Annals of Burns and Fire Disasters - vol. XXVII - n.

4 - December 2014

FREE THIN ANTEROLATERAL THIGH FLAP FOR POST-BURN NECK

CONTRACTURES - A FUNCTIONAL AND AESTHETIC SOLUTION

Sarkar A.,1 Raghavendra S.,1* Jeelani Naiyer M.G.,1 Bhattacharya D.,1 Dutta G.,1
Bain J.,1 Asha J.2

Department of Plastic & Reconstructive Surgery, IPGME&R, Kolkata, India

1

Department of Surgery, MR Bangur Hospital, Kolkata, India

2

SUMMARY. Neck contractures after burn injuries produce restrictions in motion and unacceptable aesthetic outcomes. Although
different methods of reconstruction have been used in the treatment of this ailment, a limited and unsatisfactory outcome often re-
sults. Free thin anterolateral flaps have been found to be a good single stage option for reconstruction of post-burn contractures of
the neck. In our study, 11 patients with post flame burn contractures of the neck underwent surgical release and coverage by a free
thin anterolateral thigh flap. Patients were followed up for an average of five years and various aspects of functional and aesthet-
ic rehabilitation were assessed. Our findings revealed that the free thin anterolateral flaps covered the defects over anterior and lat-
eral aspects of the neck with good colour match and contour. Furthermore, none of the flaps had any significant early or delayed
complications. Two cases had to be reoperated for partial loss of flaps and all patients were satisfied with functional and aesthet-
ic outcomes. We therefore consider free thin anterolateral thigh flaps to provide a good single stage reconstruction for post-burn
cervical contractures with good functional and aesthetic outcomes.

Keywords: post-burn neck contractures, anterior cervical contractures, anterolateral thigh flap, free thin anterolateral thigh flap

Introduction procedures and to avoid emergency releases under less con-

Burns of the head and neck have always presented a
challenge to burn teams. With a steady decline in the mor-
tality of burn patients over the past six to seven decades,
addressing the issues of debilitating post-burn sequelae has
become more vital in order to adequately rehabilitate sur-
vivors into society. A burn patient who receives the best
1
trolled conditions.3 Anterior cervical contractures cause
considerable problems, including flexion deformity with
restricted extension, lateral flexion and rotation, headache
and neck pain, insomnia, depressive illness, lip ectropion
(oral incontinence, drooling), micrognathia, and poor aes-
thetic appearance. Although different methods of recon-
struction are used for the treatment of neck contractures,

of treatment, including early physiotherapy, adequate splin-
tage in position of function and early debridement with
skin grafting is expected to heal without any significant
contractures. However, post-burn contractures are dis-
tressingly common in India and other developing nations.
The incidence of burn cases has been estimated to range
from 60-70 lakhs annually in India.2 In the emergency set-
ting, most cases are treated in ill-equipped peripheral units
with inadequately trained staff. This, in turn, gives rise to
the enormous burden of post-burn contractures and defor-
mities which have to be dealt with in the comparatively
few tertiary care centres.2
Neck contractures often take priority over other areas,
depending on the severity of disfigurement. Early neck re-
lease may be necessary to facilitate intubation for elective
including the use of split-thickness skin graft, local flaps,
local flaps combined with split-thickness skin grafts, ex-
panded local flaps, thin pedicled flaps, free flaps, and ex-
panded free flaps, a limited and unsatisfactory outcome of-
ten results.4-9 One of the reasons for this is that the exact
dimension of the defect is in fact greater than expected
because of contraction of adjacent tissues. Reconstruction
of this area therefore remains a challenging problem in
terms of restoring both function and appearance.
Free flaps have advantages in terms of providing tis-
sue with similar colour and texture that gives good neck
contour with minimal donor site morbidity. Also, prolonged
periods of neck splintage are not required, the pliability of
the flap results in excellent neck mobility after postoper-
ative rehabilitation, and only a minimal chance of recur-

* Corresponding author: Dr. Raghavendra S., no.1-4-155/138, “Ganesh Nilaya”, Jyothi Colony, Raichur-584101, Karnataka, India. Tel.: +91-9830322400; e-mail:
doctorraghavendra@yahoo.co.in

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Annals of Burns and Fire Disasters - vol. XXVII - n. 4 - December 2014

rence exists.10,11 We therefore used a technique of free thin

anterolateral thigh flap in an effort to improve the outcome
after excision of post-burn anterior cervical contractures.

