compromising its vascularization, the possibility of a simultaneously dual approach because of the distance between the donor and recipient site, and the possibility of primary closure without the need for skin grafting. The case report presented in this study emphasizes the possibility of the use of a microsurgical ALT sandwich flap to correct a high output esophagocutaneous fistula.
Keywords:
Reconstruction; Microsurgery; Fistula; Esophagus
... As a result of its great success, the ALT has become an increasingly [25] [26], [27] popular technique in Europe , . To achieve better cosmetic results, bulky aps can be thinned out during primary or in following [28], [29], [30] second procedure . Over the years the ALT ap has become the workhorse for reconstruction of skin and soft tissue defects and [27], [28], [29], [30], especially over the past decade, replacing many other aps [18] . ...
... To achieve better cosmetic results, bulky aps can be thinned out during primary or in following [28], [29], [30] second procedure . Over the years the ALT ap has become the workhorse for reconstruction of skin and soft tissue defects and [27], [28], [29], [30], especially over the past decade, replacing many other aps [18] . ...
Introduction: Free tissue transfer is warranted when local aps cannot be harvested outside the zone of injury or when soft tissue defects are extensive and are complicated by exposure of bone, tendon, vessel, nerves or implants. The free anterolateral thigh ap is one such option. It is a fasciocutaneous (FC) ap based on the septocutaneous or musculocutaneous perforators of the descending branch of the lateral circumex femoral artery. : This prospective study was conducted from June 2021 to December 2022. A total of 10 patien Materials And Methods ts were included in the study : Out of 10 patients, 6 were females and 4 were males. The maximum patients were in the age Results group of 41-60 years. Maximum patients had malignancy as the etiological factor. The ap was used for lower extremity defect reconstruction in 5 patients while for the rest it was done for upper extremity, scalp and abdominal defect reconstruction. The maximum length of the ap taken was 22cm and the maximum width taken was 18cm. The average pedicle length was 11cm. All required STSG coverage for closure of donor site. The mean duration of ap harvest was 2hrs 10min and the mean duration of surgery was 6hrs 52min. Flap congestion was seen in 3 patients which required re-exploration. Out of these, 2 aps had complete necrosis. The free anterolateral thigh ap is a workhorse ap for reconstruction of Conclusion: large complex defects. It is easy to harvest with relatively constant anatomy, offers long and large pedicle, and has minimal donor site morbidity.
... As a result of this series, our group has adopted a strategy similar to Tsai et al. [2], where the thigh is considered an ideal donor site with minimal donor site morbidity [18]. Therefore, when treating major burn of the head and neck, we spare this region from skin harvesting, if possible, in order to preserve it for eventual reconstructive needs [2] ( Figure 5). ...
... Even if several stages of revision may be needed to remove the excess bulk, the ALT flap remains our flap of choice for neck reconstruction. Attention must be paid to insetting of the flap and secondary defatting procedures to recreate a smooth contour [14,18]. Optimal results are obtained by minimizing the donor site morbidity while scar resurfacing is achieved, which can be challenging in the neck area mainly because of the large size of the area involved and the damage to free-flap donor tissue after major burn injury. ...
Background: Recent advances in burn care have significantly improved the survival rate of patients with extensive burn injuries, placing greater emphasis on reconstruction to improve the long-term outcomes of scar deformities. Anterior and lateral neck contractures are common after burn injuries; they limit range of motion, complicate airway management and create significant cosmetic deformities. Traditional methods have been used to release contractures and improve function. However, they are subject to variable results, residual neck tightness, recurrence and suboptimal cosmetic appearance. Microvascular free tissue transfer is a more technically challenging and time-consuming method, but it offers the potential to overcome the long-term limitations of simpler options. In this paper, we present our experience with microvascular free flaps for the release of burn scar contractures of the neck as a potential high-quality permanent solution. Methods: Over a 10-year period, nine free flaps were performed on burn patients with total body surface area (TBSA) burns between 20 and 70%, who developed moderate to severe neck contractures. Four anterolateral thigh (ALT) flaps, four radial forearm free flaps (RFFFs) and one ulnar forearm flap were used to release neck contractures. Results: All nine flaps were completed successfully with significant improvement in the neck’s range of motion. Good aesthetic results were achieved with smooth contour and thin coverage. Overall, the patients were satisfied. However, five out of nine cases required at least one secondary procedure for flap defatting to reach optimal results. Conclusion: Post-burn scar contractures of the cervical region compromise the cosmetic appearance and airway security of recovering burn patients, imposing a significant impact on their psychological and functional quality of life. Consequently, cervical contractures can be prioritized when planning reconstruction for burn patients. Free flaps can be considered an important and reliable method of reconstruction for neck contracture deformity following burn injuries.
... [3][4][5] The use of tissue expanders allow the surgeon to repair the extensively damaged areas as well the donor site morbidity usually associated with local or free flaps. 5,6 The study was undertaken to evaluate the scars and defects over the face and neck and to analyze the results of reconstruction by various sizes and volumes of rectangular tissue expanders, their outcomes and their complications. Hudson in 2003 gave forth a simple analogy to compare the expanded tissue to a (threedimensional) cardboard rectangular box, which was to be made completely flat. ...
... Preservation of the vascular pedicle was of paramount importance in the planning of transposition flaps, but they tend to resurface only narrow defects. 6 Advancement flaps, which were used most commonly, were random flaps and require expander insertion immediately adjacent to the scar. ...
Background: The visibility, vulnerability and social stigmata of facial scars whether by burn, nevi or trauma can be compelling for the patient as well as challenging for the surgeon. Restoration to normal form and aesthetics require tissue replacement which has good colour and texture match and produce minimal visible scarring. Although many other options are available for a given defect, tissue expansion offers the best alternative which meets almost all the criteria of an ideal procedure.Methods: Among 92 patients with deformities over various facial subunits were operated and expanders 50 ml to 300 ml inserted subcutaneously adjacent to the scar. Prior planning, accurate measurement and choice of ideal expander is extremely important. A precise and practical method of calculation for determination of amount and duration of expander was used. Any secondary deformity to adjoining vital structures was avoided.Results: Results were meticulously and critically analyzed. Different shapes, dimensions and volume of expanders were used depending on the anatomical site which was to be expanded. A total of 118 expanders were inserted in 92 patients. The average volume of tissue expanders used was 170.33 ml. Majority of the expanders used had volume of 200 ml (62.71%). Post-expansion volume was 240.67 ml and the over expansion done was 41.3% over the pre-expansion volume of 170.33 ml. Surgical outcome and cosmesis was assessed by the patient’s perspective and was considered fair by 57.61% patients.Conclusions: The study underlines the clinical application, reasons for overexpansion as well as shortcomings and complications of tissue expansion.
... As a result of its great success, the ALT has become an increasingly popular technique in Europe [4], [5], [6]. To achieve better cosmetic results, bulky flaps can be thinned out during primary or in following second procedure [7], [8], [9]. Over the years the ALT flap has become the workhorse for reconstruction of skin and soft tissue defects and especially over the past decade, replacing many other flaps [6], [7], [8], [9], [10]. ...
... To achieve better cosmetic results, bulky flaps can be thinned out during primary or in following second procedure [7], [8], [9]. Over the years the ALT flap has become the workhorse for reconstruction of skin and soft tissue defects and especially over the past decade, replacing many other flaps [6], [7], [8], [9], [10]. ...
Introduction:
Limb-threatening wounds of the upper extremity pose a challenge to the micro vascular surgeon. The aim of this study is to analyze the outcome of free anterolateral thigh flaps for upper extremity soft tissue reconstruction.
Methods:
A retrospective review of patients undergoing this procedure from 2005 to 2012 was performed. Case note analysis was performed to determine demographic and perioperative factors, and complications and outcomes.
Results:
Thirty-two patients with a mean age of 53 years (9-84 yrs) underwent upper extremity reconstruction with an anterolateral thigh (ALT) flap. There were 24 (75%) males and 8 (25%) females. The etiology of the soft tissue defects was: infection (44.6%); post-tumor ablation (40%); and trauma (15.6%). The defect site was most commonly in the forearm (53.1%), followed by the elbow (12.5 %), arm (12.5%) and hand (21.9%). The mean timing of free flap transfer was 6.8 days after admission to our institution (minimum 1 days, maximum 9 days). Mean operative time of surgery was 4 h 39 min (minimum 3 h 2 min, maximum 6 h 20 min). The mean hospitalization was 24.8 days (minimum 5, maximum 85). The ALT success rate was at 92.3%. Partial flap necrosis was documented in five cases (15.6%). Complete flap loss occurred in two post-traumatic cases who both lost their limbs.
Discussion:
This flap, in the hands of experienced surgeons, provides reliable coverage of upper extremity defects.
... This impairs movement, especially abduction and causes difficulty in walking, sitting, squatting, micturation, defecation, and also sexual activity. [15] In India, squatting is necessary posture for micturation and defecation and is often debilitating especially to rural patients. Another predicament is recurrent ulcerations as perineal and groin burn contractures are not in steady location. ...
