Post-burn neck contracture: effectively managed with supraclavicular artery flap

Summary

Post-burn neck contracture is one of the most common burn sequels. These contractures affect the patient significantly causing both functional limitations and esthetic disfigurements, which lead to cosmetic, functional and social problems. Our objective was to determine the role of supraclavicular artery island (SAI) flap as an option for the reconstruction of soft tissue defect of the neck after release of post-burn contracture. The study was conducted at the Department of Plastic & Reconstructive Surgery, Dow University of Health Sciences & Dr. Ruth KM Pfau Civil Hospital Karachi, Pakistan, from February 2015 to April 2018. Patients of both genders in any age group who required reconstruction of soft tissue defects after release of post-burn neck contracture were included. Patients with neck irradiation, trauma, failure of previous surgery, bleeding diathesis, or severe scarring at the supraclavicular region were excluded. A total of 31 supraclavicular flaps were performed in 28 cases for reconstruction of soft tissue neck defect. Mean age was 29.8 years. Patients were followed for 3 months postoperatively. Complete flap necrosis was observed in 1 (3.2%), distal necrosis in 2 (6.4%) cases, postoperative hematoma of the neck was found in 1 (3.2%) and wound dehiscence was reported in 2 (6.4%) cases. Donor site was closed primarily in 25 (81%) cases while the rest were skin grafted. Supraclavicular artery flap is an effective choice with impressive recovery, acceptable skin color match and restoration of anatomic function at the recipient site without any major complications.

Introduction

Post-burn neck contracture is one of the most common burn sequels. These contractures affect the patient significantly causing both functional limitations and esthetic disfigurements that lead to cosmetic, functional and social problems.¹ Contracture of the neck is an extremely disabling condition; the neck develops a fixed flexion deformity with restricted extension and rotation. Delayed treatment, initial poor management of the burn, lack of a well-staffed and managed burn unit and the longer term outcome in burn patients are the main reasons for this problem.²

Due to these major complications, multidirectional movements of the neck necessitate special considerations in its reconstruction.³ Many methods have been advocated to release the contractures and provide soft tissue coverage, including Z-plasty, skin grafts (split and full thickness), local skin flaps with or without tissue expansion, pedicle flaps and free flaps. Skin grafts or local flaps are not helpful in the reconstruction of bigger or complex scars with contracture.³ Skin grafts do not take well and local flaps have an inadequate amount of tissues to cover the resultant defect after contracture release.^4,5,6

The supraclavicular artery island (SAI) flap is a loco-regional fasciocutaneous flap taken from skin on the shoulder and supraclavicular area, which is gaining popularity for reconstruction of head and neck defects. Pallua et al. described the SAI flap for reconstruction of cervicomental scar contractures and provided a clear anatomic description of the blood supply to this flap, demonstrated successful flap harvest and found the SAI flap to be safe and reliable.⁷ The supraclavicular flap, due to its satisfactory aesthetic appearance and location far from the area of injury, provides a good alternative for reconstruction.^8,9 Current study determines the role of the supraclavicular artery flap as an option for the reconstruction of soft tissue defect of the neck after release of post-burn contracture.

Methodology

Department of Plastic & Reconstructive Surgery, Dow University of Health Sciences & Dr. Ruth KM Pfau Civil Hospital Karachi. A total of 28 patients were included through non-probability consecutive sampling. Thirty-one flaps were performed to provide soft tissue coverage of the defect during the period from February 2015 to April 2018. The patients included in the study were aged 14-50 years, of both genders, and clinically fit besides having post-burn neck contracture of more than one year duration. Patients with a history of neck irradiation, trauma or severe scarring in the supraclavicular and neck region, blood clotting issues and who refused to give their consent to being involved in the study were excluded. All the demographic information was documented on a proforma including age, duration of neck contracture, surgical outcome and donor site morbidity. Data were analyzed using statistical package for the social sciences software (SPSS version 21).

