Annals of Burns and Fire Disasters - vol. IX - n. 1 - March 1996

EXTENSIVE BURN SCAR CARCINOMA IN THE SCALP AND ITS TREATMENT WITH FREE FLAPS: THREE CASE

AcartOrk S., Dalay C., Yavuz M, Irik G, Kesiktas E.

Department of Plastic and Reconstructive Surgery and Burn Unit, (~ukurova University Medical Faculty, Balcali Hospita

SUMMARY. The malignant potential of an unstable burn scar is ever present. It may develop in the scalp regio body, such as the lower and upper extremities and the prestemal region. This paper presents three cases of extensi oping in an unstable burn scar. Deep extensive excision is necessary for this kind of expansive turnoral invasion, and are not sufficient to reconstruct the complex scalp defect. After extensive excision of the tumour, free latissimus do (two cases) and free radial artery forearm flap (one case) were carried out to reconstruct the excisional defect. It is sue transfer is a good choice in the reconstruction of deep extensive scalp defects.

Introduction

Malignant degeneration in long-standing bum scars is frequently seen in clinical observation. In particular, ulceration, which will heal spontaneously with appropriate treatment, may occur in patients who suffered burns in early childhood and have lived their lives with the burn scar. Malignant transformation of unstable bum scars must however also be considered as their malignant potential is always present. A malignant neoplasm can appear in the burn scar in the scalp region' or other parts of the body, such as the lower' and upper' extremities and the prestemal region.
The exact incidence and precise mechanism of the malignant degeneration of bum scars are not known. The commonest histological type of burn scar carcinoma is squarnous cell carcinoma Basal cell carcinoma is believed to occur when the bum is more superficial and the hair follicles and sebaceous glands are intact.
Different reconstruction techniques have been described for repairing scalp defects created by tumour excision. These techniques depend on the extent of the tumour. Local rotation or transportation flaps are widely recommended and are particularly useful in bringing hair-bearing skin to sites that require hair for aesthetic reasons The multiple flap technique described by Orticocheall and Jurill and the pericranial flap described by Fonsecall may not be sufficient to cover defects after excision of extensive tumours in burn scars. Distance flaps, both tubed" and flat," may be required when the skin is insufficient to cover major defects.
Free flaps transferred from a distance by means of microsurgical techniques are reliable procedures for the coverage of major scalp defects. These flaps offer the great dvantage of one-stage repair with rich vascularization providing abundant skin and subcut~ groin flap," free thoracodorsal axillai artery flap, free latissimus do flap and free inferior epigastri advocated for this purpose.
This paper presents three patients who had lived many years with a bum scar on the scalp, aft r bum scar carcinoma during adolescence. Because of the wide expansion of the tumour and infiltration to the cranium, extensive excisions were performed and the scalp d~fects were repaired with free tissue transfers.

Case reports
Case 1

F.A., a 39-year-old female, had suffered during infancy a deep bum in the parieto-occipital region, living a zone of instability in the central area or me scar admission a tumoral mass developed in treated in another hospital with local thickness skin graft (STSG). On admis sented a grey-brown cauliflower-like t to-occipital region (Figs. la, b). Biop! tumour was a squamous cell carcinon palpable adenopathy in the left cervica indicated erosion and destruction of th( ded to perform a wide excision of the cred during infancy n, leaving a zone of Six months before the scar which was excision and splition the patient preumour in the pariey revealed that the a. The patient had area. Radiography cranium. We deciscalp and cranium, with the aid of a neurosurgeon, and t ? use a free flap for coverage. Following wide excision the scalp defect measured 10 x 14 cm, with a cranium defec of 8 x 10 cm and a dural defect of 5 x 5 cm (Fig. ]c).