Background: Groin and perineal burn contracture is a rare postburn sequel. Such postburn contractures causes distressing symptoms to the patients and in the management of these contractures, both functional and cosmetic appearance should be the primary concern. Material and Methods: This is prospective and descriptive study conducted in the Department of Plastic Surgery at Tertiary Care Teaching Hospital over a period of 1 Year. First dressing was seen on third or fourth postoperative day and percentage of graft take/loss was noted. Complications, if any, were recorded. Indwelling urinary catheter drainage was instituted for 3 to 4 days postoperatively. Once the graft stabilized, patients were discharged and advised to wear compression garments. Results: In our study, 77.1% of the patients, post burn contractures of the groin and perineum were because of Open chulla. Other less common causes were hot water (14.3%) and flame burn (8.6%). Majority of the patients were brought with complaints of difficulty in squatting (80.0%) followed by limitation of movements of hip joints (71.4%) and (44.3%) impairment of walking. In our series of 70 patients two types of operative procedures were performed: (1) release of contracture with split thickness skin grafting; (2) release of contracture and closure by multiple Zplasties. Moreover, 30 (42.9%) patients having bilateral groin contractures underwent release of contracture with split thickness skin grafting. 29 (41.4%) patients underwent release of unilateral groin contracture with split thickness skin grafting and 4 (5.7%) patients underwent release of unilateral groin contracture and closure by multiple Zplasties.Conclusion: To conclude, recuperation from perineal burns, both in acute period and chronic phase in case contracture occurs, is a difficult challenge physically and mentally. The agony that a burn patientendures during treatment is evident even to an onlooker.
... After 1-8 years of follow-up, the patients were satisfied with the functional and esthetic results. The finger's range of motion (ROM) ranges from 20-80° at the MCP joint, 25-85° at the PIP joint, and 20-50° at the [20][21][22]. The process of safely performing flap thinning has been studied by several centers worldwide, but it remains unresolved [10,[23][24][25]. ...
Background
Hand defects, especially complex defects involving tendon or bone exposure, are challenging to reconstruct. With the limited size and options of local flaps, the free-thinned anterolateral thigh (ALT) flap remains an excellent choice. However, many authors have described thinning procedures differently, leading to inconsistent outcomes. We present our clinical experience of immediate thinning ALT flaps depending on the anatomical structure of the perforator.
Materials and methods
Between 2007 and 2021, we used a free ALT flap in 42 cases to cover hand defects after crushing and friction injuries, burning and burn scars, and animal bite wounds. There were 38 males and 4 females; the mean patient age was 31.2 years. Thinning procedure was performed in all flaps. The primary and microdissected thinning procedure was performed for 35 single flaps and 7 chimeric flaps, including 14 flaps for the fingers (29%), 4 flaps for the palm (8%), 12 flaps for the hand dorsum (24%), and 19 flaps for combined areas (39%).
Results
The mean flap thickness was 18.6 (11–30) mm before defatting and 6.0 (3–12) mm after defatting, an approximately 65% reduction. The retained fascia island around the perforator was ≤ 1 cm in 73.5% of cases, 2–3 cm in 18.4%, and the remaining 8.1% had a fascia size ≥ 4 cm. The incidence of a well-survive flap was 93.9%. Three cases had partial to total necrosis. None of the patients required a secondary defatting procedure.
Conclusion
Every case has a perforator pattern after running through the fascia, which allows surgeons to choose the appropriate thinning method. Perforators that run parallel to the superficial fascia are not good candidates for thinning. Instead, the thinning process should be performed with more perpendicular perforators.
Level of evidence: Level IV, therapeutic study
... ALT has become the workhorse over the years for skin ,soft tissue defects replacing many other flaps. 13,14,15,16 Similarly, scalp being an aesthetic & functional body unit protecting the cranium,extensive soft tissue defects of scalp present a reconstructive challenge. ...
Introduction Extensive soft tissue defects pose a great deal of challenge to the reconstructive surgeon.The aim of this study is to analyse the outcome of free anterolateral thigh(ALT) flaps for soft tissue reconstruction of defects following tumor excision,trauma and post burn. Methods : A retrospective review of 19 patients undergoing ALT Flaps for various reasons from Dec 2018 to Jan 2021 was performed to determine perioperative factors, demographic profile , complications and outcomes. Results : The mean age the study population was 47.2 years. The male to female ratio was 2.16:1 (68.5 % male, 31.5% females). The etiology of soft tissue defect was post- tumor resection – 47.36%, truam-36.8%, post burn reconstruction- 10.5% . The defect sites were most commonly leg-31.5%, upper extremity- 26.3%, buccal mucosa- 15.7%, scalp-10.5%, tongue- 10.5%,breast- 5.2%.Flaps were harvested from right thigh in 52% of cases and left thigh in 58% of the cases. Donor site was closed primarily in 11 cases (57.8%), SSG coverage was done for 8 cases ( 42.8%). The minimum operating time was 205 minutes and maximum was 435 minutes, with an average time of …………..The minimum hospital stay post op was 12 days , maximum being 45 days.
... Microvascular free flaps are also used in reconstruction of joint contractures and HTS when injured or deficient regional tissue precludes local flaps, skin grafts, or tissue expansion, where success rates for free flap transfer in burn reconstruction range from 78% to 96% [59] . Excessive free flap bulk is averted by the use of thinner fasciocutaneous flaps such as the anterolateral thigh [60] or parascapular [61] flaps in the head and neck region [62] and thin fascial flaps such as the temporoparietal fascial or serratus fascial flaps in the dorsum of the hand, which offer better color, thickness, and texture match [63] . ...
Survival from burn injury has improved considerably over the past two decades such that the quality of life of the victim of thermal injuries has become a major concern. Severe proliferative scarring or hypertrophic scarring (HTS) is an all too frequent complication of burn wound healing that severely compromises quality of life for surviving burn victims. Prevention of such scarring in burn patients involves better understanding of the pathophysiology of scar formation, development of newer methods for determining depth of burn injury and earlier and advanced surgical interventions. Many established and evolving novel treatments for HTS in patients after thermal injury exist and include antifibrotic pharmaceuticals and cellular-based therapies as reviewed herein.
... Neck contracture characterized by a limited range of cervical motion may result in severe impairment of function and deterioration of esthetic. Cervical burn associated with lower facial and lower lip burns have impact on the face and chest, causing lip ectropion, micrognathia, and mandibular retrusion (12,13). ...
Background: Deformities of burn scars in chin and upper neck are a tragedy for patients and pose a great challenge to plastic surgeons due to limited available methods for reconstruction of three-dimensional appearance. In this paper we present a new technique for correction of cervicomental angle with a dermal fat flap.
Methods: Fourteen patients ages from 18 to 24 years old with extensive neck deformities were enrolled to the study. During the operation, first we deepithelialized a triangular scar area in the upper neck, then created a dermal fat flap and flip it up to the chin, restoring the chin shape and volume, after that for subsequent reconstruction of cervicomental angle, after releasing skin from lateral sides of the triangle defect, we approximated the AB and AC line to the upper edge of the defect by V-Y advancement. The remaining defect covered with a full-thickness skin graft.
Result: In all cases, the chins were reshaped with a dermal fat flap. The mean cervicomental angle was 144 + 14.6° preoperatively that was reduced to 108.9+6.15° postoperatively. The neck and chin preserved with better contours.
Conclusion: This is a new technique which has never been described before in the literature and it is innovative compared to the traditional techniques. Good cosmetic outcomes make this technique preferable for all burn neck deformity with obtunded cervicomental angle.
Key word: burns scar, neck, flaps.
... The grades define the functional impairment and help to compare the improvement after surgery. 11 We employed the supraclavicular artery flap among half of our patients. This thin, hairless and pliable flap provides an ideal color-texture match to that of the facial skin. ...
Background:
Burn in developing countries still has high burden of inadequately managed severe burns. This study compared supraclavicular artery flap and skin graft in managing neck post-burn contractures.
Methods:
In National Institute of Rehabilitation Medicine and Pakistan Institute of Medical Sciences, Islamabad, Pakistan, 30 patients with neck post-burn contractures were enrolled. Half of patients randomly underwent supraclavicular artery flap and half received skin graft. The outcome measures including initial improvement in neck extension, patient's satisfaction with color-texture-match and recurrent contracture formation rate were assessed.
Results:
Among patients, 80% were female and 20% were male. Preoperatively, each group had post-burn contractures of grade II among 26.66% of patients, grade III among 60% and grade III among 13.3%. Postoperatively after three months in the two groups, 86.66% improved to grade I and 13.3% improved to grade II. Patient's satisfaction with color-texture was 84.66% in supraclavicular artery flap group, whereas it was 42.66% for skin graft group. Complications were hypertrophic scar at donor site (13%) and flap tip necrosis (6.66%) in supraclavicular artery flap group. In skin graft group, partial skin graft loss was noticed among 33% of patients and delayed healing of donor site among 20%. The recurrent contracture formation rate at one year was 73.33% in skin graft group, whereas there was no case of recurrent contracture in supraclavicular artery flap group.
Conclusion:
Supraclavicular artery flap was superior to skin graft in managing post-burn neck contractures. It provided better color-texture match and was associated with no recurrence of contracture formation.
... Free anterolateral thigh flaps are reliable and large flaps with long pedicles. Yang et al. [13] reported that a good cervical contour was obtained by this flap. However, there can be a significant colour and contour mismatch. ...
The deep inferior epigastric artery perforator (DIEP) flap has been widely used for approximately 30 years as an effective method for breast reconstruction, defect repair, and perineal reconstruction. However, few literatures have reported on thinned pedicle DIEP flaps for scrotal reconstruction. The present study presents a series of reconstruction of the scrotum using thinned pedicle DIEP flaps. Five patients with large scrotal skin defects were admitted to our hospital from October 2010 to December 2015. Among these patients, three patients had testes and spermatic cord exposure after accidental injury, while two patients had testes exposure after machine extrusion. All of these patients were repaired using thinned pedicle DIEP flaps. During the 12–24-month follow up, one patient experienced a bulky flap, and a subsequent thinned flap was successfully made. The other four flaps were successfully transplanted with good esthetic and functional results. All donor sites were primarily closed; there was no functional disturbance, such as dysuria and abdominal hernia, and the sensation of these flaps partially recovered after 6 months. The thinned pedicle DIEP flap is robust, reliable, and resilient, and offers good-quality skin cover and cushion to the testes. This flap can be considered a good choice for scrotal reconstruction.
