Phẫu Thuật Tạo Hình Và Tái Tạo Sẹo Bỏng: Atlas Các Kỹ Thuật Mới

45
Suggested Reading
Grishkevich VM.  Post-burn microstomia: anatomy and elimination
with trapeze-flap plasty. Burns. 2011;37:484–9.
suggested Reading

47
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Elimination of Postburn Dorsal Nasal
Contracture
Introduction
Because of its anatomical location and forward protru-
sion, the nose incurs more severe burns, especially the
alae and dorsum. The nose is shortened, its tip is pulled
up, the nasofrontal angle (nasion) is smoothed, and the
epicanthus/fold appears at the medial corners of the eyes.
Scars in children are especially traumatic because of the
restriction of nose growth over time. Therefore, the nose
contracture should be released early, before reconstruc-
tion of the rest of the face. A wide scar in the glabella
allows for the nasofrontal angle and medial canthus of eye
to be reconstructed with local flaps; the preferred tech-
nique is trapeze-flap plasty.
Contracture Anatomy
Nasal contracture is caused by scars that spread over the nose
bridge, nasion, canthal area of the eyes, and glabella region of
the forehead. As a result of the vertical contracture of the scars,
the nasal dorsum becomes wider, scar folds form over the
medial corners of the eyes (epicanthus), the nasofrontal angle
disappears, and the nasal tip is pulled up (Fig. 5.1a, b). Because
of scar protrusion, the scar surface surplus is formed in the
zone of the nasofrontal angle (nasion) in the intercanthal
region. This allows contracture to be eliminated using local
tissues only. Therefore, nasal contractures are of the medial
type, according to our classification, and are best treated with
plasty using opposing adipose-scar trapezoid flaps.
5

48
a
b
c
d
e
f
g
h
i
Fig. 5.1  Nasal contracture released with trapeze-flap plasty. (a) Pre-­
operative view: face deformed with scars including the forehead, nose,
and medial part of cheeks; nasal contracture, nasofrontal angle
smoothed, wide; epicanthus formed bilaterally; (b) nose shortened,
nose tip elevated; (c) trapeze-flap plasty planning: opposing flaps in
nasofrontal angle zone, apex of the trapeze flap is at midline, base at
medial canthus; (d) trapezoid adipose-cutaneous flaps mobilized and
transposed towards one another; (e) transposed flaps sutured in place;
(f) end of operation; (g) 7 days after reconstruction: flaps are viable,
nose elongated by 1.5  cm, epicanthus eliminated, nasofrontal angle
restored; (h) 2 years after reconstruction: normal nasal development, no
nose contracture or deformity recurrence; (i) trapeze-flap plasty
(scheme)
5  Elimination of Postburn Dorsal Nasal Contracture

49
Surgical Technique
Reconstruction is aimed at the release of the nasal dorsum
contracture, elimination of the epicanthus, restoration of naso-
frontal angle depth, and thinner nasal dorsum (Fig. 5.1c–f).
Two trapezoid flaps are marked in the nasofrontal angle
(Fig. 5.1c). The suture is applied through the nasal tip for trac-
tion (Fig. 5.1d). The tips of the flaps correspond to the nasal
dorsum medial line and are approximately 1 cm in width; the
bases of the flaps are located at the level of the inner corner of
the eye and are approximately 1.5  cm wide. The flaps are
mobilized with a full subcutaneous fat layer until the contrac-
ture is completely released and the epicanthus is eliminated
(Fig. 5.1d). By applying traction via suture and elevating scars
on the contracted nasal dorsum, the contracture is released,
and the nose elongated. As a result, the nasal dorsum wound
becomes narrower, the nose longer, and the nasal tip reaches
the appropriate level. Then, the flaps are transposed towards
one another with moderate tension, so that the apex of one flap
reaches the base of the opposite flap (Fig. 5.1e, f). The flaps
are sutured to each other and to the wound borders. Results are
shown in Figs. 5.1g, h and 5.3. Simultaneously, other anatomi-
cal facial units may be reconstructed. The scheme of the oper-
ation is shown in Fig. 5.1i. Trapeze-flap plasty is successfully
used in cases of severe nasal deformity in patients of any age,
including young children (Figs. 5.2 and 5.3).
a
b
c
d
Fig. 5.2  Postburn nasal
contracture release with
trapeze-flap plasty. (a)
Pre-surgery: nasal contracture
and deformity, medial
epicanthus, nasofrontal angle
smoothed, wide; (b)
trapeze-flap plasty planning;
(c) end of operation: adipose
scar trapezoid flaps counter-­
transposed; (d) 2 months after
reconstruction: flaps alive,
nose elongated, epicanthus
eliminated, and nasofrontal
angle restored
Fig. 5.3  Follow-up result after full face reconstruction, including nasal
contracture release: nose contracture eliminated, nasofrontal angle
restored
Surgical Technique

50
Conclusion
As a result of trapezoid adipose-scar flap transposition,
the plasty zone and the nose itself are elongated by 1.3–
1.8 cm (average of 1.5 cm). Epicanthus (scar fold over the
medial corner of the eye) disappears; nasofrontal angle
depth and nasal bridge shape are restored. The flaps have
a steady blood circulation and do not undergo rotation;
therefore, no flap loss or other postoperative complica-
tions occur. Follow-up results are good; long-term follow-
up did not reveal any flap shrinkage, re-contracture of the
nasal dorsum, or epicanthus recurrence. The nasofrontal
angle (nasion) retains its normal depth; the nasal dorsum
preserves normal width and contours. Operational scars
and flap borders become barely visible. Nasal contracture
elimination, elongation of the nose, nasal dorsum and
nasofrontal angle restoration, and elimination of epican-
thus significantly improve facial appeal.
Suggested Reading
Grishkevich VM. The elimination of postburn nasal contracture in chil-
dren with trapeze-flap plasty. J Burn Care Res. 2011;32:566–9.
5  Elimination of Postburn Dorsal Nasal Contracture