Methods

The study period was from March 2005 to July 2010.

Eleven patients with anterior cervical contracture under-
went free flap reconstruction at our Hospital. There were
seven women and four men, with a mean age of 31.9 years
(range: 19 to 45 years). In all cases the injuries were caused
by flame burns. All patients had been treated for burn in-
juries at primary care and district hospitals, with incon-
sistent splinting history. The goals of surgical reconstruc-
tion of post-burn anterior cervical contracture with free
flap were twofold: to improve the functional capacity of
patients measured in terms of improvements in neck flex-
ion, extension, lateral flexion and rotation; and to improve
the aesthetic appearance of the patient in terms of en-
hancing the cervicomandibular angle and resurfacing the
burn scar over the anterior neck.
Fig. 1 - Pre- and post-operative images of patient.
Procedure

The apparent defect size was estimated by comparing
each patient with another person of similar height and
weight. The patient was placed in a supine position with
the neck in hyperextension. Fibreoptic tracheal intubation
was done for anesthesia. Two teams worked simultane-
ously to carry out excision of the cervical scar and to har-
vest the free flap. Vasoconstrictive agents (epinephrine
1:100,000) were infiltrated into the scar. The initial inci-
sion was made from the scar down to the investing layer
of the deep cervical fascia. The scar was excised with the
end point being full cervical extension. The average size
of the defect was 8x7cm. Dissection of recipient vessels
was performed. Anterolateral thigh flaps were used from
an unburned thigh. Preoperatively, perforators were iden-
tified with a hand held Doppler probe around the midpoint
between the anterior superior iliac spine and the supero-
lateral border of the patella. An incision was made 2.5cm
medial to this straight line above the fascia and a subfas-
cial dissection was performed to identify perforators pierc-
ing the fascia arising from branches of the lateral circum-
flex femoral system. The descending branch of the later-
al circumflex femoral system was easily found after re-
tracting the rectus femoris muscle medially. The skin is-
land was designed only after localizing cutaneous perfo-
rators. An average 10x8cm wide anterolateral thigh flap
was used.
Approximately 1cm of fascia was preserved around the
perforator to ensure integrity of the perforator and to dis-
tribute the force of traction. Retrograde intramuscular dis-
section was performed along the direction of the chosen
musculocutaneous perforators under loupe (4.5 x) magnifi-
cation. The motor nerve to the vastus lateralis was pre-
served to maintain function of the residual muscle. After
harvest, the flap was thinned down to 0.5-1cm thickness
by removal of subcutaneous fat. The average diameter of
the artery and the vein was 2.2mm and 2.5mm, respec-
tively. Primary donor-site closure was attempted where pos-
sible but was only achieved if the width of the harvested
flap was less than 7cm. A split thickness skin graft was
used for coverage in the rest of the cases. Insetting of the
flap to the defect was done with 3-0 polypropylene half
buried mattress sutures. End-to-end microsurgical anasta-
mosis of the vessels was then performed using 10-0 nylon
under a microscope. A closed suction drain was placed un-
der the flap and at the donor site wherever primary closure
was carried out. Postoperative splinting was not necessary.
Patients were followed up at a plastic surgery facility.
Results
All flaps survived well. In two cases there was partial
necrosis of the flap (<1/4th), which was managed by split
thickness skin grafting. Two cases had distal epidermal
loss of 3cm of the flap which was managed non-opera-
tively. Pre-operative and post-operative images for the pa-
tients are shown in Figs. 1,2 and 3. The complications can
be attributed to excessive defatting, the long distance from
only one perforator and to the flap design. The average
operative time was 6.5 hours. The donor sites were closed
primarily in four cases and by using a split-thickness skin