... Preoperatively, Doppler ultrasound [5] and computed tomography angiography were performed for evaluation of suitable perforators arising from the lateral circumflex femoral system. Intraoperatively, the patient is positioned supine with the neck in hyperextension. ...
Anterior neck burns represent a major reconstructive challenge due to severe sequalae including restriction in movement and poor aesthetic outcomes. Common treatment options include skin grafting with/without dermal matrices, and loco-regional and distant free flap transfers with/without prior tissue expansion. Such variation in technique is largely influenced by the extent of burn injury requiring resurfacing. In order to optimize like-for-like reconstruction of the anterior neck, use of wide, thin and long flaps such as the anterolateral thigh (ALT) perforator flap have been reported with promising results. Of note, some patients have a tendency towards severe scar contractures, which may be contributed by the greater extent of inflammation during wound healing. We report our experience at 4 years’ follow-up after secondary reconstruction of severe, anterior neck burn contractures in two patients by harvesting the ALT flap with a butterfly design. This technique provides adequate wound resurfacing of the burned neck and surrounding areas, and provides good neck extensibility by addressing both anterior and lateral aspects of the scar defect simultaneously. Such a flap design reduces tension on wound edges and thus, the risk of contracture recurrence in what remains a particularly challenging type of burn reconstruction.
... [52] Thin, free-flap options from the anterolateral thigh, scapular/parascapular areas, and radial forearm are most useful in burn reconstruction and may also be used in axilla. [53,54] SPLINTING FOR AXILLARY CONTRACTURES ...
Many epidemiological studies have revealed the incidence of axillary contractures next only to elbow contractures as sequelae to burn injury. Even if it may be possible to prevent adduction contracture of the axilla through early splinting and range of motion exercises that counteract the position of comfort, it continues to pose a frequent problem to burn surgeons. In the increasing degree of severity, axillary contractures may involve one or both axillary folds and also involve the hair-bearing dome of the axilla. Unless severe functional disability is present, we recommend a minimum 6-month wait following wound healing to allow for scar maturation to achieve better results. In milder presentations, it may be possible to perform Z-plasties, Y–V plasties, or many other local flaps on isolated axillary bands, with the caveat that if the contractile bands are in the midst of scarring, such linear contractures may only be effectively released and resurfaced with skin grafts. While the innovative use of local skin flaps must be encouraged, we recommend a low threshold of using acceptable thickness skin grafts for coverage. Controversy exists on the best technique for axillary resurfacing in severe cases of axillary involvement. While it is relatively simple and expeditious to release the contracture and cover the extensive defect with skin grafts, it requires meticulous postoperative regimen of splinting and physiotherapy. In selected cases, uninvolved adjacent scapular and back areas allow for many fasciocutaneous and myocutaneous flaps for durable long-term results. Free flaps, traditionally less popular in this region, may be an alternative option if areas adjacent to axilla are also involved.
... Burn scar contracture is a common problem in healing burn wounds of the neck. It can cause both pain and dysfunction if not treated adequately [1]. The treatment of such wounds often involves a combination of surgery and splinting therapy [2]. ...
... 11,12 In extensive defects, robust cover of exposed deep structures with effective contouring of the submental and cervical subunits has been achieved with thinned fasciocutaneous free flaps such as anterolateral thigh or thoracodorsal artery perforator flaps. 13 However, such techniques are complex, require microvascular surgical expertise, and leave a donor site usually requiring secondary split-thickness skin graft reconstruction. Interestingly, there is no description of the use of a dermal substitute for reconstruction of a cervical soft-tissue defect following necrotizing fasciitis. ...
Introduction: Although we have previously described the use of a novel polyurethane biodegradable dermal substitute in the reconstruction of 20 free flap donor sites, and extensive cutaneous defects, including a large area of exposed calvarium secondary to burn injury, our experience with this material now extends to 35 free flap donor site reconstructions and 13 major or complex burns. Methods: The polyurethane material (NovoSorb BTM; PolyNovo Biomaterials Pty Ltd, Port Melbourne, Victoria, Australia) was recently employed in another complex wound scenario, implanted into a large anterior cervical cutaneous and soft-tissue defect remaining after serial radical debridement for necrotizing fasciitis. Results: Implantation, integration, delamination, and split-skin graft application proceeded without complication, mirroring our previous experience in other wounds (including major burns). The result was a robust, supple, mobile, and well-contoured reconstruction over the deep tissues of the neck. The functional and cosmetic outcomes exceeded all expectation. Discussion: The wound environment created after necrotizing fasciitis infection and debridement is austere. In this particular case, reconstructive options were limited to large free flap repair, skin graft alone, and skin graft augmented by commercially available collagen/glycosaminoglycan dermal matrix. Each option was discarded for various reasons. Our previous success with NovoSorb BTM, developed at our center, prompted its use following regulatory approval. The patient was physiologically stronger after the temporization afforded by the biodegradable temporizing matrix over 4 weeks of integration. Conclusion: This is the first description of the successful use of an entirely synthetic biodegradable dermal substitute for the reconstruction of both necrotizing fasciitis and an anterior cervical defect.
... The defect should be replaced with the donor tissues matching texture, color, and pliability. Skin flaps including free flaps meet these criteria to replace scar tissues and repair the resulting defect post release, providing superior functional outcomes [8][9][10]. Indeed, the gold standard for burn scar reconstruction is to use adjacent skin flaps to minimize differences in skin characteristics. ...
Burn contractures produce restrictions in motion and unacceptable aesthetic results, frequently with persistent wounds. Proper planning and tissue selection are essential to minimize donor site morbidity optimizing outcomes. The principle of burn reconstructive surgery requires that the defects after release should be replaced with donor tissues which have matching texture and color as well as enough pliability. Autologous skin grafting or flap surgeries meet these criteria to replace scar tissues and resurface the subsequent to post-released scar defects. Despite the benefits, the use of flaps is often limited in burn patients for many reasons. If a surgeon intends to release completely and reconstruct in one-stage operation, a large defect may result in large donor site morbidity, necessitating flap surgery including free flap surgery. A lot of different methods and procedures are available for resurfacing the defects, and these are reviewed. In this article, algorithms for the release of burn contractures and reconstructive methods are presented. These treatment algorithms should aid in achieving significant improvement in both joint motions and aesthetic deformities.
... Free fascial flaps provide thin, pliable and mobile reconstructive substrate with a reliable vascularity and potential for sensibility. [10] They are particularly useful for hand, neck and scalp defects. Commonly used flaps are tensor fascia latae, radial forearm, temporoparaietal flap and lateral arm flap. ...
... Extensive defects of the tongue, which result after tumor resections, represent a difficult problem for the plastic surgeon, especially if he tries to cover the defect in a single operator time and if he wants the resection to be made in the healthy tissue in order to avoid local recurrence [1][2][3][4][5]. Free flaps allow the one-stage reconstruction, and this is the main reason why the most complicated technique has become very used in head and neck surgery. ...
Background:
Successful tongue reconstruction after total glossectomy for advanced tongue or base of tongue cancer should restore swallowing, speech function, and cosmesis.
Methods:
The anterior lateral thigh flap sensitive myocutaneous (ALTF) with vastus lateralis muscle was used to reconstruct the oral defect in a patient undergoing total glossectomy with laryngeal preservation for T4 tongue cancer.
Results:
Good functional outcomes, measured by independent feeding, speech and swallowing, were achieved.
Conclusions:
The anterolateral thigh myocutaneous flap for total tongue reconstruction creates a free neotongue tip with an adequate volume, producing acceptable swallowing function and cosmesis. The reconstruction with free flaps is a feasible method of restoring the functional outcomes in speech and deglutition among patients who undergo total glossectomy with laryngeal preservation.
... There are many advantages in reconstructing hemiglossectomy defects with the FRF flap: (1) easiness of harvest, (2) 2-team approach, (3) long pedicle, and (4) a thin and pliable skin paddle (15). However, it has some obvious disadvantages (16,17). The FRF flap requires sacrifice of the major artery of the forearm, the radial artery. ...
Background:
To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap.
Material and methods:
The clinicopathologic data of 46 tongue carcinoma cases hospitalized from December 2009 to April 2014 were obtained from Nangjing Stomatological Hospital, Medical School of Nanjing University. All the subjects were evaluated for the articulation and the swallowing function 3 months after the surgery.
Results:
Among these 46 patients, 12 patients underwent tongue reconstruction after hemiglossectomy with ALT flap; 34 patients underwent tongue reconstruction with FRF flap. The differences in the incidence of vascular crisis, the speech and the swallowing function between two groups were not significant (P﹥0.05).
Conclusions:
Thin ALT flap could be one of the ideal flaps for hemiglossectomy defect reconstruction with its versatility in design, long pedicle with a suitable vessel diameter, and the neglectable donor site morbidity.
... Because patients are often concerned about further scarring of the unburned area, preoperative communication with patients is important to balance the width of scar excision with the potential for primary closure of the donor site. Jui-Yung Yang et al. 20 have studied the utility of free thin anterlateral thigh flaps combined with cervicoplasty for the management of post-burn injury anterior cervical contractures with results comparable to our study. Free thin anterolateral thigh flaps offer a good option for reconstruction of postburn anterior cervical contractures after failure of other modalities and provide the potential for a one-stage reconstruction for correction of functional and aesthetic disability. ...