Fig. la - Recurrent and advanced squamous cell carcinoma on burn scar, occipital area; posterior view. Fig. 1b - Recurrent and advanced squarnous cell carcinoma on burn scar, occipital area; lateral view. Fig. 1c - Large excision of tumoral tissue and cra lymph node dissection performed and recipient arter: for microanastomosis. Fig. 1d - Left latissimus dorsi myocutaneous flap prepared with long vascular pedicle. Fig. le - Latissimus dorsi myocutaneous flap su and microvascular anastomosis completed. Donor area mostly primarily. Split-thickness skin graft in only a small area Fig. 1f - Flap and split-thickness skin graft on tenth day after flap operation

modified cervical lymph node dissection, a left free latissimus dorsi (LD) myocutaneous flap was prepared, as described by Maxwell et al." (Fig. Id). The LD myocuta neous flap was sutured to the parieto-occipital area. End to-end arterial microvascular anastomis was performed on the external carotid artery just after the facial branch and the thoracodorsal vein was sutured end-to-( nal jugular vein. On removal of the micro the flap immediately became full and pink. excessive tension of the distal suture line,  sutures were removed on distal skin edges, replaced on the LD muscle in the distal at The donor area was mostly sutured primar area measuring 6 x 8 cm was covered " post-operative course was uneventful.

Case 2

A.B., a 55-year-old male, had suffefed head burns during childhood. Five years ago the scar became unstable and there was a non-healing wound in the frontoparietal region. STSG was applied after excision ~f this area. On admission the patient presented ulceration mass in the parietal region (Fig. 2a). Ther~ ble regional adenopathy. Radiography showed erosion and destruction of the cranium in this area. A biopsy revealed the tumour to be a basal cell carcinoma. Following extensive excision the scalp defect in the parietal area measured 8 x 12 em and the cranium defect 7 x 11 ern (Fig. 2b). There was no dura defect. We decided to use a free radial artery (RA) forearm flap from the patient's right forearm. This flap was prepared as described by Soutar et al.' (Fig. 2c). The free forearm flap was sutured to the open area in order to cover the defect (Fig. 2d). The superficial temporal artery was too thin and its diameter too small and we considered that its arterial blood flow would not be sufficient to nourish the forearm flap. The radial artery of the flap was therefore anastomosed to the external carotid artery using a 6 em vena interposition. Two vein microanastomoses were performed: vena comitans to the facial vein, and the subcutaneous vein of the flap to the external jugular vein. On removal of all clamps, the free forearm flap immediately became full and pink. MG was applied to the donor defect. The post-operative course was uneventful and there were no post-operative flap or donor area complications (Figs. 2e, f).

Fig. 2a - Basal cell carcinoma in parietal region. Fig. 2b - Excision of tumour and cranium. Fig. 2c - Radial artery forearm free flap prepared and ready for transfer. Fig. 2d - Radial artery flap on parietal region. Fig. 2e - Two weeks after flap operation.

Case 3

H.C.. a 60-year-old male, had su the bilateral parietal area in infancy scar in this area. On admission he pres tumoral lesions. Biopsy in the area in cell carcinoma in the scalp (Figs. 3a, b pable regional adenopathy. Radiogragraphy showed erosion and destruction of the parietal cramu excision the scalp defect measured 14 the cranium defect 12 x 12 em and t em. The dura defect was repaired wit the fascia lata. It was decided to cov free LD flap. The LD flap was elevated pedicle with an 18 x 20 cm skin isla replacement of the LD myocutaneo defect area, the thoracodorsal artery the left external carotid artery after it the vein to the external jugular vein. were performed end-to-end. On removal of all clamps the flap immediately became full and pink (Figs. 3e, 1). The donor area was partly closed primarily and partly with STSG in the area. During the post-operative course a partial flap necrosis developed in the distal skin portion of the flap. The necrotic portion was excised, and STSG was ured to the occipital area or area mostly sutured 11 area.