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 Annals of Burns and Fire Disasters - vol. XXVII - n. 4 - December 2014

Fig. 2 - Pre- and post-operative images of patient. Fig. 3 - Pre- and post-operative images of patient.

graft in the other seven cases. There were no donor site

complications. After an average of 5 ½ years of follow-
up, the average cervicomandibular angle was improved by
59.28 degrees (preoperatively, 55.72 degrees; postopera-
tively, 115 degrees). The average defect after release of
contracture and scar excision was 7.6 x 7.3 cm. The av-
erage dimensions of the flaps were 9.2 x 8.6cm. The func-
tional improvement was evaluated as follows: a mean in-
crease in extension of 35.09 degrees (pre-operatively, 18.09
degrees; post-operatively, 53.18 degrees), a mean increase
in rotation of 46.09 degrees (pre-operatively, 29.63 de-
grees; post-operatively, 75.72 degrees), and a mean in-
crease in lateral flexion of 23.95 degrees (pre-operatively,
17.5 degrees; post-operatively, 41.45 degrees) . The aver-
age hospital stay was 16.36 days. The results are present-
ed in Tables I and II.
Discussion
Burn wounds that heal over areas of joints and near
mobile anatomic structures result in burn scars called con-

Table I - Overview of defect size, flap dimension, donor site management, complications and re-operation for each patient
Sl No Age Sex Hospital Duration Defect Flap Donor Complications Re-
(yrs) (M/F) Stay since size Dimension Site Operation
(Days) Burns (in cms) (in cms) (Y/N)
(months)
1 41 F 19 9 12x10 14x12 STSG epidermal loss distal 3 cm N
2 21 F 11 12 8x10 10x10 STSG nil N
3 36 M 30 10 11x7 13x9 STSG flap necrosis, distal 1/4th Y, STSG
4 26 M 18 11 8x5 10X6 STSG flap necrosis, distal 2cm Y, STSG
5 34 F 8 8 9x7 10x8 STSG nil N
6 45 F 10 18 5x7 6x8 Primary closure nil N
7 41 M 10 14 8x6 9x7 STSG nil N
8 19 F 20 6 10x10 12x12 STSG epidermal loss distal 3cm N
9 23 F 11 15 4x6 6x8 Primary Closure nil N
10 29 F 17 20 4x6 6x7 Primary Closure nil N
11 32 M 26 12 5x7 6x8 Primary Closure nil N
31.90 7F;4M 16.36 12.27 Avg:-7.6x7.3 Avg:-9.2x8.6

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Table II - Functional parametres, pre-operative and post-operative (all values in degrees)

Sl No Cervicomandibular Cervicomandibular Neck Neck Neck Neck Lateral Lateral
Angle Angle Extension Extension Rotation Rotation Bending Bending
(pre-op) (post-op) (pre-op) (post-op) (pre-op) (post-op) (pre-op) (pre-op)
1 60 120 5 45 12 75 10 40
2 50 115 10 48 21 70 10 38
3 55 120 8 50 10 80 15 45
4 70 125 20 52 18 72 20 40
5 60 110 30 60 40 77 20 43
6 80 115 40 58 45 75 18 42
7 3 110 10 60 25 80 10 45
8 40 105 9 45 20 70 10 35
9 50 110 22 56 45 74 23.5 42
10 70 115 25 58 40 79 26 43
11 75 120 20 53 50 81 30 43
Avg:- 55.72 120 18.09 53.18 29.63 75.72 17.5 41.45
Average Improvement in CervicoMandibular Angle: 120-55.72 =64.28 degrees
Average Improvement in Neck Extension: 53.18-18.09 =35.09degrees
Average Improvement in Neck Rotation: 75.72-29.63 =46.09degrees
Average Improvement in Lateral Bending: 41.45- 17.5 =23.95degrees