Neck contractures after burn injuries produce restrictions in motion and unacceptable aesthetic outcomes. Although different methods of reconstruction have been used in the treatment of this ailment, a limited and unsatisfactory outcome often results. Free thin anterolateral flaps have been found to be a good single stage option for reconstruction of post-burn contractures of the neck. In our study, 11 patients with post flame burn contractures of the neck underwent surgical release and coverage by a free thin anterolateral thigh flap. Patients were followed up for an average of five years and various aspects of functional and aesthetic rehabilitation were assessed. Our findings revealed that the free thin anterolateral flaps covered the defects over anterior and lateral aspects of the neck with good colour match and contour. Furthermore, none of the flaps had any significant early or delayed complications. Two cases had to be reoperated for partial loss of flaps and all patients were satisfied with functional and aesthetic outcomes. We therefore consider free thin anterolateral thigh flaps to provide a good single stage reconstruction for post-burn cervical contractures with good functional and aesthetic outcomes.
Background
Free tissue transfer is often considered a last resort in burn reconstruction due to its complexity and associated risks. A comprehensive review on free flap outcomes in delayed burn reconstruction is currently lacking. The study aimed to evaluate the available evidence on the failure and contracture recurrence rates in free flap delayed burn reconstruction.
Methods
A systematic review and meta-analysis was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The protocol was registered on PROSPERO (CRD42023404478). The following databases were accessed: Embase, PubMed, Web of Science, and Cochrane Library. The measured outcomes were free flap loss and contracture recurrence rate.
Results
Of the 1262 retrieved articles, 40 qualified for inclusion, reporting on 1026 free flaps performed in 928 patients. The mean age was 29.25 years [95% confidence interval (CI), 24.63–33.88]. Delayed burn reconstruction was performed at an average of 94.68 months [95% CI, − 9.34 to 198.70] after initial injury, with a follow-up period of 23.02 months [95% CI, 4.46–41.58]. Total flap loss rate was 3.80% [95% CI, 2.79–5.16] and partial flap loss rate was 5.95% [95% CI, 4.65–7.57]. Interestingly, burn contracture recurrence rate was 0.62% [95% CI, 0.20–1.90].
Conclusions
This systematic review provides a comprehensive evaluation of the free flap outcomes in delayed burn reconstruction. The flap loss rate was relatively low, given the complexity of the procedure and potential risks. Furthermore, burn contracture rate was found to be extremely low. This study demonstrates that free flaps are a safe and effective option for delayed burn reconstruction.
Burn contracture affects close to one-third of all burn patients, leading to significant functional impairment and costs. Effective prevention and treatment strategies are necessary to decrease morbidity and unnecessary costs. This scoping review aimed to summarize prevention and treatment strategies used for management of burn scar contractures published in the literature since 2000. A comprehensive PubMed review was performed in October 2022 to identify methods of burn contracture prevention and treatments. Non-English, duplicate, and unavailable articles were excluded. Data were extracted including publication year, techniques, and outcomes. A total of 327 publications met criteria for inclusion. Most articles were published in 2011 (n = 22). Treatment strategies were discussed in 82.9% of studies, prevention in 16.5%, and both in 0.6%. The most common areas discussed included the upper extremity (n = 127) and neck (n = 102). Flaps were the most frequently used method (n = 208), followed by autografts (n = 89). Most preventative therapies were still in early stages of development. Burn contracture management requires a highly individualized approach with many available reconstructive techniques available. Further research is needed to improve prevention techniques and decrease morbidity and cost to patients.
Background: The gold standard for burn scar reconstruction is to utilize adjacent skin flaps for the ease of operation and to match the skin characteristics. The objective of this study is to share our experiences using propeller flap cover for “postburn contracture of axilla (PBCA)” release reconstruction.
Materials and Methods: This 5-year retrospective observational study was undertaken in the Plastic Surgery Department of GMCH, Guwahati, from 2016 to 2020 with the data available after obtaining the Ethics Committee approval. The patient records and photographs were gathered from the Medical Records and the Plastic Surgery Department of GMCH, Guwahati, respectively. Patients treated with a propeller flap cover were scrutinized.
Results: The patients operated for PBCA were 36. There were 12 males and 14 females with a mean age of 21 years. Twelve patients with spared axillary dome skin underwent a central axis subcutaneous pedicle propeller flap. The flaps had dimensions of 8–12 cm in length and 6–9 cm in width. The pedicle was approximately 2–2.5 cm in diameter. The few complications seen included wound dehiscence and delayed wound healing, edge hypertrophy, band contractures, marginal necrosis, and pin cushioning. During follow-up, no recontractures were seen.
Conclusions: We conclude that central axis subcutaneous pedicle propeller flap is a simple and effective treatment for mild-to-moderate PBCA with spared axillary dome skin. These flaps provide durable soft tissue cover with enhanced flap survival, functional mobility, and esthetics.
Burns are a global public health problem accounting for an estimated 965,000 deaths annually. Facial burn incidences per 100,000 were 15.1 for emergency department visits, 1.3 for hospital admissions and 1.4 for burn center admissions. Minor burns comprise approximately 95% of burn injuries seen in Emergency Departments in the U.S. Assessment of a burned patient is divided into primary (rapid, systematic approach to identify and manage life- threatening conditions) and secondary survey (more thorough head- to- toe evaluation, size and depth of the burn). Once the patient has been deemed suitable for outpatient care, a series of measures are implemented in order to minimize further damage (removal of head covers, cooling of the burn etc.), relieve pain, prevent infection and promote healing/limit scarring. Primary assessment of patients with moderate and severe burns aims at quick identification and treatment of life-threatening conditions (possible inhalation injury, formation of edema and airway obstruction). Early intubation of patients with significant burns, inhalation injury and facial/neck burns before transfer has been emphasized. After establishment of an adequate airway, establishment of i.v.lines for fluid resuscitation is necessary. Fluid replacement is monitored by checking on diuresis, lactate, base deficit and central venous saturation. Inhalation injury significantly increases morbidity and mortality. Fiber optic bronchoscopy continues to be the standard technique to assess the presence and severity of inhalation injury. Targeted therapies for inhalation injury are limited. Supportive respiratory care (pulmonary toilet, mechanical ventilation) is one of the fundamental tenets. Medical adjuncts line bronchodilators, mucolytic agents, anticoagulants, and anti-inflammatory agents further support clinical treatment. Most burns go on to heal spontaneously; some are indeterminate or of mixed depth and some will necessitate escharotomy and skin grafting. Specific problems encountered in cases of perioral (microstomia), eyelid (ectropion, corneal exposure), eyebrows (aesthetic), neck (contractures, torticollis, limited mobility of head), scalp (cicatricial alopecia), nose (deformities, amputation), ears (otochondritis, deformities) burns are highlighted in the various sections.
Objective:
To introduce the surgical procedures and experiences in restoration of lower facial esthetics for a male and a female patients who suffered from burn injuries. The difference of surgical methods which varied from sexes were discussed.
Materials and methods:
The clinical data of the patients was collected and retrospectively analyzed. The cervical contracture was repaired by pre-expanded free scapular flaps with sufficient pliable tissue for large defects. Moreover, for the male patient, prefabricated double pedicle scalp flap was applied to rebuild the beard region. The patients were followed up for 2 years. Surgical procedures and outcomes were detailed in the article.
Results:
All the flaps were survived well. The facial hair-bearing area of the man was recovered with natural appearance. The reconstructed mental cervical angels and mandibular margins were clear. The neck extension mobility was improved. The 2 patients were satisfied with the outcomes of the treatments.
Conclusion:
The treatments of facial and neck scar varied from sexes and different requirements. For male patient, the combination of scalp and scapular flaps was a feasible method to achieve natural beard and cervical appearance. For female patient, bilateral expanded scapular flaps could meet the demands of large tissue supply and a relative hidden donor site.
Postburn contractures are the result of deep burns that are not treated properly and promptly. Severe contractures require more than one surgery to be completely relieved. Their surgical treatment is very difficult and challenging for reconstructive surgeons. The author presents a case with severe postburn contracture of the index finger especially at the DIP joint with an angle of 110 degrees, which was released with a full skin graft in two stages of reconstruction. The application of this procedure enables the complete release of severe contractures and protects the fingers from their loss as a result of the shortening of vascular structures.
In this article, we describe reconstruction of a McCauley's Grade I postburn anterior neck contracture with extensive scarring in a 34-year-old woman using a free thin anterolateral thigh (ALT) flap. To our knowledge, this is the first case of reconstruction of Grade I neck contracture using a thin ALT flap that has been reported. By selecting the correct patient, adhering to recommended standards of microvascular technique, and implementing appropriate postoperative nursing care, we achieved a near-normal neck contour in this patient in a single-staged procedure.
Introduction
Nowadays, super-thin ALT flap, which is elevated above the superficial fascial plane, is gaining popularity. Although there is a huge demand for thin flaps for various types of extremity reconstruction, the technique for ALT flap thinning remains controversial. In this study, we investigated the distance and vector between penetrating points of perforators in deep and superficial fascia using color duplex and clinical measurement to suggest reliable super-thin flap elevation technique.
Materials and Methods
From June 2018 to February 2020, 44 patients with various types of defects who were treated using super-thin ALT flaps were enrolled; 69 surgically detected perforators were analyzed. All patients’ flap outcome and characteristics of the perforators were analyzed. In addition, the effects of patients’ body mass index (BMI) and thickness of super-thin flap were evaluated.
Results
Average traveling length of perforator at the deep adipofascial layer (DAL) was 2.43 cm, and vector of traveling was randomly arranged. The mean thickness of super-thin ALT flap was 6.8 mm. The thickness of super-thin flap was not significantly correlated with patients’ BMI (ranged from 17.4 to 34.2 kg/m²; p = 0.183).
