期刊名称：ePlasty: Open Access Journal of Plastic and Reconstructive Surgery
印刷版ISSN：1937-5719
出版年度：2018
卷号：18
语种：English
出版社：Open Science Co. LLC
摘要：DESCRIPTIONA 41-year-old woman with a history of flame burns to her neck, chest, abdomen, and upper and lower extremities bilaterally presented to the clinic for reconstruction following bilateral mastectomy for breast cancer. She subsequently underwent excision of contractures on her neck and left upper extremity with reconstruction using bilateral pre-expanded latissimus dorsi (LD) myocutaneous flaps.QUESTIONSWhat is the pathophysiology behind the formation of burn scar contractures?What are the options for reconstruction of neck contractures?What are the options for reconstruction of upper extremity contractures?What is the pre-expanded LD concept?DISCUSSIONBurn injuries remain a common cause of traumatic injuries worldwide and can lead to significant deformity secondary to scar contractures. After full-thickness skin loss, wound contraction and epithelialization from the margins lead to contractures.1Risk factors for developing contractures include a prolonged inflammatory state, high microbial burden, increased burn depth, wound or incision site tension, and genetics. A variety of treatments exist, including surgery and CO2laser therapy, with the basic tenet of treatment being tension release. Burn scar contractures of aesthetically and functionally sensitive areas demonstrate a particular challenge to the reconstructive surgeon.Contractures of the neck may distort facial features and limit neck mobility; therefore, reconstructive goals focus on restoration of neck mobility and function while maintaining pleasing facial aesthetics. Scar contractures may be released and excised, with the resultant defect being reconstructed with skin grafting.2,3Pedicled flaps from the chest, back, or cervicohumeral region may be also used for reconstruction and demonstrate a lower risk of postoperative contracture as compared with skin grafting. Pre-expansion of both locoregional and free flaps offers several advantages including increasing flap size and thinning of tissue for better contour, which holds particular importance in neck reconstruction.4Similarly, upper extremity contractures have significant morbidity to function and mobility. Reconstructive options for upper extremity contractures include skin grafts, local skin/fasciocutaneous/muscle flaps, and free flaps.5Full-thickness skin grafts are preferred over split-thickness grafts, as the former gives a more durable and cosmetically pleasing result with a lower risk for recontracture. In the case of an extensive burn, a full-thickness skin graft is impractical and a flap reconstruction is often necessary.2Both local and free flaps have been successfully used in burn contracture reconstruction. The major advantage of using flaps is the low reoccurrence rate.5Tissue expansion is a well-accepted and reliable method to provide extracutaneous tissue in reconstruction. Pre-expansion has also been shown to improve flap vascularity by increasing both the number and caliber of vessels in the flap.6These characteristics of expanded tissue prove worthwhile in burn reconstruction when nonburned/noncontracted tissue can be difficult to find. We describe a patient who underwent reconstruction of burn scar contractures to the neck and left upper extremity using pre-expanded LD flaps. Tissue expanders may be placed under the latissimus muscles and expanded to the desired size.7,8After expansion and allowing sufficient time for tissue remodeling (maximized at 6-12 weeks following expansion), the LD flap is raised in the standard fashion. The flap can be tunneled through the axilla for use in neck, chest, or upper extremity reconstruction, or it may be used as a free flap for distant reconstruction.A 41-year-old woman presented to the clinic for discussion of breast reconstruction following a diagnosis of right-sided breast cancer. She reported a history of 80% to 90% total body surface area burns sustained in adolescence. On examination, she was noted to have burn scar contractures to her neck and upper extremities (Figs 1a–1b). Given the severity of her neck contractures, we decided to place bilateral LD tissue expanders at the time of her mastectomy for later scar revision, in addition to placing breast tissue expanders for delayed breast reconstruction. Postmastectomy, each LD tissue expander was inflated to 1000 cm3to maximize flap dimensions (Figs 1c–1i). The patient was then taken to the operating room for excision and reconstruction of her neck contractures. The pre-expanded right LD flap was used to cover the neck defect on the left after scar release (Figs 2a–2c). As we were able to obtain satisfactory neck closure using the right LD flap alone, the patient underwent a second operation to excise and reconstruct her left upper extremity contractures, using the pre-expanded left LD flap (Figs 3a–3c). Postoperatively, the patient reports doing well with improvement in her mobility and function (Figs 4a–4g). This case demonstrates the utility of pre-expanded flaps for use in burn scar reconstruction.
