SUMMARY. The expanded shoulder flap is presented as an alternative for the treatment of cervical retraction secondary to burning. The flap has an axial pattern, mainly based on the transverse cervical artery.The anterior limit of the flap is a line that goes from ear lobule, towards the shoulder, to the deltoid muscle. The incision for inclusion of the tissue expander is made at the shoulder, and on that line, with extension and posterior, lateral and medial detachments broad enough to slightly exceed the expander dimensions, with the valve being placed in infraclavicular position.In the immediate postoperative period, a volume around 15 % to 20 % of the tissue expander's total capacity was infiltrated, which was followed by weekly infiltrations until the expanded area reached a circumference approximately 2 to 3 times larger than the supposed wound after creating the resection of the retraction.The expanded shoulder flap allows coverage of large extensions, by using a single donor shoulder, as it permits not only release of retraction, but also replacement of associated cervical scars by leaner skin, better adjusted to the region's anatomy.Twelve patients were treated with this method, with good results in all cases, and there being no flap delay. Closing of the donor area happened without any stress, which resulted in scars of good quality.
Verwendung des expandierten Schulterlappens bei den Verbrennungsfolgen
Almeida M. F.
Der expandierte Schulterlappen wird als eine Alternative zur Behandlung der narbigen Halskontrakturen infolge einer Verbrennung vorgestellt. Es handelt sich um einen Achsenlappen, der von A. cervicalis transversa versorgt wird. Die vordere Abgrenzung des Lappens bildet eine Linie, die von dem Ohrlappchen bas zum Deltamuskel verlauft. Die Inzision auf der Schulter zur Einlegung des Gewebeexpanders war auf dieser Linie plaziert. Es wird r0ckwarts, lateral and medial so prapariert, dass der gestaftete Raum ein wenig grosser als die Abmessungen des Expanders wird. Port wird in der subklavikularen Region plaziert. Unmittelbar nach der Operation wurde der Expander auf etwa 15-20 % des Gesamtvoluments eingefiilit. Die Abfiillung setzete weiter einmal in der Woche fort solange die expandierte Region einen zwei bas dreimal grdsseren Umfang als der Umfang des vorausgesetzten, nach der Exzision der Narbe gestalteten Defektes aufwies. Mit Verwendung einseitigeres expandiertes Schulterlappens konnen merkliche Defekte gedeckt werden. Expandierter Schulterlappen ermoglicht nicht nur Lockerung der Halskontraktur, aber auch dern Ersatz der Narben durch die Haut, die der befallenen Region entspricht. Mit Verwendung dieser Methode wurde 12 Patienten behandelt. Die Ergebnisse waren in alien Falle gut. Die Delay Technik wurde bei der Vorbereitung des Lappens nicht verwendet. Der Verschluss des Sekundardefektes konnte durch eine gerade Sutur ohne Spannung gemacht werden. Die resultierende Narben wies eine gute Beschaffenheit aus.
Key words: epaulette flap, neck reconstruction, expanded flap, cervical contracture
Cervical contracture is usually a result of 3ra degree burns affecting that region, frequently associated with gross deformities of the face, such as inferior labial and palpebral ectropion, besides deviations of the labial commissure, nose and ears (8).
When treatment is not performed in due time and manner, a classical synechia which may lead to formation of a keloid similar to a tumor, involving skin, the platysma muscle and the superficial cervical aponeurosis occures. If occurring during childhood, it may cause mandibular deformities and luxation of cervical vertebrae.
Time elapsed before the appearance of sequelae is variable, usually around 6 months after the accident, although, in severe traumas, they may be visualized by the 3`a month. In one year they will have assumed definitive characteristics.
Tissue elasticity capacity is a physiological phenomenon that can be observed during the individual's growth phase, in the abdomen during pregnancy, and in the breasts during puberty and breastfeeding.
According to Pitanguy, the pioneers in the use of these principles were the Brazilian Indians, through the introduction of decorative objects of increasingly larger sizes in the ears and lips (11).