Conclusion
The novel elevation technique for super-thin ALT might be useful, as evidenced by perforator traveling distance and vector in DAL. Preoperative color duplex ultrasonography is helpful to detect the running course of the perforators during elevating the flap. This anatomic concept must be considered to obtain reliability of the super-thin ALT flap.
Caustic ingestion can result in a range of injuries, from mild oropharyngeal burn to rapidly progressive life‐threatening complications. Thus, early recognition of the injury along with aggressive treatment of life‐threatening complications and long‐term follow‐up are essential in reducing morbidity and mortality. Acid ingestion tends to cause mucosal injury via coagulation necrosis. Esophageal injury is typically attenuated, and perforation is less common as coagulum that forms on the mucosal surface limits deeper penetration of the caustic agent and, in contrast to alkaline solutions, acid preparations are less viscous and tend to pass quickly into the stomach. The severity of esophageal and gastric injury resulting from caustic ingestion depends upon the following factors: corrosive properties (pH) of the ingested substance, concentration and amount ingested, physical form of the agent, and duration of contact with the mucosa. Caustic injury of the esophagus has been associated with a 1000‐fold increased risk of esophageal carcinoma.
Squamous cell carcinoma of the tongue is the most common malignancy of the oral cavity, the lateral border being the commonest site. The treatment strategies mandate surgery followed by appropriate reconstruction as the first line of management. There are many suitable methods of reconstruction of tongue defects after surgery, but the principle of an ideal reconstruction method should provide not only satisfactory structural cosmesis, but also good restoration of function. We present our experience with the skin lined free flaps reconstruction for defects of the tongue and floor of mouth, and present analyses of the functional outcomes of reconstruction. This prospective longitudinal study included 93 patients and was conducted in a tertiary care center in Punjab. All patients underwent free flap reconstruction after tumor removal. The functional outcome of the tongue following reconstruction was evaluated 9 months after the completion of treatment. Functions were assessed and matched with sexes and age-matched normal individuals. The data obtained were analyzed by the student ‘t’ test and the p values < 0.05 were considered statistically significant. The duration of swallowing in patients with FRF flap and ALT flap when compared to the normative was significant (< 0.05). There were changes in configuration and volume of the oral cavity after surgery which generates resonant and articulatory alterations, thus the intelligibility of the patient’s speech is lowered. There is also a restriction in the tongue movements and reduction in the sensations of the reconstructed part of the tongue. Both the free ALT flap and the FRF flap can provide acceptable functional restoration of the tongue after radical tumor resection.
Pediatric burn injuries are frequently complicated by burn scar contractures that often create functional limitations. Usually release followed by skin grafts, local flaps or tissue expansion is adequate. In rare instances, when the contracture is severe and simpler forms of reconstruction have failed, microsurgical free tissue transfer becomes essential. Even though in pediatric patients it can be technically more demanding and there is a reported risk of vasospasm, free tissue transfer has proven to be a good alternative. It is a one-stage procedure that guarantees decent functional outcomes. The perforator anterolateral thigh flap is a workhorse flap in microsurgery. The versatility of this flap allows it to be used in various anatomic locations. In this paper we report its use in neck, wrist, foot and face reconstructions. Flap success rates were 100%, with no cases of partial or complete flap loss. No acute or chronic complications were noted. Only one patient required reoperation for thinning of the flap to allow proper shoe fitting. All patients had good functional outcomes and the contractures were fully released. Joint function was regained in all patients except one that required wrist fusion. When indicated, the free perforator ALT flap is an excellent option for challenging reconstructions.
Despite the wide and growing use of microsurgery, its application in primary burn reconstruction is not very frequent as it faces a number of additional challenges in this setting. A retrospective analysis of the clinical records of all patients submitted to microvascular free tissue transfer for primary burn reconstruction over an 8-year period (from January 2009 to December 2016) was performed. An evaluation of the indications, timing, principles of flap selection, complications and outcomes of free tissue transfer in primary burn reconstruction was made. Fourteen patients required 18 microsurgical flaps for acute soft tissue reconstruction (1.1% of all patients admitted). 64.3% of the patients were male. The mean age was 59.64 years, and mean TBSA was 10.5%. The majority of the injuries were caused by flames (71.4%), followed by electrical contact (21.4%). The primary indication for microsurgical reconstruction was tissue deficit with exposure of tendons, nerves, vessels, bone and/or joints after debridement. The procedure was more often performed in the early period after injury (between the 5th and 22nd day). The most frequently used flaps were the Latissimus dorsi and the anterolateral thigh flap. Major complications included 2 total flap failures (11.1%) and a partial flap failure that required reconstruction with another free flap. Microsurgical free flaps have a valuable role in primary burn reconstruction. Despite the reported higher complication rate in this specific clinical scenario, their use may reduce the total number of surgeries needed to achieve wound closure.
A patient presented with a complex penetrating facial wound by high temperature steel. The hot steel penetrated right temple, ethmoid bone, and maxillary sinus, and then exited from his left cheek. He kept his right eye but lost his sight. For functional and esthetic considerations, treatments were provided in a staged procedure. First, the debridement was performed under the endoscope. The dead bone was removed, broken teeth were extracted, and necrotic tissue was cleaned. The exposed wounds were cleaned, and dressing was changed daily until the exudation was widely reduced. Then, a 50-mL expander was placed in the left cheek, and an 80-mL expander was put in the scalp just before the defect in the temple area. Five months later, expander inflation was accomplished. Expanders were taken out and expanded flaps were transposed to cover the defect. At the same time, an anterolateral thigh flap was harvested to repair the inner lining of the cheek and the gingiva. Thereafter, several operations were performed to revise the wound scar and the remaining deformity. Both defects in the temple and left cheek were restored with a satisfactory functional and aesthetic outcome. The temporal area was repaired with haired expanded scalp, whereas the face was repaired with an expanded facial flap with similar texture and color. The oral commissure regained balance and integrity. The defect of the gingiva was repaired. A severe penetrating wound in the cranium and face can be nicely repaired using tissue expander and microvascular reconstruction.
Background:
Thinned perforator flaps, reported techniques and degree of thinning differ by study. This study investigated the anatomy of subcutaneous tissue according to the varying fattiness and identified which component and how much of the subcutaneous tissue layer needed to be excluded to meet target flap thickness using computed tomography(CT).
Methods:
Three stratified fattiness groups consisting of 30 donors were made for TDAP, SCIP and ALT flaps. The thickness of the superficial fat layer (SFL) and the deep fat layer (DFL) were measured at 3 points in TDAP, 2 points in SCIP and 3 points in ALT flaps, and the proportion of SFL and DFL to exclude to reach target flap thickness (4, 6, and 8mm) was calculated.
Result:
The median proportion for SFL ranged from 54.8% to 75.2% for TDAP, 62.1% to 72.7% for SCIP and 48.7% to 69.1% for ALT depending on donor fattiness. The estimated % reduction of thickness after thin flap elevation along superficial fascia was approximately one third of the whole layer. A variable proportion of SFL and DFL needs to be excluded to obtain required thinness and in very thick groups, part of the SFL must be removed to reach any of the target thicknesses for three flaps.
Conclusion:
The present study demonstrated the frequent need for SFL manipulation when obtaining a thin perforator flap. To cope with various combinations of donor site fattiness and different required thicknesses effectively, an appropriate thinning method should have increased adaptability, including the ability to control SFL thickness.
Las secuelas de quemaduras cervicales son frecuentes e invalidantes, tanto en el plano funcional como en el plano psicosocial. Esto está en relación con una retracción, una hipertrofia, una discromía o una deformidad. La afectación del platisma es frecuente y agrava las secuelas funcionales. Pueden producir un déficit de extensión cervical, así como secuelas estéticas con pérdida de definición del ángulo cervicomentoniano. La prevención se basa en un tratamiento riguroso en la fase aguda junto a una rehabilitación cuidadosa basada en la contención postural. Antes de determinar la estrategia terapéutica es fundamental la caracterización precisa de las lesiones. El tratamiento se basa en un amplio desbridamiento, teniendo en cuenta la afectación del platisma, así como el aporte de una cobertura adecuada. Las características de la piel aportada deben estar lo más próximas posible a las de la piel cervical en términos de color, textura y grosor. Siempre que sea posible, se debe preferir el aporte de piel procedente de las regiones próximas, cervical o supraclavicular. En estas indicaciones a menudo es indispensable la expansión cutánea. Los colgajos cutáneos preexpandidos locales y regionales responden particularmente bien a estas exigencias. Los injertos de piel total supraclavicular o abdominal, expandidos o no, son una buena alternativa. Los colgajos musculocutáneos y los colgajos libres tienen un lugar restringido en el arsenal terapéutico debido a que se usan tejidos poco adaptados a la región cervical. La rehabilitación postoperatoria sigue siendo la clave del éxito quirúrgico, independientemente de la técnica utilizada.