51
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Split Ascending Neck Flap in Burned
Face Resurfacing
Introduction
Postburn face and neck deformities, contractures, and large
nevi are very traumatic cosmetic defects for patients and
present serious problems for surgeons. Much attention is
therefore paid to the development of the most effective
reconstructive techniques. The problem is especially press-
ing in cases of total or extensive deformities (more than half
of the cheek plus neck damage). The skin of the neck matches
the skin of the cheeks better than any other transplant, but its
displacement is restricted by platysma. Axial vessels are fre-
quently injured during mobilization of the cervical flaps,
leading to tissue necrosis. We overcame these obstacles by
locating and preserving the vascular bundle of the skin of the
anterior neck surface. Tissue expansion may be used to make
neck flaps larger; however, a high rate of complications
restricts extensive use of expanders. Various flaps are moved
or rotated from neighboring and distant regions, and free tis-
sue transfer has been used. However, differences in skin
quality is a serious cosmetic disadvantage of these flaps.
Anatomy and Variants of the Split Ascending
Neck Flap
The flap’s name, split ascending neck flap, was proposed by
Dr. Joel Feldman, a well-known plastic surgeon, who was a
reviewer of the original article published in 1993 [1]. The
flap has axial circulation and consists of healthy skin of the
anterior surface of the neck with a thin layer of fat; platysma
remains in place and is not disrupted. The critical goal of this
technique is to preserve axial circulation of the flap. This
area of the skin is supplied by a superficial cervical artery
perforator that exits behind the middle portion of sternoclei-
domastoid muscle. Axial vessels originate from that anatom-
ical point and must be spared and remain in situ (Figs. 6.1
and 6.2, symbol “+”). Axial circulation of the cervical skin,
preserved during the flap mobilization, allows:
(a) Mobilization of a thin neck flap (without platysma,
i.e.,“split” flap);
(b) Transposition of the flap with tension;
(c) Prevention of postoperative complications caused by
insufficient blood supply.
The usual cervical flap transposition on the cheek is about
4–6  cm (Fig.  6.2a, b). Displacement of the flap can be
increased considerably when including in the flap (via mobi-
lization) the anterior thoracic adipose-cutaneous layer, which
is separated from the clavicles, sternum, and pectoral fascia
down to the level of the second rib and anterior axillary edge
(Figs. 6.2, 6.3, and 6.4). In this way, the cervico-thoracic flap
is formed without thoracic skin incision. The thoracic flap
segment is displaced up towards the neck, covering the donor
wound.
It has been observed that the cervical flap’s efficacy
becomes significantly higher when the tissues of the peri-
auricular area and lateral cervical surface are included in
the cervical flap down to the perforator exit (symbol “+”
6

52
in Figs.  6.2a, b and 6.4b, c). This extension of the flap
makes it larger and more mobile; the upper flap’s perim-
eter becomes longer. As a result, a cervico-periauricular
flap is formed. The mobilized periauricular and lateral
cervical segment of the flap includes skin, subcutaneous
fat layer, and sternocleidomastoid fascia. When the tho-
racic tissue is included in flap mobilization, the cervico-
thoraco-periauricular flap is formed. As a rule, we used
the more extensive cervico-­thoraco-­periauricular flap for
total or extensive cheek deformity resurfacing. For iso-
lated upper-half cheek deformity elimination, thoracic tis-
sue is not included in the flap formation. Here, the flap
includes the lower cheek’s skin with a thin subcutaneous
fat layer along with the cervico-­periauricular flap. As a
result, the cervico-facio-­periauricular flap is formed (see
Chap. 7).
3 cm
b
c
a
Fig. 6.1  Axial blood supply of the neck skin, a distribution of flap
branches of a. cervicalis superficialis. (a) Locating the exit point of the
cutaneous branch of a. cervicalis superficialis; (b) distribution of cuta-
neous vessels of anterior neck skin (scheme); (c) cadaver dissection:
exit of cutaneous branches and distribution in flap; additional perforants
marked with white; on platysma—external jugular vein
6  Split Ascending Neck Flap in Burned Face Resurfacing

53
a
b
c
Fig. 6.2  Boundaries of split ascending neck flap. (a, b) Solid line—
borders of scars excision; dotted line—borders of cervico-thoraco-­
periauricular flap mobilization right and left sides. PA periauricular
facio-cutaneous flap; Cer cervical split adipose-cutaneous flap; Th tho-
racic adipose-cutaneous flaps (cervico-thoraco-periauricular flap); “+”
exit location of the cutaneous branch of the superficial artery of the
neck. (c) Split cervico-thoraco-periauricular flap was used for simulta-
neous resurfacing of wide face: cheeks and chin
a
b
c
d
e
Fig. 6.3  Split ascending neck flap mobilization and transposition on
the face. (a) Planning cheek resurfacing: solid line—borders of scars
excision; dotted line—cervico-thoraco-periauricular flap mobilization;
“+”—perforators exit behind the middle part of sternocleidomastoid
muscle; (b, c) the flap is elevated and distended by tight tamponing of
the space under the flap with sterile gauze; scars excised; (d) flap trans-
posed on the wound; (e) cheeks completely resurfaced (end of
operation)
Anatomy and Variants of the Split Ascending Neck Flap

54
a
b
c
d
e
f
Fig. 6.4  Lower face resurfacing with split cervico-thoraco-­
periauricular ascending neck flap. (a–c) Before surgery, planning (dot-
ted line—mobilization borders of cervico-thoraco-periauricular the
flap; solid line—scar excision borders; “+” perforator exit; on right
side, the periauricular segment included; (d) scars excised, split ascend-
ing neck flap mobilized and transposed on the lower face: flap is viable
(5 days after surgery); (e, f) results (3 weeks after surgery): deformity
of the lower face eliminated, face resurfaced with native skin with mini-
mal operational scars; no donor site deformity
6  Split Ascending Neck Flap in Burned Face Resurfacing