tractures that cause dysfunction of the joints and defor-
mity of the mobile structures. This is in contradistinction
to a contraction, which is an aspect of normal wound heal-
ing that causes the centripetal reduction of the burn wound
and the subsequent contracture. The contracture is defi-
cient in length and is unyielding in character. Such a scar
traversing the antecubital fossa, for example, would pre-
vent full extension of the elbow due to the inadequate
length of the scar. This contracture has been termed an ex-
trinsic contracture as it extends across a joint and con-
nects two major anatomic parts. A cheek scar pulling the
lower eyelid or the corner of the mouth into malposition
is termed an intrinsic contracture. The pathologic process
of wound contracture involves contraction of tissue by my-
ofibroblasts until the limits of motion are reached. Wound
contracture occurs during scar remodeling as collagen un-
dergoes reorganization. The resulting distortion may be ei-
ther extrinsic or intrinsic. Whereas extrinsic contracture re-
quires release, intrinsic contracture requires replacement of
tissue. Several nonsurgical methods have been proposed to
limit contractures, including external pressure (splints,
bandages, elastic garments), intralesional injection of
steroid, use of silicone gel, and avoidance of the use of
pillows while sleeping for at least a 2-month period. Un-
fortunately, these conservative measures alone achieve lit-
tle success in the case of neck contractures.
Johnson and Dalsgaard12 note faster healing and less
scarring when early tangential excision and grafting is used
in the face. Selection criteria for early excision and graft-
ing of burns to the face and neck include wounds that are
expected to take more than 3 weeks to granulate sponta-
neously, surgery that is not life threatening, and the avail-
ability of operative facilities and ancillary support. The
practice of early tangential excision and grafting has re-
sulted in fewer cases of neck contractures that are resist-
ant to treatment. Also, the use of full thickness grafts is
superior to split-thickness grafts in preventing wound con-
traction because the presence of the dermis in the graft
produces myofibroblast inhibition in the wound bed. De-
spite adhering to these principles, a small proportion of
patients still suffer from poor results, even with full-thick-
ness skin graft combined with aggressive rehabilitation and
splinting. There are several main disadvantages of skin
grafts: (1) fixation of large grafts to wound bed; (2) par-
tial/patchy nature of the graft which gives unaesthetic re-
sult and also prolongs morbidity; (3) the tendency for re-
contracture necessitating further procedures; (4) poor colour
match with surrounding skin, especially in the Indian sub-
continent; and (5) dry and scaly appearance, which is less
of a problem when using full-thickness skin grafts.13 In
these patients, the use of a free flap offers a solution for
correcting a severe functional and aesthetic impairment.
The basic principles in reconstruction of neck con-
tractures are:14,15
i) delay reconstruction until scars have matured;
ii) avoid creating vertical linear scars;
iii) orient scars parallel to relaxed skin tension lines;
iv) release extrinsic contracture before intrinsic contrac-
ture;
v) match donor skin according to thickness, colour, and
texture;
vi) advance unburned skin caudally rather than cephali-
cally when possible to decrease the possibility of ia-