Mutter, in 1842, was the first to describe the transposition of a shoulder cutaneous flap for repair of the neck's anterior region, in post-contracture by burning, according to several researches (1, 3, 15).
In 1951, Iturraspe described its use in the treatment of anterior cervical radiodermatitis (7).
Neumann, in 1957, presented the first clinical report of the use of a skin expander, reflecting the use of an air inflated balloon for partial reconstruction of the auricular pavilion, thereby obtaining a 50% gain in extension (9).
Initially devised for mammary reconstruction, the tissue expander model now in use was created by Radovan, in 1976 (12).
In 1978, Arufe reported vast case reports and experience in the use of non-expanded shoulder flap, started in 1953 (1).
Austad and Pasyk, in 1982, described histomorphological alterations of skin and subcutaneous cellular tissue in animal experiments. They conclude that the derma and the subcutaneous cellular tissue have their thickness sharply decreased in the expanded tissue, whilst the epidermis does not show significant alterations (2).
Cherry and Austad, in 1983, analyzed the characteristics of flaps submitted to expansion, and observed their greater vascularization and viability in comparison with delayed flaps. They suggested maintaining the fibrous capsule as a means to increment blood supply (4).
The objective of this paper is to present our experience with the expanded shoulder flap in the treatment of post-burn cervical retraction.
This flap was used in 12 patients, 7 female and 5 male, with ages ranging between 16 and 63.
The expanders used had a 400 ml capacity (3 cases) or a 500 ml capacity (9 cases), and featured a rectangular format, smooth surface and remote adult valve.
Initially, a line was drawn from the ear lobule, towards the shoulder, to the deltoid muscle, representing the flap's anterior limit. An incision was made at the shoulder and on that line, for inclusion of the expander, with extension and posterior, lateral and medial detachment broad enough to slightly exceed expander dimensions. The valve was placed in infraclavicular position. If needed, this anterior limit may be exceeded, without compromising flap safety. The area to be detached was previously infiltrated with a 0.25% lidocaine solution with adrenaline at 1:200,000 U.I. We aimed at placing the tissue expander at 1 cm to 2 cm away from the incision. Synthesis was performed in three planes, with non-absorbent threads.
In the immediate postoperative period, a volume around 15 % to 20 % of the tissue expander's total capacity was infiltrated, varying according to the degree of skin stress observed. The following infiltrations were of 10 % of the tissue expander's total volume, with a 10day interval for the subsequent infiltration and 7-day intervals for the remainder. All infiltrations were done with scalp number 25.
Expansion progressed until the circumference of the expanded area reached a size of approximately 2 to 3 times the width of the supposed wound to be created after resection of the retraction.
Between one to two hours before the final surgery, a supplementary infiltration of physiological serum was made until cutaneous stress was obtained, with the aim to achieve some extra expansion. Prophylactic antibiotic therapy was applied for 24 hours.
All the related retraction cases were satisfactorily treated, leading to functional recovery of the region, including total or partial removal of adjacent scars. Complementary procedures for treatment of the associated defects, such as the labial ectropion, other retractions and unfavorable face scars, were preferably treated during the same surgical procedure, whenever possible.
In one of the cases we had to interrupt the expansion due to exposition of the prosthesis (8.3 %). Even so, we chose to transpose the flap, thus achieving a good final result.
In none of the cases was re-expansion performed. There were no cases of hematoma, infection or necrosis of the flap. There was one case of seroma (8.3 %) in the expander pocket, which resulted in its removal and posterior re-insertion. With 8 patients, late resection of a "dog ear" was done at the flap base.
Reconstruction of large retractions is a challenge for plastic surgery. The creation of the tissue expander made it possible to approach such regions, by applying similar tissues, with a minimal sequela of the donor area.
Post-burn cervical retraction is an extremely limiting sequela from the functional standpoint, as not only does it restrict extension and lateral head movements, but also leads to inferior labial ectropion, exteriorization of the tongue and open bite, in those cases initiated in childhood. There may also happen association keloid formation, with frequent ulcerations, pain, pruritus, and likelihood of malignant alteration.
