Pre-expanded occipito-dorsal flap reconstruction for neck burns: A novel approach
© Author 2014
Received: 26 November 2013
Published: 6 April 2014
Reconstruction of the neck following a burn injury poses a significant challenge to reconstructive burn surgeons. Here, we report a case of successful application of pre-expanded occipito-dorsal flaps in the reconstruction of postburn scars and contractures in the neck. The patient was a 10-year-old boy who sustained scars and contractures secondary to a burn injury 4 years ago. “Super-thin” flaps were obtained through pre-expansion in the occipito-dorsal area and then transferred to the recipient site. This approach resulted in an esthetic satisfaction and a significant functional improvement, thereby having significant clinical implications in the reconstruction of soft tissue damage secondary to burn injuries in the neck.
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Transfer of “super-thin” flaps expanded from the occipital, clavicular, or pectoral area has been previously described as an alternative approach to minimize the risk of complications associated with the conventional reconstruction techniques.  Here we report a case of successful reconstruction of postburn scars and contractures in the neck using pre-expanded occipital dorsal flaps.
Tissue expansion is an effective method for replacing scarred tissue secondary to burn insult. Being increasingly applied in reconstruction of the head and neck, this technique enables generation of flaps with a good cosmetic color match and reliable vascularity of an axial or random pattern.
The occipito-cervico-dorsal flap that is based on a descending branch of the occipital artery and arises close to the junction of rectus capitis and trapezius has been described previously. In this flap, the occipital artery, transverse cervical artery, circumflex scapular artery, and dorsal intercostal perforator artery are all closely related, but have distinct anatomical territories which can be visualized with a hand-held Doppler device. Although distal partial necrosis may occur in larger flaps and thus restrict the size of the donor tissue that can be raised, modification of the pre-expansion procedure performed in this case study significantly improved primary closure of the donor wound and the post transfer vascularity in the flap. Moreover, with the help of a portable Doppler, the extent of dissection required can be minimized.
In general, our unit prefers using expanded supraclavicular or pectoral skin whenever available, since it allows for vertical transfer rather than pedicle rotation. However, pectoral and supraclavicular skin was heavily scarred due to the original burn injury in the patient reported in this paper, and occipito-dorsal flap was the only source of local autologous skin for neck reconstruction. To avoid possible failure of the distal flap associated with aggressive thinning, we adopted a delayed liposculpture approach. Additionally, we utilized tissue expansion that might have conditioned the flap vasculature, thus increasing the chance of a successful outcome. It would be our interest to evaluate the possibility and benefits of using a central skin bridge to ensure the expander pockets remain separate in future.
In summary, this case report suggests that pre-expanded occipito-dorsal flap is worth considering when supraclavicular skin is not available for neck reconstruction. Although the skin on the back may be thick in some individuals and thus impose a limitation to the application of this flap, flap thinning using liposuction technique may be an effective solution. Nevertheless, patients should be counseled on the risks of tissue expansion and skin necrosis.
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