Surgical technique

Defect was sharply created by releasing the contracted scar until the adequate extension of the neck was attained. Supraclavicular artery island flap was harvested by the technique formerly described by Pallua, Di-Benedetto and Alves.^10,11,12 Position of supraclavicular artery was marked in the triangle created medially by the posterior margin of the sternocleidomastoid muscle, inferiorly by the clavicle and laterally by the external jugular vein (Fig. 1). This point was used as the arc of rotation of the flap and to determine the length of the flap. Skin island was marked and the flap was raised from lateral area to medial at the sub-fascial plain of the deltoid muscle until the supraclavicular fossa. Level V lymph nodes and fat must also be dissected and mobilized around the supraclavicular artery to attain a greater arc of rotation; this was also carried out at a sub-fascial plain to guard the pedicle. Deep to the sternocleidomastoid muscle in the posterior triangle of the neck, accessory nerve was present that innervated the trapezius muscle; hence it rests beneath the supraclavicular flap and its pedicle although it was in deeper tissue planes; dissection must be kept at a sub-fascial level, to avoid damage to this nerve. The flap was rotated and inset into the defect. Any raw area left after the inset of flap was covered with a split thickness skin graft harvested from the thigh, and tie-over dressing was applied over it. The donor site was closed primarily over a drain after extensive undermining of surrounding tissues in most of the cases; otherwise split thickness skin graft was applied. The defect site and neck were also typically closed over a drain. We used Watusi splint to prevent re-contracture. Extra-corporeal circuit tube for open-heart surgery, cut to the required length, was used. A bandage is threaded through these tubes and used to position them around the neck. They are very economical, well tolerated by patients since the rounded margins do not irritate the skin, and allow a certain degree of neck flexion and extension. In the recovery room, ward and after discharge the patient was advised to sleep without a pillow under the head and instead use a small pillow under the shoulder blades. Regular flap monitoring was done. Skin graft was checked after 3-5 days and graft donor site dressing was changed after 12-14 days. The patient was regularly followed in the outpatient clinic and scar therapy was advised. Once the flap and graft were stable, usually after 10-14 days, regular full range of motion exercise of the neck and shoulder was started.

Fig. 1.

Results

A total of 31 supraclavicular flaps were harvested in 28 cases for reconstruction of soft tissue neck defect after release of post-burn contracture from February 2015 to April 2018. Of the 28 cases, 21 were female and seven were male, and mean age was 29.8 years. Patients were followed for 3 months postoperatively. Complete flap necrosis was found in 1 case, and the defect was covered using other reconstruction techniques. There was distal tip necrosis in 2 cases, which was debrided and advancement of the flap and skin grafting was done in later stages. Postoperative hematoma in the neck was found in 1 patient: it was evacuated by removing a few stitches and placing a corrugator drain. The wound was left to heal by secondary intention. Wound dehiscence was reported in 2 cases: dressings were kept on for a few days and later the area was skin grafted. In 25 cases the donor site was closed primarily, and skin grafting was done in 6 cases, which took well (Figs. 2,3,4). No restriction of shoulder movements was found at the flap donor site (Table I). No long-term complication was observed in the patients.

Fig. 2.

Fig. 3.

Fig. 4.

Table I.

Discussion

The skin in the neck region is thin and pliable in order to have a wide range of motion in three dimensions. Neck contractures are very common sequelae after flame burns, scald injuries and chemical burns. Patients with post-burn neck contractures frequently have marked limitations in neck mobility.^13,14,15 Patients in the younger age group (<12 years) often end up with mandible and cervical vertebrae deformities, and drooping lower lip and dribbling of saliva are not uncommon conditions associated with post-burn contracture.^16,12 Reconstruction of the neck is quite a difficult task because the scar in this region is easily noticeable.¹⁷ Soft tissue reconstruction of these defects can be done by skin grafts, local, regional and free flaps.¹⁸

Skin grafting of these defects is a simple option but has limitations in that large defects and movements of the neck cannot be restricted for good graft take. Graft also produces secondary contraction and this is aesthetically not acceptable to the patients. Local flaps can only be used for small defects.¹⁹ Regional flaps are another option for the reconstruction of these defects. Generally, pectoralis major, trapezius and latissimus dorsi are used as musculocutaneous flaps, while deltopectoral and supraclavicular flaps are commonly used as fasciocutaeous flaps. Musculocutaneous flaps have various advantages but in this case they are too voluminous, which can restrict neck movements. Arc of rotation of the deltopectoral flap is very short and donor site needs skin grafting for tensionless closure, which is aesthetically unacceptable, especially for females.