55
Axial Blood Supply of the Neck Skin
Our observations showed that subcutaneous muscle of the
neck (platysma) prevents the stretching of the neck’s skin-fat
layer, and thus limits the possibility of its transfer to the face.
Therefore, we began mobilizing the neck’s skin using only
the upper fatty layer above platysma, including only a thin
layer of subcutaneous fat in the skin flap (i.e., splitting the fat
layer). We left the subcutaneous muscle in situ. Therefore,
the thin flap was given the name split neck flap.
The blood circulation of the anterior neck skin is supplied
by two sources: (1) main (axial vessel) and (2) additional per-
forant arteries (Fig. 6.1b, c). The main source is the cutaneous
branch of the superficial artery of the neck (superficialis
colli), which is one of four of the thyrocervical trunk (truncus
thireocervicalis) that comes off the subclavian artery. The
superficial artery of the neck has a diameter of 1.8–2.3 mm at
its source and moves backward and outward along the front
surface of the anterior scalenus muscle. It then crosses the
supraclavicular fossa and reaches the edge of the trapezoid
muscle, where it divides into multiple branches. The origin of
the skin branches of the superficial neck artery (which is
1–1.2 mm in diameter and has a stem of 1–1.3 cm in length)
as a rule is projected in the middle of the posterior edge of
sternocleidomastoid muscle or up to 2 cm posteriorly. This
corresponds to the area of crossing of the external jugular
vein and sternocleidomastoid muscle. Then, the main stem of
the skin branch of the superficial artery divides into two to
three arteries of the second order, which then produces three
to four branches, forming a strong net of the arterial anasto-
moses that spread over the entire skin surface of the anterior
neck and connect with the similar vascular system of the
opposite side. The adventitia of the wall of skin vessels is
tightly connected to connective tissues of the reticulated skin
layer and subcutaneous fat cellular tissue.
The additional source is made up of three to five perforant
arteries, which are the skin branches of the upper thyroid
artery and facial artery (the system of exterior carotid
artery). The diameter of the perforant arteries does not
exceed 0.2–0.3  mm; they perforate the platysma, branch
inside the skin, and connect with the vascular system of the
main source of blood circulation. The venous outflow is
through the external jugular vein. These observations allowed
us to determine the boundaries for mobilization on lateral
surfaces and provided the safety of the mobilization toward
the chest wall.
Common Principles of the Split Ascending
Neck Flap Use
1. Planning (Fig. 6.3a): A solid line marks scars that will be
excised and a neck flap incision 4 cm in length along the
middle cervical line for flap splitting (Fig. 6.3b); dotted
line: borders of flap mobilization.
2. Flap mobilization (Fig. 6.3b): Healthy skin is separated
from scars, the periauricular flap is mobilized, including
the fascia of the sternocleidomastoid muscle, and the
donor wound is primarily closed. On the neck, the flap is
separated from the platysma. On the chest wall, the
adipose-­cutaneous layer is separated from manubrium,
clavicles, and pectoralis major fascia down to second ribs
and the edge of axillary fossa. Then the neck flap is dis-
sected 4 cm along the middle line.
3. The space under the flap is tightly packed with gauze dur-
ing scar excision to control bleeding and flap-stretching
(Fig. 6.3b, c).
4. The flap is transposed to the face with tension (Fig. 6.3d),
and often the inner surface of the flap is sutured to the
wound tissues over the face’s solid structures; the inner
layers of the flap and wound borders are closed with
absorbable sutures.
5. Space under the flap on the neck is actively drained for
5  days. On the face, the flap is drained separately
(Figs. 6.3e, 6.6g, and 6.7j); no immobilization is needed.
Common Principles of the Split Ascending Neck Flap Use

56
Using a Cervico-Thoraco-Periauricular Flap
(a) One-stage operation can restore the lower part of the
face (Fig. 6.4a–f);
(b) Two-stage reconstruction can restore both cheeks in total
(Fig. 6.5a–g);
(c) Two-stage reconstruction in conjunction with additional
corrective surgeries can restore half of the facial skin and
remove soft tissue defects (Fig. 6.6a–i);
(d) After the operation, transposed with tension on the face,
the split neck flap preserves all natural properties and
does not differ from facial skin (Fig. 6.7a–l).
Fig. 6.5  Total resurfacing of both cheeks with two-stage transposition
of split ascending neck flap. (a) Before operation; (b, c) first stage of
reconstruction planning: solid lines—incisions for scars removal; dot-
ted line—borders of flap mobilization; (d) result of the first stage of
surgery; (e) planning of the second stage; (f, g) results: cheeks are
totally restored with native neck skin; short line of operation scars; the
donor site is not deformed, neck contours and cervico-mandibular angle
are normal (1 year after surgery)
a
b
c
d
e
f
6  Split Ascending Neck Flap in Burned Face Resurfacing

57
a
b
c
Fig. 6.6  Resurfacing of half the face (soft tissue defect and skin) with
split ascending neck flap. (a) View after deep burns; (b) before the oper-
ation; (c) planning of the first step of face restoration: borders of scars
excision and cervico-thoraco-periauricular flap; (d) results: 9 months
after first-stage surgery; (e) planning the second-stage operation: borders
of the cervico-thoraco-periauricular spit flap, borders of scar excision;
(f) Inner layer of elevated previously transposed flap consists of a thin
layer of connective tissue; (g) end of the operation; (h, i) final results
g
Fig. 6.5  (continued)
Using a Cervico-Thoraco-Periauricular Flap

58
g
h
i
d
e
f
Fig. 6.6  (continued)
6  Split Ascending Neck Flap in Burned Face Resurfacing

59
a
b
c
d
e
f
Fig. 6.7  Technique of two-stage resurfacing of both cheeks, subman-
dibular region, and chin with thin cervico-thoraco-periauricular split
ascending neck flap. (a, b) Pre-surgery, face deformed with scars; plan-
ning of operation: solid line—border of scars excision on the face; dot-
ted line—borders of flap elevation; “+”—exit of perforators; (c, d)
result of the first stage of the operation on the face; (e, f) planning the
second-stage reconstruction; (g, h) flap elevated; (i, j) flap transposed
on the cheeks and chin with tension; (k, l) results of the second stage
Using a Cervico-Thoraco-Periauricular Flap

60
Fig. 6.7  (continued)
g
h
i
j
k
l
6  Split Ascending Neck Flap in Burned Face Resurfacing

61
Lower Face One-Stage Resurfacing with Split
Neck Flap
Using the cervico-thoraco-periauricular flap, one-stage
reconstruction can restore the lower part of the face
(Fig. 6.4a–f).
Two-Stage Total Cheek Resurfacing
Using
a
staged
adipose-cutaneous
cervico-thoraco-­
periauricular flap, half of the face can be resurfaced (skin and
soft tissue defects) (Fig. 6.5a–g). The technique is based on
the repeated use of the cervico-thoraco-periauricular flap,
allowing simultaneous restoration of cheeks and chin.
Half-Face Resurfacing (Skin and Soft Tissue
Defect)
Severe half-face tissue defects and deformity can be elimi-
nated with two-stage cervico-thoraco-periauricular flap
transposition (Fig. 6.6a–i).
Half-Face Resurfacing (Skin and Soft Tissue Defect)