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 Annals of Burns and Fire Disasters - vol. XXVII - n. 4 - December 2014

trogenic lower lip ectropion;
vii) reconstruct the contracture regions with the head and
neck in full extension, rotation, and lateral flexion to
minimize the postoperative tension;
viii) resurface according to regional aesthetic units;
ix) create the cervicomandibular contour; and
x) replace the contracture area with like tissue.
Because the burned regions limit the options of local
flaps, there is a need for microsurgical techniques for any
possible free flaps.
The ideal free flaps for reconstruction of post burn
contractures of neck should have the following features:
i) like tissue for replacing like area;
ii) thin flap for molding the cervical contour;
iii) less donor-site morbidity;
iv) sizable pedicles for microsurgical anastomosis; and
v) no need to change position intraoperatively.
If the thigh area is unburned, the free anterolateral
thigh flap has all of the aforementioned features of ideal
flaps, especially after thinning procedures. The anterolat-
eral thigh flap supplied by the lateral femoral circumflex
system was first introduced by Song et al.16 in 1984 and
was developed for widespread clinical application by
Koshima et al.17,18 in 1993. A thorough understanding of
the anatomic variations of the perforators and the opera-
tive technique is essential for harvesting the anterolateral
thigh flap safely and reliably.19 It has many advantages for
reconstruction of cervical contractures because the flap is
relatively thin, less hairy, and has good pliability in Asians.
The pedicle vessels of the flap are up to 10cm long and
are wide (approx. 2 mm), and repositioning the patient is
unnecessary for harvesting the flap. The thinning proce-
dure is performed by removal of the deep fat layer with-
out damage to the subdermal plexus. However, care must
be taken not to thin too much around the perforators dur-
ing this procedure. In addition, the donor site is far enough
from the recipient site that preparation of the flap can com-
mence at the same time as the scar excision, and because
the donor scar is in the unexposed area, its location per-
mits easy concealment with minimal clothing.
The free anterolateral thigh flaps are thinned to fit the
surface after release, scar excision without the bulkiness
that other myocutaneous and thick flaps have. Unfortu-
nately, there is poor colour and texture matching between
unburned skins and free thin flaps. Some cases also showed
hairy growth similar to the donor sites (thighs). The con-
tracture should always be released first at the full cervical
extension by the horizontal incision over the submental re-
gion, and then this cervical defect can be measured for the
requirement of flap design. Because patients are often con-
cerned about further scarring of the unburned area, pre-
operative communication with patients is important to bal-
ance the width of scar excision with the potential for pri-
mary closure of the donor site. Jui-Yung Yang et al.20 have
studied the utility of free thin anterlateral thigh flaps com-
bined with cervicoplasty for the management of post-burn
injury anterior cervical contractures with results compara-
ble to our study. Free thin anterolateral thigh flaps offer a
good option for reconstruction of postburn anterior cervi-
cal contractures after failure of other modalities and pro-
vide the potential for a one-stage reconstruction for cor-
rection of functional and aesthetic disability.

RÉSUMÉ. Les contractures du cou en suite des brûlures produisent des restrictions en mouvement et les résultats esthétiques in-
acceptables. Bien qu’il y ait différentes méthodes de reconstruction dans le traitement de cette affection, il y a souvent un résultat
limité et insatisfaisant. Les lambeaux libres antérolatérales minces ont été trouvés à être une bonne option en une seule étape pour
la reconstruction des contractures du cou post-brûlures. Dans notre étude, 11 patients atteints de contractures du cou en suite d’une
brûlure causée par la flamme ont subi la libération chirurgicale et la couverture par un lambeau libre antérolatérale mince de la
cuisse. Les patients ont été suivis pendant une moyenne de cinq ans et de divers aspects de la réadaptation fonctionnelle et esthé-
tique ont été évalués. Nos résultats ont révélé que cette solution a refait la surface des défauts plus antérieure et latérale du cou
avec une bonne correspondance des couleurs et des contours. En outre, aucun des lambeaux avait des complications précoces ou
tardives importantes. Deux cas ont dû être réopérés pour une perte partielle de lambeaux. Tous les patients étaient satisfaits des ré-
sultats fonctionnels et esthétiques. Enfin, nous considérons cette solution adéquate pour assurer une bonne reconstruction en une
seule étape pour les contractures cervicales post-brûlures avec de bons résultats fonctionnels et esthétiques.