The supraclavicular flap is thin, pliable and the color match is excellent.¹³ The thinness of the dermis permits suitable adaptation on the suture line and the lack of hair makes it suitable for females. This flap has a pivot point near to the neck, allowing utilization of the whole surface of the flap, which is unlikely with trapezius and deltopectoral flaps.²⁰ In a study of 349 supraclavicular flaps, complete necrosis was reported in 1.4%.¹⁴ They identified the cause of this failure to be extensive dissection around the perforator, which led to injury or spasm of the vessel.¹⁴ To avoid this complication, a cuff of soft tissue should be left around the vascular pedicle.²⁰

Distal tip necrosis of the flap was seen in 2 (6.4%) cases, comparable to a study that showed the same results for their series of 41 flaps.²¹ Another study reported epidermolysis and partial flap necrosis in 1 out of 11 cases. Dimension of the flap used in their study was smaller compared to ours; the cause of failure was identified as related to the patient, who was asthmatic and was on steroid treatment postoperatively.²² Another study showed 7 out of 20 cases (35%) of partial flap necrosis: superficial epidermolysis was seen in 5 cases (25%) and necrosis of distal 2 cm in 2 cases (10%), which were managed conservatively.¹⁴ We adopted the same management plan for these complications in our study.

In our study the donor site was closed primarily in 25 (81%) cases, and in 6 (19%) cases skin grafting was done, which took well. This is comparable to a study in which the donor site was closed primarily in 10 cases but the width of the flap was smaller.¹³ Wound dehiscence at the donor site was reported in 2 (6.4%) cases: dressings were kept on for a few days and then were skin grafted. While one study reported cellulitis in 2 patients and wound dehiscence in 1 patient, the reason mentioned was that they were not using a drain.¹⁷ As there is extensive undermining of the flaps in the donor area in order to achieve tensionless closure, it also increases the chances of postoperative fluid collection. Postoperative hematoma in the neck was found in 1 (3.2%) patient: it was evacuated by removing a few stitches and using a corrugator drain. The wound was left to heal by secondary intention. No restriction of shoulder movement was found at the flap donor site, because while harvesting the flap the motor nerve of the shoulder was preserved, as recommended in other studies. ^13,15 In the same study donor site complications such as wound dehiscence and seroma were reported in 0 to 15% of cases, which were treated with local care, as mentioned in our study.

Pallua et al. and Vinh et al. showed very similar rates of patient satisfaction with the aesthetic results of supraclavicular flap after release of post-burn neck contracture, namely 87.5% and 86.7%, respectively.^9,23

In our study length of the flap ranged from 15 to 24 cm and the mean was 18 cm, which is slightly smaller than a mean of 21.7 cm reported in the study of Ismail H et al., but in some cases the distal ends were trimmed in order to ensure their vascularity.²⁰ We are convinced, like Vinh et al. mentioned in their study of 103 cases, that flaps longer than 22 cm make their distal ends risky.²³ In order to prevent re-contracture, we used a Watusi splint. The Watusi splint was first described in 1976 and the name Watusi stemmed from an African tribe. This splint is a custom-made flexible splint that provides some degree of rotation and extension and decreases overall restriction. A study by Nosanov et al. showed that use of the Watusi splint resulted in an increased range of motion of the neck.²⁴ A comparative study between the SAI flap and the fasciocutaneous free flap concludes that there is a decrease in operating room time with the SIA flap, while both have similar lengths of stay and wound healing.²⁵ The supraclavicular artery island flap is a versatile and reliable reconstruction option and an excellent alternative to traditional regional and free flaps for providing soft tissue coverage of post-burn neck and face defects.

Conclusion

The supraclavicular artery island flap is an effective choice for reconstruction of soft tissue defects of the neck after release of post-burn contracture, with impressive recovery, acceptable skin color match, and restoration of anatomic function at the recipient site. The donor site generally heals well with relatively good aesthetic acceptability.