62
Two-Stage Face Resurfacing with Split
Ascending Neck Flap
For details of this technique and follow-up, see (Figs. 6.7,
6.8, and 6.9).
a
b
d
c
Fig. 6.8  Follow-up results of two-stage restoration of the face with split ascending neck flap. (a) Pre-surgery: severe face deformation with scars;
(b–d) results 8 months after second-stage reconstruction with cervico-thoraco-periauricular flap
6  Split Ascending Neck Flap in Burned Face Resurfacing

63
a
b
c
Fig. 6.9  Results of two-stage face and submandibular region resurfacing with split ascending neck flap. (a) Pre-surgery view, planning first-stage
surgery; (b, c) 1 year and 6 months after reconstruction of submandibular region, cheeks, chin, and lower lip
Two-Stage Face Resurfacing with Split Ascending Neck Flap

64
Conclusion
Split ascending neck flap is optimal for burned face resur-
facing. Flap’s transposition on the face with tension can
be used safely if vascular supply is preserved. Follow-up
results of face resurfacing with a cervico-thoraco-­
periauricular flap are good. Neck skin matches the texture
of face skin, preserves natural properties, and grows after
surgery. Face contours are normal, without secondary
deformities, and there is no soft tissue excess. The length
of surgical scars is minimal. The donor site (neck and
chest wall) does not have scars and looks normal (See
Chapters 7 and 8).
Reference
1. Grishkevich VM, Ostrovsky NV. Postburn facial resurfacing with a
split ascending neck flap. Plast Reconstr Surg. 1993;92:1385–92.
6  Split Ascending Neck Flap in Burned Face Resurfacing

65
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Burned Half-Cheek Resurfacing
Techniques
Introduction
It is no secret that facial skin is different from skin from any
other part of the body. A perfect graft should not only match
the size and thickness of the recipient site, but also be com-
patible in texture, color, and softness. Neck skin has always
been viewed as having the closest of all the desirable charac-
teristics. It was used in cheek resurfacing for years but was
limited by vascular complications and necrosis. Rotated and
transposed flaps led to significant scarring of the donor site.
We decided to develop a more standardized approach to
treating partial cheek burns when repair can be carried out
using mobilized local tissues. Our study of the vascular sup-
ply of the skin of the neck described in a previous chapter 6
enabled us to use cervical skin to the maximum potential
without increasing the risk of vascular compromise and
necrosis. These techniques, if used properly, carry a very low
risk of flap necrosis while covering a significant portion of
the cheek and minimizing surgical scarring.
The choice of surgical technique depends on the location
of the scars on the cheek. While common principles of split
ascending neck flaps remain true for all cheek reconstruc-
tion, differences in planning and staging of the surgery are
worth mentioning. Here we present four types/forms of
cheek deformity (lower, lateral, medial, and upper) and tech-
nical details of the surgeries specific for each type.
Split Ascending Neck Flaps Design
and Specific Technical Features of Half-­
Cheek Resurfacing
The split ascending neck flap is used in several variants,
depending on the size, the form of the scar’s surface, and its
location on the cheek. The flap consists of the basic neck
split flap (without platysma) that includes the neck’s anterior
surface [1]. The area posterior to the center of the sternoclei-
domastoid muscle, where axial vessels originate, is spared
(superficial cervical artery perforator exit) and is not mobi-
lized or included in the flap (Fig. 7.1a, symbol “+”). These
vessels, providing the anterior neck’s skin with blood, make
the cervical flap an axial type. Axial circulation of the neck
skin allows flap undermining without platysma, with only a
thin layer of fat (thus the name “split flap”), which makes the
flap very thin. This axial circulation allows transposition of a
cervical mobilized flap on the face with significant tension,
without concern for tissue necrosis. Cervical flap advance-
ment may be increased by a 4-cm incision along the vertical
anterior mid-cervical line from the chin down, as seen in
Fig. 7.1b.
The cervical flap transposition on the cheek is approxi-
mately 3–4  cm; however, the flap’s displacement can be
increased considerably when including in the flap a mobi-
lized anterior thoracic adipose-cutaneous layer. Preparation
of the thoracic extension of the split neck flap consists of
separation from the clavicles, manubrium, and pectoral fas-
cia down to the second ribs, and can laterally extend to the
anterior edge of the axilla. Thus, a cervico-thoracic flap is
formed without thoracic skin incision. The thoracic segment
of the flap is displaced on the neck, covering the donor
wound.
7

66
a
b
c
d
Fig. 7.1  Cervico-thoraco-periauricular flap design for lateral half-­
cheek resurfacing. (a, b) Lateral cheek deformity, planning: solid lines
depict borders of scars to be excised and incisions in periauricular and
submental areas flap preparation; dotted line depicts the boundaries of
flap elevation (undermining); “+”—the site of perforator exit; (c, d)
cervico-thoraco-periauricular flap resurfaced the cheek, flap alive; neck
and cheek contours preserved (5 days after operation)
It has been observed that the cervical flap’s efficacy
becomes significantly higher when the facio-cutaneous layer
of the periauricular area and lateral cervical surface are
included in the cervical flap down to the perforator exit
(symbol “+”). This addition makes the cervical flap larger
and more mobile, and the upper flap’s perimeter becomes
longer. As a result, a cervico-periauricular flap is formed.
7  Burned Half-Cheek Resurfacing Techniques

67
Lateral Cheek Resurfacing
Depending on the form of the scar’s surface, two variants of
cervico-thoraco-periauricular flaps are used: (1) an anterior
neck flap prepared with skin incision along anterior mid-­
cervical line (Fig. 7.1a, b); and (2) a flap prepared without
the neck’s midline skin incision (Fig.  7.2). Planning and
technical details are shown in Fig. 7.1a–d.
The mobilized periauricular and lateral cervical segment
of the flap includes skin, fat layer, and sternocleidomastoid
fascia. When thoracic tissue is included in the flap, the
cervico-­thoraco-periauricular flap is formed (Fig. 7.1a, b).
Lateral cheek resurfacing with a cervico-thoraco-­
periauricular flap without midline neck skin incision is
shown in Fig. 7.2.
a
b
Fig. 7.2  Reconstruction of
the lateral cheek without
cervical midline incision. (a)
Lateral cheek deformity, the
chin not involved; surgery
planning; (b) 3 weeks after
operation, flap alive,
deformity eliminated
Lateral Cheek Resurfacing