In 1984, Song and coworkers described the thigh as a donor site for three new flaps, which they raised from its posterior, anteromedial, and anterolateral aspect [500]. Of these three flaps, the anterolateral thigh flap became most popular, especially in head and neck reconstruction. Although originally described as a fasciocutaneous flap which is nourished by a septocutaneous perforator of the descending branch of the lateral circumflex femoral artery, the design of the flap significantly depends on the course and location of the cutaneous vessels, the anatomy of which can vary considerably. Because of the fact that the perforator often takes its course through the vastus lateralis muscle instead of running strictly along the intermuscular septum, parts of the vastus lateralis muscle have to be included into the flap in these cases. Besides the possibility of raising large skin paddles on a single perforating vessel, the vastus lateralis muscle can be transferred as a muscle-only flap, being safely perfused by the descending branch. Thus, a number of flap raising possibilities arise at the anterolateral thigh, offering a wide spectrum of flaps to be harvested. In one of the first large clinical series, Zhou et al. described successful transplantation of this flap in 32 patients, most of them having defects in the region of the face and scalp [623]. Based on a single perforator, a flap design was described reaching in length from the distal end of the tensor fasciae latae muscle to a level 7 cm above the patella and in width from the medial edge of the rectus femoris muscle to the lateral intermuscular septum. According to Koshima and coworkers, who reported on 22 reconstructions of head and neck defects, the flaps can have up to 25 cm in length and 18 cm in width [282]. Two years later, the same author combined the anterolateral thigh flap with neighboring skin-, myocutaneous-, and bone flaps using the lateral circumflex femoral system to treat massive composite defects of the head and neck, performing an additional anastomosis at the distal end of the descending branch [293]. In 1995, the usefulness of the anterolateral thigh flap to cover defects in the lower extremity was demonstrated by Pribaz and coworkers, especially because of the possibility to harvest and transfer the flap in epidural anesthesia [411]. An important variation of designing the anterolateral thigh flap was introduced by Kimura et al. in 1996, who performed a primary radical thinning procedure, only leaving a small cuff of fatty tissue around the perforator [276]. With this procedure, ultrathin flaps could be created, being very useful to cover superficial skin defects [72, 276, 575, 609]. To improve intraoral defect coverage, Wolff et al. performed additionally de-epithelialization of the thinned flaps to create a mucosa-like flap surface [595]. In the following years, the exceptional wide spectrum of indications and the high reliability of the flap were reported especially from authors of the Asian countries. In 2002, Wei et al. published a series of 672 anterolateral thigh flaps with a total flap failure in only 12 patients [575]. An even larger number of 1284 patients were presented by Gedebou and Wei in the same year, who described the anterolateral thigh flap as one of the most useful soft tissue flaps, especially in head and neck reconstruction [161].
Le sequele delle ustioni cervicali sono frequenti e invalidanti sia sul piano funzionale che sul piano psicosociale. Esse sono in rapporto con una retrazione, un’ipertrofia, una discromia o una deformazione. Il coinvolgimento del platisma è frequente e aggrava le sequele funzionali. Esso può portare a deficit di estensione del collo nonché a sequele estetiche con perdita di definizione dell’angolo cervicomentoniero. La prevenzione si basa su una gestione rigorosa nella fase acuta nonché su una rieducazione attenta basata sulla contenzione posturale. La precisa caratterizzazione delle lesioni è fondamentale prima di determinare la strategia terapeutica. Il trattamento si basa su un ampio sbrigliamento, che prenda in considerazione il coinvolgimento del platisma nonché l’apporto di una copertura adeguata. Le caratteristiche della cute apportata devono essere quanto più vicine possibile alla cute cervicale in termini di colore, trama e spessore. Occorre privilegiare, quando possibile, l’apporto di cute di regioni vicine, cervicali o sopraclavicolari. L’espansione cutanea è spesso indispensabile in queste indicazioni. I lembi cutanei pre-espansi locali e regionali rispondono particolarmente bene a questi requisiti. Gli innesti di cute totale sopraclavicolari o addominali, espansi o meno, sono una buona alternativa. I lembi muscolocutanei e i lembi liberi hanno un posto limitato nell’arsenale terapeutico per l’uso di tessuti poco adatti alla regione cervicale. La rieducazione postoperatoria è, anche in questo caso, la chiave del successo chirurgico, a prescindere dalla tecnica utilizzata.
This study presents 3 cases of women ages ranged from 25 to 52 years with anterior cervical contractures caused by burns that resulted in functional and aesthetic deficit. Contracture release in 3 patients and reconstruction was done using a sub-fascial flap whose main pedicle was the supraclavicular artery and the occipito-postero-cervical vessels that were preserved. The flap was designed differently from the classically described that uses the skin of the shoulder but which presents differences of color and texture with relation to the skin of the neck. The results were satisfactory and no complications such as infections or necrosis.
Learning objectives:
After studying this article, the participant should be able to: 1. Explain the epidemiology of severe burn injury in the context of socioeconomic status, gender, age, and burn cause. 2. Describe challenges with burn depth evaluation and novel methods of adjunctive assessment. 3. Summarize the survival and functional outcomes of severe burn injury. 4. State strategies of fluid resuscitation, endpoints to guide fluid titration, and sequelae of overresuscitation. 5. Recognize preventative measures of sepsis. 6. Explain intraoperative strategies to improve patient outcomes, including hemostasis, restrictive transfusion, temperature regulation, skin substitutes, and Meek skin grafting. 7. Translate updates in the pathophysiology of hypertrophic scarring into novel methods of clinical management. 8. Discuss the potential role of free tissue transfer in primary and secondary burn reconstruction.
Summary:
Management of burn-injured patients is a challenging and unique field for plastic surgeons. Significant advances over the past decade have occurred in resuscitation, burn wound management, sepsis, and reconstruction that have improved outcomes and quality of life after thermal injury. However, as patients with larger burns are resuscitated, an increased risk of nosocomial infections, sepsis, compartment syndromes, and venous thromboembolic phenomena have required adjustments in care to maintain quality of life after injury. This article outlines a number of recent developments in burn care that illustrate the evolution of the field to assist plastic surgeons involved in burn care.
Contractures to the cervical region as a result of burns has the capacity to cause restrictions in range of movement, function of the lower face, cervical spine distortion and poor aesthetic outcomes that remain a surgical challenge. Consequently, physical and aesthetic deformities as a result of cervical contractures are reported to cause depression having implications for patients' quality of life and psychosocial wellbeing. At the time this research was conducted, there were no case reports describing a closed platysmotomy approach in burn patients. In this article, we review the literature surrounding closed platysmotomies and present what we believe to be the first reported case in the treatment of cervical contractures utilising a closed platysmotomy approach in a burns patient. A closed platysmotomy approach for the treatment of cervical contractures is a less invasive technique. Further investigation is warranted to determine the feasibility of this reconstructive approach in the area of burn scar management.
Based on Reddy's high-order shear deformation theory, geometrically nonlinear governing equations of composite laminated plates are obtained in the form of displacements by the virtual displacement principle. All five-displacement functions satisfy the boundary conditions that two adjacent edges simply supported and the other two adjacent edges clamped. Galerkin's method is used to transfer nondimensional governing equations to an infinite set of nonlinear algebraic equations. Linear equations of sparse matrix are solved by Biconjugate Gradients Stabilized Method and nonlinear algebraic equations are solved by parameter-regulated iterative procedures. Numerical results of deflection and bending-moment are presented and compared with that of Kirchhoff and Reissner-Mindlin plate theory for different composite materials.
Post-burn scar contractures are a commonly encountered problem in the field of plastic and reconstructive surgery. Nevertheless, many physicians still lack adequate knowledge on beneficial treatments. In this up-to-date atlas, leading specialists in post-burn treatment and the reconstruction of post-burn scar contractures depict in detail not only surgical techniques but also a variety of advantageous wound treatments. Many new methods invented by the authors are presented. Operative techniques are depicted in detail, and clear guidance is provided on selection of the most appropriate flap surgery. Advice is also given on how to prevent permanently disabling restriction of joint movement as a result of contractures and how to achieve good aesthetic reconstruction. This atlas is designed to appeal to a wide audience, from beginners to specialists. It will prove invaluable for doctors of every kind who deal with wound management. © Springer-Verlag Berlin Heidelberg 2010. All rights are reserved.
This is a clinical prospective study with preoperative and post operative evaluation of treatment options for post burn complications and prevention. In this clinical research 46 patients were opted even more than 200 cases had being treated. This study was over 2 years period and we kept only those patients who came for follow up for 6 months to 2 years. Most of the patients were between age 4 years and 46 years, only one was 70 years and 3 patients were less than 3 years old.32 patients were female and 14 were male. Most the patients were flame burn only 2 were acid victim females with neck contracture. Contracture involves neck, axilla, elbow, hip joint, knee joint. Treatment options were Skin graft, Z-Plasty and local flaps. Patients who were going through treatment of burn and with risk of post burn contracture were splinted to prevent this complication.
Caustic injuries of the esophagus occur as a result of ingestion, more commonly of alkali substances than acids. The majority of caustic ingestions occur as accidents in children, but can be seen both from accidental and purposeful exposure in adults. With increased attention to safety in commercial products, the demographics of these injuries has moved more toward the developing world, but the problem still exists worldwide. The identification of the ingested substance, history of the ingestion, and initial physical examination are critical in determining the risk of extensive injury and the need for further evaluation. Flexible and rigid endoscopy and plain radiography will often determine those patients with stage I and II injuries requiring little or no intervention versus those with stage III and IV injuries that could require esophageal stenting or esophagectomy, and have a high risk for long-term sequelae. If not prevented by early treatment, esophageal stricture is the most common complication. Symptomatic strictures can be treated by dilation or complex surgical reconstruction.
Background: To compare free thin anterolateral thigh (ALT) flap with free radial forearm (FRF) flap in the reconstruction of hemiglossectomy defects, and to introduce our methods and experience in the tongue reconstruction with free thin ALT flap. Material and Methods: The clinicopathologic data of 46 tongue carcinoma cases hospitalized from December 2009 to April 2014 were obtained from Nangjing Stomatological Hospital, Medical School of Nanjing University. All the subjects were evaluated for the articulation and the swallowing function 3 months after the surgery. Results: Among these 46 patients, 12 patients underwent tongue reconstruction after hemiglossectomy with ALT flap; 34 patients underwent tongue reconstruction with FRF flap. The differences in the incidence of vascular crisis, the speech and the swallowing function between two groups were not significant (P>0.05). Conclusions: Thin ALT flap could be one of the ideal flaps for hemiglossectomy defect reconstruction with its versatility in design, long pedicle with a suitable vessel diameter, and the neglectable donor site morbidity.