Mots-clés: contractures du cou post-brûlures, contractures cervicales antérieures, lambeau antérolatérale de la cuisse, lambeau libre
antérolatérale mince de la cuisse

BIBLIOGRAPHY Philadelphia, 2007.

2. Hanumadass ML: Some thoughts on organization of delivery of
1. Hawkins HK, Pereira CT: Pathophysiology of the burn scar. In: burn care in India. Indian J Burns, 11: 18-20, 2003.
Herndon D (ed): "Total Burn Care", 608-19, Saunders Elsevier, 3. Wilson RD, Knapp C, Traber D L et al.: Safe management of the

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child with contracted neck: A new method. South Med J, 63: 1420-
5, 1970.
4. Masser MR: The preexpanded radial free flap. Plast Reconstr Surg,
86: 295, 1990.
5. Kobus K, Stepniewsky J: Surgery of post-burn neck contractures.
Eur J Plast Surg, 11: 126, 1988.
6. Laitung JK, Batchelor AG: Successful pre-expansion of a free
scapular flap. Ann Plast Surg, 25: 205, 1990.
7. Kenney JG, DiMercurio S, Angel M: Tissue expanded radial fore-
arm free flap in neck burn contracture. J Burn Care Rehabil, 11:
443, 1990.
8. Balakrishnan C: The preexpanded radial free flap. Plast Reconstr
Surg, 88: 171, 1991.
9. Hyakusoku H, Pennington DG, Gao JH: Microvascular augmen-
tation of the super-thin occipitocervico-dorsal flap. Br J Plast Surg,
47: 465, 1994.
10. Kobus K, Stepniewski J: Free flaps versus conventional surgery.
Ann Plast Surg, 15: 14, 1985.
11. Edlich RF, Nichter LS, Morgan RF et al.: Burns of the head and
neck. Otolaryngol Clin North Am, 17: 361, 1984.
12. Voinchet V, Bardot J, Echinard C et al.: Advantages of early burn
excision and grafting in treatment of burn injuries of the anterior
cervical region. Burns, 21: 143, 1995.
13. Iwuagwu FC, Wilson D, Bailie F: The use of skin grafts in post-
burn contracture release: A 10-year review. Plast Reconstr Surg,
103: 1198, 1999.
14. Feldman JJ: Reconstruction of the burned face in children. In: Ser-
afin D, Georgiade (eds): “Pediatric Plastic Surgery”, Vol 1, Mos-
214
by, St Louis, 1984.
15. Neale HW, Kurtzman LC, Goh KBC et al.: Tissue expanders in
the lower face and anterior neck in pediatric burn patients: Lim-
itations and pitfalls. Plast Reconstr Surg, 91: 624, 1993.
16. Song YG, Chen GZ, Song YL: The free thigh flap: A new free
flap concept based on the septocutaneous artery. Br J Plast Surg,
37: 149, 1984.
17. Koshima I, Yamamoto H, Hosoda M et al.: Free combined com-
posite flaps using the lateral circumflex femoral system for repair
of massive defects of the head and neck regions: An introduction
to the chimeric flap principle. Plast Reconstr Surg, 92: 411, 1993.
18. Koshima I, Fukuda H, Yamamoto H et al.: Free anterolateral thigh
flaps for reconstruction of head and neck defects. Plast Reconstr
Surg, 92: 421, 1993.
19. Kimata Y, Uchiyama K, Ebihara S et al.: Versatility of the free
anterolateral thigh flap for reconstruction of head and neck de-
fects. Arch Otolaryngol Head Neck Surg, 123: 1325, 1997.
20. Yang JY, Tsai FC, Chana JS, Chuang SS, Chang SY, Huang WC:
Use of free thin anterolateral thigh flaps combined with cervi-
coplasty for reconstruction of postburn anterior cervical contrac-
tures. Plastic and reconstructive surgery, 110: 39-46, 2002.
This paper was accepted on 20 October 2014.