68
Lower Cheek Resurfacing
Technical Details (Figs. 7.3 and 7.4)
Lower cheek deformities are eliminated using a cervico-­
thoraco-­periauricular flap. Before surgery, the borders of
scars to be removed and boundaries of flap mobilization are
marked (Fig. 7.3a). The solid line marks the incisions to be
made; the dotted line marks the boundaries of flap mobiliza-
tion by undermining; the symbol “+” indicates superficial
cervical artery perforator exit that needs to be preserved for
viability of the flap. The flap includes the anterior neck
­surface; the thoracic segment reaches down to the second
ribs and the anterior edge of axilla; and the periauricular seg-
ment includes retroauricular and lateral cervical regions. The
first incision separates the cheek’s healthy skin from scars
and forms the periauricular segment and a flap angle in the
submental region. Then, the periauricular segment is mobi-
lized, including the sternocleidomastoid fascia for steady
circulation. The donor wound in the periauricular region is
primarily closed with the posterior neck’s skin displacement
forward and upward. Then, the cervical flap is mobilized
with a thin fat layer without platysma.
Mobilization continues down to the upper chest wall, sep-
arating the adipose-cutaneous layer from clavicles, manu-
brium, and pectoral fascia down to the second ribs and
axillary border. The superficial cervical artery perforator exit
(symbol “+”) remains in situ. The space under the flap is
tightly tamponed with gauze for intra-operative skin disten-
tion and hemostasis while facial scars are being excised
(Fig. 7.5b). After excision of the scars, the flap is transposed
on the cheek with moderate tension, covering the wound up
to 6 cm in width, from the ear to the oral commissure. The
periauricular flap segment is placed anterior to the ear and
sutured to the fascia and wound edges (Figs.  7.3a–c and
7.4a–c).
a
b
c
Fig. 7.3  Lower cheek resurfacing with cervico-thoraco-periauricular
flap. (a) Planning: solid lines mark incisions around scars, the periau-
ricular area, and submental angle; dotted lines outline boundaries of
flap mobilization; (b) 5  days after surgery, the space under the flap
drained; (c) 6 months after the operation: scars removed, cheek skin
restored, donor site not injured, contours of the neck normal
7  Burned Half-Cheek Resurfacing Techniques

69
a
b
c
Fig. 7.4  Lower-medial cheek and chin resurfacing with cervico-­
thoraco-­periauricular flap. (a) Scars covered the lower cheek and part of
chin, deformed oral angle and nasolabial fold; (b, c) 7 days after recon-
struction: the flap is alive, scars removed, the cheek restored with iden-
tical skin. The flap does not look like a patch, and normal contours of
neck and mento-cervical angle are seen
Lower Cheek Resurfacing

70
Medial Cheek Resurfacing
The unique feature of resurfacing of isolated medial cheek
scars is the presence of intact lateral cheek skin. This skin is
healthy and is included in the flap. Reconstruction is per-
formed with a regular cervico-facio-thoraco-periauricular
flap (Figs. 7.5, 7.6, 7.7, and 7.8).
In cases of combined medial and upper cheek deformi-
ties, the residual healthy skin of the lower and lateral cheek
with a thin fat layer is included in the flap, which forms a
cervico-thoraco-facio-periauricular flap (see Fig.  7.4a).
Tissue expansion of facial segment allows one to avoid inclu-
sion of thoracic tissue; the flap in such cases is cervico-facio-­
periauricular (Fig. 7.7).
a
b
c
d
Fig. 7.5  Medial cheek and
mouth angle resurfacing with
cervico-facio-thoraco-­
periauricular flap. (a)
Pre-operation, planning; (b)
mobilized cervico-facio-­
periauricular flap expanded
with gauze tampons; (c) flap
transposed on the cheek; note
placement of drains—cervical
and under the flap (d) 12 days
after operation, the flap is
viable
7  Burned Half-Cheek Resurfacing Techniques

71
a
b
Fig. 7.8  Results of medial cheek
(simultaneous chin, nose, upper lip, and
philtrum restoration). (a) Pre-surgery,
planning; (b) one-and-a-half years after
reconstruction
a
b
c
d
Fig. 7.6  Upper-medial cheek tissue defect elimination with cervico-­
facio-­periauricular flap. (a) Before the operation, scars and soft tissue
defect of left cheek; (b) planning the operation: solid line—incision,
dotted line—boundaries of flap mobilization; (c, d) 1 week and 2 weeks
after reconstruction with a cervico-facio-periauricular flap
a
b
c
Fig. 7.7  Medial soft tissue defect of the right cheek elimination with the expanded cervico-facial flap prepared from the lateral cheek. (a) Pre-­
surgery view, planning of balloon insertion; (b) facial skin expanded; planning of operation; (c) 2 years after reconstruction
Medial Cheek Resurfacing

72
Upper Cheek, Eyebrow, and Nose
Resurfacing
The upper cheek is reconstructed with a cervico-facio-­
periauricular flap. First, the healthy lower cheek skin is
expanded (Fig. 7.9a, b). After completion of expansion, cer-
vical and periauricular flap segments are additionally mobi-
lized and the flap is transposed on the upper cheek and
sutured in place. It matches well to the surrounding healthy
facial skin and contralateral cheek. Typically, the longer the
period post-reconstruction, the better the results, to the point
when the cheek appears normal and does not look like a
patch of foreign skin. The tension on the flap and tissues of
the face, neck, and chest wall gradually disappears as a result
of tissue growth. Therefore, the cheek and neck contours
look normal, and the neck and chest wall surfaces, as donor
sites, are not damaged with operation scars. With skin growth
and release of tension, no breast or nipple displacements are
usually seen. The disfigured contours of the facial features,
neck, and chest wall due to flap tension are only temporary.
a
b
c
Fig. 7.9  Upper cheek, nose, and eyebrow reconstruction with a
cervico-­facio-periauricular expanded flap and a temporal pedicle flap.
(a) Multiple facial deformities, planning of operations; (b) restored
nose and eyebrow, expanded cervico-facial flap; planning cheek resto-
ration; (c) results (2 years after surgery): cheek, temple, nose, and eye-
brow restored
7  Burned Half-Cheek Resurfacing Techniques