For a clamped orthotropic rectangular plate, the bending deflection due to a concentrated force can be treated as the superposition of deflections of simply supported plate under three load cases, a concentrated force, moments along two opposite edges and moments along the other two opposite edges. The solution satisfies the boundary conditions of the clamped plate. Matlab program is developed for calculating the deflections of four plates with different thickness and concentrated force positions. The analytical solutions are compared with Finite Element Method results, demonstrating the accuracy of the proposed solution. Finally, the reasonability of Kirchhoff plate assumptions is discussed through the case of clamped plate under a concentrated force.
Because of its intimate anatomic relation to the skin of the neck, the platysma muscle plays a central role in the appearance of the neck. This discussion outlines the role of the platysma muscle in cervical flaccidity and presents the way to correct deformities of the neck caused by this flaccidity.
Using the simple high-order shear deformation laminate theory and large deformation theory, the geometric nonlinear analysis of rubber rectangular composite laminate plate was presented. Compared with linear theory, the results including stress and strain distributions were more reasonable.
The anterolateral thigh (AL-T) flap has many advantages in head and neck reconstruction, because of its long and wide vascular pedicle (about 2 mm in diameter), relatively thin skin, and good pliability. Elevation of the flap is possible simultaneously with tumor resection at the supine position and time for completion of the operation is thereby shortened. Furthermore, an AL-T flap can be used as a thinned flap, an adipofascial flap, a sensate flap, or combined with another flap where the pedicle is anastomosed to the branches of the AL-T flap pedicle. However, several anatomical variations have been identified. From our experiences, septocutaneous perforators were found in 28 of 74 cases (37.8%), and no perforators were found in 4 cases (5.4%). Musculocutaneous perforators which require a complicated procedure for dissection (81.9%) were much more common than septocutaneous perforators (18.2%). The incidence of long-term morbidity with the AL-T flap is low but it is increased when the flap includes the vastus lateralis muscle or is wider and requires additional skin grafting at the donor site. The AL-T flap has many advantages and can be used to reconstruct many types of head and neck defects. However, anatomic variations and donorsite morbidity must be considered if the flap is to be used safely and reliably.
The authors propose a more extensive lipectomy than usual along and above the mandibular branch, to obtain better results in the neck and lower face in rhytidectomy. The operative technique is based on anatomical findings. Results are excellent when the procedure is indicated and properly performed. Lipectomy is recommended in patients with abnormal fat deposits about the lower face and neck; it. is not advised for obese patients.
A nonlinear analysis of simply supported, antisymmetric, angle-ply rectangular plates under uniform axial compression is presented. The solution is based on von Karman's equations for large deflections. A double Fourier series solution is assumed for both the stress function and the transverse deflection. Numerical results are obtained for plates made of graphite/epoxy. Results obtained for square plates are compared favorably with those obtained by a different solution scheme. The effect of plate aspect ratio and the effect of load eccentricity on the response characteristics of the plate are investigated. In some of the studies the number of layers is varied.
The authors discusse their approach to the correction of post-burn contractures of the neck based on a ten year followup of 147 burn patients treated by them. The value of staged, partial excisions performed independently or in combination with simple or complex flap procedures and skin grafts is stressed. Particular attention is given to the use of free flaps and various local skin flaps. Numerous treatment examples are presented, and the results are analyzed and discussed.
The surgeon who wants to get a good result in the correction of the senile neck by doing rhytidoplasty should, in the cases where the problem is aggravated and involves cutaneous flaccidity, muscular relaxation, and adipose collection, perform an extensive operation including a wide detachment of the cervical flap, submental and submandibular lipectomies, and the sectioning and raising of the platysma.
The anatomical basis for some common anterior neck deformities, the key to which is the presence or absence of decussation of the platysma muscles at the midline, is described. A plea is made to be specific in describing these deformities, and to approach corrective surgery anatomically.
A statistical analysis of 1,500 consecutive rhytidectomies is presented. In rhytidectomy, complications occur in a significant percentage of the operations. The plastic surgeon must be aware of the incidence and significance of these complications, and also he must know how to avoid or manage them.
The use of pretransfer tissue expansion of a free scapular flap is described. This technique allows coverage of large defects with good quality skin and tensionless closure of the donor site.
Neck contracture after burn injury can result in severe functional as well as aesthetic deformities. Contracture can recur even after wide and complete release and full-thickness skin grafting. Recurrence is partly due to the inherent difficulties in both early postoperative immobilization and the required long-term splinting. When adjacent tissues are also burned, adequate local tissue for reconstruction may not be available; therefore, free-tissue transfer may be necessary. The large surface area that is required after adequate release may be provided by tissue expansion before free-tissue transfer. In the case presented the use of tissue-expanded radial forearm free flap for the reconstruction of a recurrent neck contracture is described.
Contemporary surgery to rejuvenate the aging neck commonly includes some type of platysma modification. Most currently used methods of platysmaplasty involve upper midline plication, muscle resection, or transection. These methods, however, have their shortcomings, often producing necks that display persistent or recurrent paramedian muscle bands, visible submandibular gland bulges, and various contour irregularities. Corset platysmaplasty was developed to avoid these postoperative imperfections. After an adequate subcutaneous and subplatysmal lipectomy has been performed, the two medial edges of the platysma are joined together with a continuous suture that runs down, and up, and down almost the full-height of the neck to create a smooth, flat, multilayered seam, leaving no free muscle edges to return as visible bands. Progressive side-to-side tightening along the midline seam defines the "waistline" of the neck. Additional submandibular suturing is then done to create strong, flat, vertical muscle pleats that correct submandibular gland bulging and refine the jawline and anterolateral neck contours. Corset platysmaplasty is useful for all patients with visible paramedian muscle bands and all patients who would benefit from having a decussated upper neck platysma opened for submuscular defatting, including patients with oblique, palpably firm necks that suggest a vertically short platysma muscle or low-lying hyoid bone. The paper is based on the results with 75 patients having undergone corset platysmaplasty, most having been followed for 1 to 3 years.
The experimental basis for free-flap preexpansion is briefly discussed. Two cases are reported in which the ankle/heel area was resurfaced and reinnervated with a preexpanded radial flap. The size of the first flap was half the surface area of the entire forearm. Direct closure of the secondary defect was possible with a single scar and without functional deficit in both cases. The flaps were well-vascularized and consisted of the sensory distribution of one peripheral nerve division, which was anastomosed in the recipient site. This preparation proved to be finer and to have better contouring capacity and skin quality than existing alternatives. It is clear that hydraulic tissue expansion facilitates great additional use of the radial flap as well as a range of other modified free flaps when there is time available for the flap to be developed prior to transfer.
On the basis of about 60 cases, we discuss the clinical use of groin, latissimus dorsi, dorsalis pedis, scapular, parascapular, and forearm free flaps. These flaps are evaluated in relation to some alternate reconstructive procedures in various regions of the body, with photographic documentation.
Burns of the head and neck pose unique and challenging problems for the physician. They may either present an immediate threat to the patient's life or result in disfiguring burn deformities. The visual impact of the injury and burn deformity affects the patient, his family, the physician, and society. A review is given.
Based on the septocutaneous artery flap concept, the thigh, which is the commonest conventional donor site for split-skin grafts, can also become a donor area for skin flaps. The thigh flap, with its large and long neuro-vascular pedicle, can be used either as a free flap or as an island flap as an alternative to the lower abdominal flap, groin flap, tensor fasciae latae myocutaneous flap, sartorius myocutaneous flap or the gracilis myocutaneous flap. The anatomical basis, operative technique and characteristics of the thigh flap are discussed.
The authors propose a more extensive lipectomy than usual along and above the mandibular branch, to obtain better results in the neck and lower face in rhytidectomy. The operative technique is based on anatomical findings. Results are excellent when the procedure is indicated and properly performed. Lipectomy is recommended in patients with abnormal fat deposits about the lower face and neck; it is not advised for obese patients.
We have suggested visual criteria for achieving and assessing success in platysma cervical lift. We believe it is now possible to satisfy these criteria in most patients, even those with a low-lying hyoid. Anterior adjustment of the platysma is more important for desirable results than posterior adjustment or posterior closure alone. If present in a heavy neck, the subplatysma fat pocket must be excised. A posterior submental incision as well as a more radical submental lipectomy with platysma sling (submental neck lift) is helpful for patients who are not yet candidates for an upward lift. The cutting of the platysma and fashioning of the sling, as well as defatting, may possibly add to the longevity of the lift, but this can be ascertained only by long-term follow-up.
Excision and grafting in deep partial and full skin thickness burns of the anterior cervical region in a series of 40 patients treated between 1982 and 1992 is reported. The advantages of surgical management of deep burns in this region in a single staged operation have proved its efficacy compared to the severe sequelae which appear when the standard conservation treatment is used. A comparative study of two groups of patients treated either by early excision and grafting (n = 19/40), or by delayed excision and grafting (n = 21/40) demonstrated the advantages of elective early excision and grafting with respect to: length of hospital care, complications and their severity, and surgical repair.
The super-thin flap technique was first devised in China. Flaps thinned by this technique are especially useful in the neck, face or hands of patients with extensive burn scarring, where the combination of thinness and suppleness is needed. However, some of these radically thinned flaps may suffer from superficial or full thickness necrosis due to the unpredictability of survival of the super-thinned area. In this paper, we present a technique of microvascular augmentation of the blood supply of the thinned flap, an example of so-called "supercharging".