Discussion

Bum scar carcinoma occurs at an~ predilection." According to Nancarrm cer by definition has a latent period, ( induction mechanism may be added t producing neoplasia. There is an i between age at the time of the orig latent period.' Burn scars on the exl scalp tend to be unstable. A scar is when it corresponds to a zone of sm the slightest trauma can cause it to ulc ation would therefore appear to be neoplasia.' Malignant transformation ble scars.
We present three cases of burr dating from childhood which had not developed into neoplasia; there had been occasional episodes of ulceration, demonstrating the characteristics of the unstable scar; malignant transformation was observed at later stages. Case 2 is particularly interesting. Malignant transformation was not observed in the unstable scar lesions which developed in the frontoparietal region and were previously treated with STSG. This observation supports the protective role of the grafting method.
In the cases we report, it was observed that tumoral tissue affected the cranium, and the full layer of the cranium was excised. As the burn scar surrounded the tumour, local flaps could not be performed. Local scalp flaps and pericranial flaps were not sufficient for this particular of bum scar area.
In such cases free flaps are a good choice. Various free flap methods have been reported for the closure of large scalp defects. McLean and Bunckell reported the first successful coverage of the cranium by free tissue transfer using omental transplantation and split-thickness grafting. Although omenturn can easily cover large defects of the head it cannot provide durable cover, and laparotomy is required. Various flaps have been applied, according to the characteristics of the individual case: free groin flap, free RA forearm flap, free LD myocutaneous flap, and inferior epigastric flap.' If after excision the defect is very large, the extensive flaps suggested by Batchelor and Sully may be used. A large free tissue transfer was required for reconstruction. Cases requiring such a large flap are however rare.
After excision of the tumour in the area covered by the burn scar, microvascular anastomoses are performed in a distant area, so that well-vascularized tissue can be transported. As a result well-vascularized tissue is transferred to a poorly vascularized area. In our cases, the LD myocutaneous flap transferred to resurface the defects in occipital and parieto-occipital regions was sufficient, length of the vascular pedicles was adequat need to perform a vein interposition (Cases length of the vascular pedicle is sufficien neck, and interpositional vein grafts are necessary. For the RA forearm flap, the vasc long enough to reach the superficial temp( vein, if this artery and vein are available. Otl graft is required to reach the neck vessels, Chicarilli et al. were able to use the suped artery in all the cases presented in their paper.
In one of our patients (Case 1), in % formed scalp reconstruction by means of an neous flap, the distal sutures were remov overcome excessive tension in the flap. In
Case 3 skin necrosis developed, including the distal myocutaneous flap. This was excised and resurfaced by means of STSG. In our opini necrosis in this patient was due to the flap's tation. Hardesty et al state that when larg  muscle flaps are used in vertically oriented defects, the weight of the flap, subjected to gravity, may pull the flap away from the recipient inset suture line prior to flap adherence, and the tension at the superior aspect of the wound caused by gravitational pull may result in local ischaemia followed by necrosis of the suture line and thus partial flap loss and separation.
The presence of clinically positive lymph glands at the time of presentation is very important. One of our patients (Case 1) had palpable lymph nodes on admission and we performed regional lymph dissection. In the other two cases there were no palpable lymph nodes on admission and we did not perform lymphadenectomy. According to Nancarrow,' block dissection should be reserved for clinically involved glands only. In the absence of palpable node involvement, prophylactic node dissection is not necessary on a statistical basis. The patient must however be observed at frequent intervals.
Microvascular free tissue transfer has a number of distinct advantages, including avoidance of the size and reach limitations imposed by regional of one-stage reconstruction without n procedures, essentially unrestricte( compared with local or regional flap lity in designing and transferrin Microsurgery is not however without cations, problems and risks.

Fig. 3a - Extensive bum carcinoma on scalp a cranium with tumour. Fig. 3b - Extensive burn carcinoma on scalp and cranium with tumor. Fig. 3c - The latissimus dorsi myocutaneous free flap with its long vascular pedicle. Fig. 3d - The latissimus dorsi myocutaneous free vascular pedicle. Fig. 3e - Latissimus dorsi myocutaneous flap or parieto-occipital area microvascular anastomosis performed in the left neck vessels. Fig. 3f - Latissimus dorsi myocutaneous fia microvascular anastomosis performed in the left neck vessels.

RESUME. La possibilité du développement malin d'une cicatrice instable après brûlures est toujours présente. Il peut se région du cuir chevelu comme dans les autres régions du corps, en particulier les extrémités supérieures et inférieures et nale. Les auteurs présentent trois cas d'une tumeur étendue du cuir chevelu qui s'est manifestée dans une cicatrice instable faut effectuer une excision étendue et profonde dans ce type d'invasion tumorale dilatable, et les lambeaux locaux ou régio suffisants pour reconstruire ce défaut complexe du cuir chevelu. Après l'excision étendue de la tumeur les auteurs ont appl libre myocutané latissimus dorsi (deux cas) et un lambeau libre de l'artère radiale de l'avant-bras (un cas) pour reconstrui l'excision.

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