73
Conclusion
The split ascending neck flap in combination with neigh-
boring tissue mobilization is optimal for burned half
cheek resurfacing. No flap loss occurred. After we started
including sternocleidomastoid fascia into the flap, no tis-
sue necrosis occurred. As the flaps are thin, no soft tissue
excess is observed. Operation scars are minimal and
located only along one or two sides of the flap and are
hardly visible, especially in the periauricular and submen-
tal regions. Skin organically flows from the neck onto the
cheek without interruption, and never resembles a patch
as in the case of many skin grafts done with other tech-
niques. The tension of the flap and donor tissues of the
neck and chest wall gradually disappear as a result of tis-
sue growth; therefore, the cheek and neck contours are
normal at long-term follow-up. The neck and chest wall
surfaces, as donor sites, are not damaged by operation
scars. With skin growth and release of tension, no long-
term breast or nipple displacement was seen. The disfig-
ured contours of the neck, face, and chest wall due to flap
tension are only temporary.
Reference
1. Grishkevich VM.  Burned unilateral half-cheek resurfacing tech-
niques. J Burn Care Res. 2012;33:e186–94.
Reference

75
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Total Cheek Resurfacing with Split
Ascending Neck Flap
Introduction
As discussed in previous chapters, the skin of the neck is the
best match for cheeks, but it is a limited resource, and its
displacement is restricted. Every attempt should be made to
resurface cheeks with neck skin. Tissue expansion is fre-
quently used to make neck flaps larger; however, when used
on the neck, it carries a high rate of complications due to
soft-tissue compression. This limits the extensive use of
expanders on the neck. Various flaps (pedicle, island, regular,
and expanded) are transplanted from neighboring and distant
regions, and free tissue transfer has been used. Differences in
skin quality, however, are a serious cosmetic disadvantage of
these flaps. We propose using a well-developed technique
based on the split ascending neck flap [1], as described in
this chapter.
First Stage of Bilateral and Unilateral Cheek
Resurfacing with Split Ascending Neck Flap
Before surgery, the borders of scars to be excised and bound-
aries of the flap are marked. Solid lines mark the incisions,
dotted lines mark boundaries of the flap mobilization, and
the symbol “+” indicates the exit location of the superficial
cervical artery perforator (Figs. 8.1b and 8.2b). For a detailed
discussion of the significance of preserving this source of
axial circulation of the neck flap, see Chap. 6. The flap
includes skin of the anterior neck surface; the thoracic seg-
ment reaches down to the second ribs and anterior edge of
the axillary fossa, and the periauricular region. Mapping for
bilateral and single cheek resurfacing is shown in Figs. 8.1b
and 8.2b. A line 4 cm in length is placed along the anterior
medial neck line in the submandibular region (Fig. 8.1b).
The first incision separates the cheek scars from the
healthy skin of the neck and forms the periauricular segment
and flap angle in the submental region. Then, a periauricular
segment (one or both) is mobilized down to the perforator
exit. It is critical to include sternocleidomastoid fascia in this
segment of the flap for steady circulation. The donor wound
in the periauricular region is primarily closed by pulling skin
of the back of neck forward and upward (Figs.  8.1c and
8.2c). Then, the cervical flap is mobilized, including skin and
only the thin fat layer without platysma. The superficial cer-
vical artery exit (symbol “+”) stays in situ. Mobilization
continues on the upper chest wall, separating the adipose-­
cutaneous layer from clavicles, manubrium, and pectoral fas-
cia down to the second ribs and axillary fossa border. In the
case of bilateral cheek resurfacing, the same steps are carried
out symmetrically. The mobilized flap is transposed with
tension on the cheek (or cheeks) for estimation of the scar
surface area that can be resurfaced. Appropriate markings
are made for scar excision.
Next, the space under the flap is tightly tamponed (packed)
with gauze for intra-operative skin distension and hemosta-
sis, while scar excision of the lower cheek is performed.
8

76
a
b
c
d
Fig. 8.1  Total bilateral burned
cheeks resurfacing with a
cervico-­thoraco-­periauricular
flap. (a) Before surgery
(6-year-old boy): total face
deformities with burn scars; (b)
planning of operation: solid line
indicates incisions: along the
lower scar edge, anterior
mid-cervical line (5 cm in
length), periauricular flap
contours, and scar borders on the
cheeks for excision; symbol
“+”—exit of superficial cervical
artery perforators; dotted line
indicates borders of flap
mobilization; (c, d) transposed
mobilized cervico-thoraco-peri-
auricular flap restored lower and
lateral cheek surfaces; neck
donor wound covered with
elevated thoracic segment of the
flap; cervical wound drained with
active drain; cheeks are drained
separately; (e, f) the cervical flap
on the cheeks expanded, planning
of the second stage of the
operation; (g, h) end of the
operation; expanded cervico-
periauricular flaps covered the
cheeks; (i, j) result (5 years after
operation): skin of the cheeks had
been restored with well-matching
neck skin; skin of the cervico-
facial region is presented as one
unit; contours of the face and
neck are preserved. Skin of the
face has preserved sensation and
normal quality (color, thickness,
elasticity). There has been no
bulking, and no operation scars
are present between the cheek
and neck
8  Total Cheek Resurfacing with Split Ascending Neck Flap

77
e
f
g
h
i
j
Fig. 8.1  (continued)
First Stage of Bilateral and Unilateral Cheek Resurfacing with Split Ascending Neck Flap

78
a
b
c
d
e
Fig. 8.2  Two-stage unilateral total cheek resurfacing with a cervico-­
thoraco-­periauricular flap. (a) Hemifacial nevus, scars, lower lid
grafted; (b) planning of the operation: solid line indicates scar excision,
periauricular flap forming and forehead tissue expansion; “+”—perfo-
rator exit; dotted line indicates flap mobilization without skin incision;
(c) the cervico-periauricular flap is mobilized, half of the cheek’s sur-
face restored, and the donor wound of the periauricular flap primarily
closed; (d) stabilized cervico-periauricular flap is expanded on the face;
temple region and eyebrow are corrected (e) 2 weeks after surgery: flap
alive, mild vascular congestion, eyebrow narrowed, facial, and cervical
contours preserved, mild lip swelling
After scar excision, the flap is transposed on the cheek (or
cheeks) with moderate tension. The periauricular flap seg-
ment is placed in front of the ear and sutured to the temporal
fascia. The upper flap border and its medial angle is sutured
to underlying soft tissues for flap suspension. As a result of
tension, the cervical part of the flap is displaced to the cheek,
and the thoracic segment moves up on the neck, covering the
donor wound. The skin edges are closed with two rows of
sutures. To prevent scar widening due to significant tension of
the flap, we use non-absorbable internal sutures. An active
drain is placed under the flap on the neck for 5 days (Fig. 8.1c, d).
The cheek is drained separately.
8  Total Cheek Resurfacing with Split Ascending Neck Flap