The anterolateral thigh flap is a septocutaneous artery flap based on the septocutaneous or muscle perforators of the lateral circumflex femoral system. Little has been reported about the variations in its vascular anatomy and its application for head and neck reconstruction. We report 22 cases in which this flap was used for the reconstruction of head and neck defects. Based on our clinical and cadevaric experiences, the derivation of the vascular pedicle of this flap has four variations by which the septocutaneous perforators are derived from the descending branch of the lateral circumflex femoral system and/or from the transverse branch of that system, or for which there are no septocutaneous perforators but there are muscle perforators originating from the lateral circumflex femoral system. Clinically, the vascular variations and the locations of perforators of this system can be determined preoperatively with stereoangiograms or simple angiograms and Doppler audiometry. The anterolateral thigh fasciocutaneous flap is suitable for reconstruction of defects in an oral floor with tongue and esophageal deficits, scalp defects with dural defects, and for large full thickness defects of the lip. The advantages of this flap are safe elevation, a long and wide vascular pedicle, skin that is generally thin, and good pliability. Even if the skin is thick, a thinner flap can be created by sacrificing a large amount of fatty tissue. Furthermore, the skin territory is very wide and long. The donor defect can often be closed directly with its scar being less noticeable. The disadvantage of this flap is that the anatomy of the pedicle vessels has irregular derivation from the main vessels. This can be overcome, however, by employing preoperative stereoangiograms.
Chimeric composite flaps combined using microanastomoses consist of two or more flaps or tissues, each with an isolated pedicle and a single vascular source. Free combined chimeric flaps using the lateral circumflex femoral system were used to treat massive composite defects of the head and neck in 10 cases. A combined anterolateral thigh flap and vascularized iliac bone graft based on the lateral circumflex femoral system and the deep circumflex iliac system was the most commonly used combination. An anteromedial thigh flap and a paraumbilical perforator-based flap were also combined with this principal combination. The advantages of this chimeric flap over other osteocutaneous flaps are: (1) The flap is relatively thin and the pedicle vessels are up to 10 cm longer and are wider than those of other flaps for easier harvesting of the flap. (2) It is unnecessary to reposition the patient. (3) The vascular pedicle to the skin can be separated from that of the bone. (4) The donor site is not close to the recipient site. (5) The donor scar is in an unexposed area. (6) The skin territory of this flap is extremely wide. (7) A combined anterolateral and anteromedial thigh flap and vascularized iliac bone graft can be easily obtained as an extended combined osteocutaneous flap. (8) Other neighboring skin flaps, such as a groin flap, a paraumbilical perforator-based flap, or a medial thigh flap, can be combined with this chimeric flap because several major muscle branches to be anastomosed derive from the lateral circumflex femoral system. Chimeric composite flaps using the lateral circumflex femoral system are considered suitable for the repair of massive composite defects of the head and neck.
Radovan's 1982 landmark work on the clinical use of tissue expanders was felt to be a panacea for multiple reconstructive problems. We have used and probably overused tissue expanders for reconstruction of many complicated pediatric facial burn problems. This has enlightened us to some of the limitations of their use, and we have, therefore, reassessed our indications for their use. From 1984 through 1990, 52 tissue expanders were used in 37 pediatric patients for face and anterior neck burn scar resurfacing. This experience, combined with the unique problems encountered with face and neck tissue expansion, provided the groundwork for operative guidelines. The long-term effects of gravity, growth, and scarring on facial features adjacent to expanded skin led to the following principles. (1) Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening or possible lip or eyelid ectropion needs to be considered when planning these flaps. Extreme overexpansion is necessary to advance unburned neck flaps over the mandibular border to avoid these problems. (2) After advancement or rotational flaps neck flaps to the face, vertically directed suture lines in the neck may need redirection to prevent linear contracture. This correction may be performed during the primary operation or during revisions. (3) Expanded cheek or neck skin should preferably replace burned areas, but at the same time, not violate unburned facial aesthetic units. (4) To counteract the affects of gravity, expanded cheek skin in conjunction with expanded neck skin, if unburned, may be the best choice for face or mandibular border scar replacement.(ABSTRACT TRUNCATED AT 250 WORDS)
The anterolateral thigh flap has many advantages in head and neck reconstruction. However, it has not yet come into widespread use because of the anatomic variations of its perforators. Herein, we describe a safe operative technique related to the patterns of the perforators and discuss its wide versatility.
A national cancer center hospital.
Thirty-eight anterolateral thigh flaps were transferred. Confirmation and dissection of the flap pedicle were simultaneously performed with tumor resection. The design and elevation of the flap were carried out immediately after the tumor resection was completed.
From the study of the anatomic variations of the perforators, septocutaneous patterns were recognized in 10 cases (26.3%) and musculocutaneous patterns in 28 cases (73.7%). All flaps were easily and safely elevated with our techniques. Thirty-six flaps survived. Partial necrosis was noted owing to excessive thinning procedure in one patient and total necrosis was noted owing to venous thrombosis at the anastomosis part in another patient.
We found that the anterolateral thigh flap has numerous advantages. It is possible to perform the flap elevation and the tumor resection simultaneously. The flap is generally thin and is suitable for reconstruction of intraoral defects. Combined flaps with neighboring tissues and other, distant flaps can be used. Furthermore, since our technique minimizes the problems of confirmation and dissection of the perforators, we conclude that this flap can be successfully used to repair a variety of large defects of the head and neck.
To ameliorate the cervicomental angle, most surgeons suggest different techniques of platysmaplasty. The aim of this anatomic study is to find a simple answer to the following question: Is suturing of the anterior edges of the platysma muscles during platysmaplasty the best procedure to use to obtain the best concave anterior neck angle? Three different surgical techniques using platysma muscle flaps were used on 20 cadavers prepared for anatomic dissection. Each piece of dissection was controlled by a radiograph of the profile of the cervical region before and after the application of these different techniques. Cephalometric measures were made and statistically analyzed. The analysis of the results demonstrates that the best concave anterior neck angle to perform platysmaplasty is one in which the platysma muscle flap is shifted posterosuperiorly but without suturing the medial borders of the platysma muscles. Suturing the midline does not deepen the concavity in the front of the neck.
We have transferred 74 free or pedicled anterolateral thigh flaps, including those combined with other flaps, for reconstruction of various types of defects. We report several anatomic variations of the lateral circumflex arterial system and discuss some technical problems with this flap. Septocutaneous perforators were found in 28 of 74 cases (37.8 percent), and no perforators were found in 4 cases (5.4 percent). In the 70 cases with perforators, 171 tiny cutaneous perforators (an average of 2.31 per case) were found. Musculocutaneous perforators (81.9 percent) were much more common than septocutaneous perforators (18.1 percent). Perforators were concentrated near the midpoint of the lateral thigh, and the selection of perforators as nutrient vessels for the anterolateral thigh flap was related to the length of the pedicle and the thickness of the skin flap. Anatomic variations of the branching pattern of perforators were classified into eight types. Flaps with perforators that arise directly from the profunda femoris artery are difficult to combine with other free flaps. Because the perforators are extremely small and tend to thrombose soon after congestion develops, these flaps are difficult to salvage with recirculation surgery. Therefore, several perforators should be included with the flap, if possible. The descending artery of the lateral circumflex femoral artery was always accompanied by two veins with different back-flow strengths. Therefore, veins for microsurgical anastomosis must be chosen carefully. Because it is nourished by several perforators arising from the descending artery, the vastus lateralis muscle can be combined with the anterolateral thigh flap. However, splitting the muscle longitudinally without harvesting its blood supply is complicated because its fibers are oblique. The rectus femoris muscle can also be combined with the anterolateral thigh flap, but its pedicle is short and its origin is very near the site of anastomosis. When the anterolateral thigh flap is combined with the tensor fasciae latae musculocutaneous flap, the large skin area of the lateral part of thigh can be transferred to repair the massive defects. The anterolateral thigh flap has many advantages and can be used to reconstruct many types of defect. However, anatomic variations must be considered if the flap is to be used safely and reliably.
Postburn scarring and contracture affecting function remain the most frustrating late complications of burn injury. Various techniques are used to release contractures; the choice depends on their location and/or the availability of unaffected skin adjacent to the contracture or elsewhere. A retrospective review was carried out of the case notes of patients who had skin grafting for the release of postburn contracture at the Burns Unit, City Hospital, Nottingham between May of 1984 and August of 1994 to evaluate the experience over this period. Information was obtained about the burn injury, contracture site, interval between burn and release of contracture, indication, age at first release, intervals between releases, operative details (donor and graft sites), complications and nonoperative treatment, and follow-up to the end of the study period. A total of 129 patients underwent skin grafting for release of contractures as opposed to any other method of correction. Full-thickness skin grafts were used in 81 patients (63 percent) and split-thickness skin grafts in 26 (20 percent). Twenty-two patients (17 percent) had both types used on different occasions. Flame burns (41 percent) were the most common causes, followed by scalds (38 percent). Two hundred thirty-nine sites of contracture were released, with the axilla (59) and the hand/wrist (59) being the most common sites involved, followed by the head/neck region (42). It was found that for the same site, release with split-thickness skin grafts was associated with more rereleases of the contracture than with full-thickness skin grafts. Also, the interval between the initial release and first rerelease was shorter than with full-thickness skin grafts (p < 0.048). It was also noted that children required more procedures during growth spurts, reflecting the differential effect of the growth of normal skin and contracture tissue. Patients reported more satisfaction with texture and color match with the full-thickness skin grafts. There was comparable donor-site and graft morbidity with both graft types. The use of skin grafts is simple, reliable, and safe. Whenever possible, the authors recommend the use of full-thickness skin grafts in preference to split-thickness skin grafts in postburn contracture release.
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