Success or failure of the process of insertion, expansion and transposition of the flap - as emphasized by several authors - will be determined by the planning, execution and postoperative period of the first surgical procedure (6, 11, 13).
The viability of inclusion of the tissue expander for this procedure depends on the existence of healthy skin in one of the shoulders. In the absence of that, other alternatives should be considered, such as flaps - either expanded or not - from adjacent regions, grafting and partial resections.
For the prescription of expansion, we should also consider the place of origin of the patient, as well as his/her psychological profile - since the infiltration sessions may require weekly commuting -, and that the patient will have to live with a transitory deformity. We prefer avoiding selfinfiltration.
Albeit numerous, the existing rules guiding the determination of the amount of tissue needed to cover the defect are not precise (6, 14). The diameter of the expanded area served as a reference in the related cases, since the main objective was to liberate retraction, while resetting the affected skin in the possible measure. We should also consider that, in case of necessity, the capacity of the tissue expander may be exceeded up to 30 %. However, there is the risk of this increased volume leading to an excessive pressure inside the tissue expander, which might lead to dome leakage (10).
Placement of the valve above or laterally to the tissue expander, with the aim of minimizing reflux, would result in its positioning near the pedicle, and was therefore avoided.
The use of a drain was rendered unnecessary by the associated infiltration of an adrenaline solution, detachment in a relatively bloodless plan and filling of the pocket by the 1" immediate postoperative expansion.
As for positioning the tissue expander immediately below the defect, its insertion in the shoulder has advantages associated with a reduced tendency to retract downwards tractioning and distorting face structures, besides allowing firstly the approach of the central region of the defect.
In regard to the flap, the irrigation pattern is axial, mainly based on the transverse cervical artery, a branch of the subclavianartery, described by Gilmore and Olson (5), and by Arufe and cols (1), which is a fact that would dispense delay, recommended by some authors (1, 15). In any event, the expansion would ensure increased blood apportionment of up to 117 %, superior to that obtained by delay, which would stay at around 73 % (4). This would enable the expansion of flap dimensions, while allowing a broader potential coverage of the defect.
The shoulder is acknowledged as the best donor area for the face and neck, when there is no possibility of using flaps from the same anatomic regions (1). Expansion would lead to leaning of the flap, with a resulting better adjustment to the neck's anatomic contour.
The expanded flap enables coverage of large areas, allowing the ear opposite the flap to be reached. This fact, besides granting liberation of the retraction, allows a large portion of the cervical scar to be resected, without any difficulties posed to the closing of the donor area (15). It further allows the use of a single shoulder as donor area, even when treating major deformities. Its use would therefore be indicated for cases of severe scar retraction involving the whole or part of the anterior cervical region.
Special care should be taken so as not to injure the accessory nerve, normally visualized during flap dissection. It innervates the trapezium and sternocleidomastoid muscles, and damage to it would bring about a fall of the shoulders and difficulties in raising the arm, as main deficits.
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Fig. 1. Anterior cervical retraction, sequela of burning: A - anterior view; B - lateral view; C - pocket created for inclusion of 500-m1 tissue expander. Detail of the dissected accessory nerve; D - expanded flap, showing a dome of 24 cm x 21 cm;
E - anterior view during postoperative period, after 1 year of evolution; F - profile view, after 1 year of evolution.
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Fig. 2. Anterior cervical retraction, burn sequela, with inferior labial ectropion:
The expanded shoulder flap was used with 12 patients, with good results in all cases. It allowed coverage of large dimensions, providing not only release of retraction but also resection of adjacent scars, and replacement by skin with histological characteristics similar to those of neck skin.
This axial pattern flap has broad reach and is characterized by simple execution and low morbidity. It shows high effectiveness associated with a satisfactory aesthetic result, and represents a safe alternative to the flaps presently used for reconstruction of the cervical retraction secondary to burns.