79
Second Stage of Cheek Resurfacing
with Expanded Split Ascending Neck Flap
Once the transposed tissues are stabilized and tension disap-
pears—this period could last from 9 to 12  months—the
expanders are implanted through an incision along the upper
cheek surgical scar. The transposed cervical flap is elevated
down to the edges of the mandible, dissecting friable fibers of
connective tissues. The inner layer of the flap consists of scar
(connective) tissue that looks like a sheet, stabilizing the
blood circulation, reinforcing the flap’s stability and tissue
safety during balloon distension. Having achieved a sufficient
increase in the surface area (Figs. 8.1e, f and 8.2d), recon-
struction is accomplished: the flap is mobilized at the periph-
ery for the flap’s better displacement and facilitation of
adaptation on the wound. Remaining scars of the upper and
medial cheek are excised, and the wound is covered with the
flap (Fig. 8.1g, h). The space under the flaps is drained. The
edges of the flap are sutured to the temporal fascia and along
the flap’s edge to the underlying tissues. The lower eyelid can
be temporarily sutured to the forehead to prevent ectropion.
The result of the surgery: the total cheek is restored with well-
matching skin and minimal surgical scarring (Figs. 8.1i, j and
8.2e).
Figure 8.2 illustrates a patient with a large deforming
nevus of the left side of the face, showing results of nevus
excision and total cheek resurfacing with a cervico-thoraco-­
periauricular flap.
The results of two-stage total cheek resurfacing in a girl
with split ascending neck flap is shown in Fig. 8.3.
a
b
c
Fig. 8.3  Result of bilateral total burned cheeks resurfacing with a
cervico-­thoraco-periauricular flap and secondary cervico-periauricular
flap expansion on the face. (a) Before the operation (7-year-old girl);
total face deformities by burn scars; (b, c) cervico-thoraco-periauricular
flap transposed on the cheeks; (d, e) both flaps expanded on the face; (f,
g) results (7 years after reconstruction): cheeks restored completely;
contours of the face and neck preserved, donor site undamaged
Second Stage of Cheek Resurfacing with Expanded Split Ascending Neck Flap

80
Fig. 8.3  (continued)
d
e
f
g
8  Total Cheek Resurfacing with Split Ascending Neck Flap

81
Two-Stage One-Cheek Resurfacing
in Children
Our observations have shown that in children, two-staged
face reconstruction is indicated, especially if the scar deforms
half of the cheek, and more so if the scars involve the chin,
lip, eyelids, or temple. Such an approach allows for avoid-
ance of negative effects caused by pressure on the solid
structures of the face. It also preserves jawline definition.
Extended pressure by skin expanders can also cause defor-
mation of the face in small children.
The goal of the first stage is to achieve as much resurfac-
ing of the cheek as possible. The second stage of reconstruc-
tion is directed toward restoration of the chin, lips, lower
eyelid, and temple. Restoration of these subunits can be suc-
cessfully performed if the extended flap surface is sufficient
to cover the areas without tension. In some cases, the flap is
attached with sutures to underlying wound tissues to
­minimize tension on the edges of the wound. The surgical
details are shown in Figs. 8.4, 8.5, and 8.6.
a
e
f
b
c
d
Fig. 8.4  Subtotal unilateral face resurfacing, injured by nevus and
post-treatment keloid scars. Consecutive operative and balloon exten-
sion of a cervico-thoraco-periauricular flap. (a) Pre-surgery: subtotal
right half face deformation with nevus and scars; (b) planning scar exci-
sion (solid line) and a facio-neck-periauricular-thoracic flap (dotted
line) elevation; “+”—perforator exit; (c) result of the first stage of
reconstruction; (d) planning of expander implantation; (e) expansion
finished; (f) 7  days after second-stage surgery; (g) 1  year after face
treatment using the new approach
Two-Stage One-Cheek Resurfacing in Children

82
a
b
c
Fig. 8.5  Postburn half face resurfacing with consecutive operative and
expander distension of split ascending neck flap. (a, b, c) Pre-surgery,
planning: boundaries of scar excision and cervico-thoraco-periauricular
flap elevation; (d, e) results of first stage of operation (9 days after sur-
gery); (f) extended flap on the face; (g) 5 days after operation: half of
face covered with flap; (h) 1 year after reconstruction
g
Fig. 8.4  (continued)
8  Total Cheek Resurfacing with Split Ascending Neck Flap

83
d
e
g
h
f
Fig. 8.5  (continued)
Two-Stage One-Cheek Resurfacing in Children

84
Fig. 8.6  Unilateral resurfacing of the face deformed by nevi and post-­
curative scars with a cervico-facio-periauricular flap, using consecutive
operative and balloon extension. (a) Before surgery; (b) first stage plan-
ning; (c) result of first-stage surgery; (d) planning of expander insertion
on the cheek and forehead; (e) tissue expansion finished; (f) end of
operation with extended flaps; (g) 2 weeks after reconstruction
a
b
c
d
e
f
g
8  Total Cheek Resurfacing with Split Ascending Neck Flap

85
Conclusion
The first step of reconstruction, tissue expansion, and the
final stage can be carried out successfully without flap
loss or other serious complications. Scars on the cheeks
are replaced with thin, pliable, well-matching skin flaps
from the neck. Some swelling and venous congestion of
the transposed tissues occurs, but circulation is usually
restored in several weeks. Follow-up observations showed
that neck skin on cheeks preserved its natural properties
(color, texture, elasticity) and is a good match to sur-
rounding facial skin, which is especially noticeable in
cases of unilateral cheek reconstruction. No soft tissue
excess is formed, and no debulking is needed. Operation
scars are minimal in length and are located only along the
upper and medial flap’s borders. Due to lower tension on
the scars after the second stage, ­overgrowth of scars or
keloid formation is not commonly seen. The skin spreads
smoothly from the neck on the cheeks and chin without
interruption by scars, creating a normal appearance. The
donor sites (neck and chest wall) remain undamaged,
without tissue defects, skin grafts, or operative scars. The
jawline and angle of the neck are usually preserved. No
eyelid ectropion is observed with lower flap tension of
second-­stage surgery. Skin tension on the face, neck, and
chest wall gradually disappears due to flap growth, which
restores more defined cheek and neck contours over time.
In children, the cervical skin on the cheeks grew propor-
tionally to underlying tissues and surrounding healthy
skin, allowing normal development of the face.
Reference
1. Grishkevich VM. Total cheek resurfacing with split ascending neck
flap: a new approach. Burns. 2015;41:609–15.
Reference

87
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Postburn Neck Scar Contracture
Classification
Introduction
Being an open part of the body, the neck often suffers burns.
Restricted head motion and apparent cosmetic defects are
indications for reconstruction. Rehabilitation aims to release
the contracture as part of skin surface restoration. The skin of
the neck has specific characteristics that distinguish it from
skin of other body areas. Therefore, after restoration, poorly
matched grafted skin resembles patches, and this poses a dif-
ficult cosmetic challenge. In many cases, burns and scars
damage only part of the anterior neck surface; in such cases,
local healthy tissues can be used for reconstruction first.
Types of neck scar contractures are based on scar location
and the extent of neck surface involvement. The following
classification system was developed after studying more than
250 patients [1, 2].
Neck Contractures: Anterior and Lateral
Groups
To better understand the types of contractures on the neck
and choices of surgeries for each deformity, we developed a
detailed classification of neck contractures. First, we divided
neck contractures into two types: anterior and lateral neck
contractures. Each type is further subdivided into subtypes:
anterior has six subtypes and lateral has two subtypes. Here
we demonstrate all eight types of contractures commonly
seen in neck burns.
9

88
Anterior Neck Contractures
For the overall scheme of anterior neck contracture classifi-
cation, see (Fig. 9.1).
1. Medial neck contracture is caused by a scar strip of
5–6 cm in width, spreading from the chin to the sternal
manubrium (Fig. 9.2). The scar strip has a different form;
the scars often cover the submandibular region and chest
wall. In this type of contracture, the skin on the lateral
cervical surfaces (donor sites) is healthy and is used for
reconstruction (Chap. 10).
2. Unilateral anterior neck contracture is characterized by
scars covering part or all of one side of the anterior neck
surface (Fig. 9.3). Due to scar contraction, healthy skin
can be displaced over a damaged neck side. Healthy skin
of half the neck surface (donor site) is used for contrac-
ture release and skin restoration (Chap. 11).
3. Medio-lateral unilateral neck contracture includes the
medial and lateral neck surface of one side (Fig. 9.4). The
lateral surface of the opposite side of the neck is
undamaged.
4. Medio-lateral bilateral neck contracture is caused by
scars that cover all anterior neck surfaces and is also
known as “total neck contracture” (Fig. 9.5). A lack of
healthy skin calls for treatment with local scar-fascial,
regional pedicle, or free flaps.
5. Mentosternal contracture or fusion (Fig. 9.6).
6. Submental contracture (Fig. 9.7).
Fig. 9.1  Anterior neck scar
contracture classification
(scheme): 1—medial;
2—unilateral; 3—medio-­
unilateral; 4—medio-bilateral
(total)
9  Postburn Neck Scar Contracture Classification

89
Fig. 9.2  Midline neck anterior scar contracture (medial type). FP flap
a
b
Fig. 9.3  Unilateral anterior neck scar contracture (edge type). (a)
Scars on the right lateral surface of the neck; (b) the left side of the neck
has healthy skin
Anterior Neck Contractures

90
Fig. 9.5  Medio-lateral bilateral (total anterior) anterior neck contrac-
ture (medial type)
Fig. 9.6  Mentosternal contracture (fusion)
a
b
Fig. 9.4  Medio-lateral one-side
anterior neck scar contracture
(medial type). (a) Scars on the
medial and right antero-lateral
neck surfaces; (b) the left lateral
neck surface has healthy skin
9  Postburn Neck Scar Contracture Classification

91
Lateral Neck Contractures
7. Lateral edge neck contracture is formed after burns of the
posterior surface of the neck (Fig. 9.8 and Chap. 12).
8. Lateral medial neck contracture occurs after burns of the
lateral surface of the neck (Fig. 9.9 and Chap. 12).
Fig. 9.7  Lateral edge neck scar contracture, scars covering the poste-
rior surface of the neck. Cr crest
Fig. 9.8  Lateral medial neck scar contracture. Scars covered lateral
neck surface; the fold formed along lateral neck surface; both sheets of
the fold are scar tissue. Cr crest
Fig. 9.9  Submental deformity and contracture
Lateral Neck Contractures

92
Conclusion
This classification defines a skin-to-burn ratio, location,
and surface size of the healthy skin and scars. Using these
parameters, one can effectively choose an adequate surgi-
cal technique that will allow the most resourceful use of
undamaged cervical skin. Knowledge of the axial blood
supply of neck skin (Chap. 6) has significantly broadened
the possibilities of treating neck contractures with undam-
aged local cervical and neighboring skin, and made the
procedure more effective. Using special techniques of
flap elevation, it is possible to restore and release midline
and unilateral anterior contractures and the edge lateral
neck contractures using healthy local tissue (see Chaps.
10 and 11). Recognition of specific types of neck contrac-
ture is easy (Fig. 9.1). The proposed classification plays
an important role in choosing the proper technique and
achieving good outcomes. It has opened up the possibili-
ties for wider use of local tissues with minimal damage to
the donor site, often avoiding skin grafting or reconstruc-
tion with pedicle and free flaps.
References
1. Grishkevich VM, Iudenich AA. Postburn deformations of neck and
correction with cervico-thoracic adipose-cutaneous flaps. Khirurgiia
(Mosk). 1985;5:45–8.
2. Yudenich VV, Grishkevich VM.  Handbook of rehabilitation of
burned. Moscow: Medicina; 1986. Ch. 5. p. 143–6.
9  Postburn Neck Scar Contracture Classification

93
© Springer International Publishing AG, part of Springer Nature 2018
V. M. Grishkevich, M. Grishkevich, Plastic and Reconstructive Surgery of Burns,

Medial Neck and Submandibular Scar
Contractures: Anatomy and Treatment
Introduction
Medial neck contracture is caused by scars that spread from
the chin to the sternal manubrium and involve the submental
and submandibular regions. The contractures can spread on
the face and chest wall. The scars are often thick and rough
and present a functional, as well as a severe cosmetic, defect.
In terms of treatment, the most important task is to restore
the surface with well-matched skin from the remaining neck
skin on the lateral surfaces. Therefore, lateral neck skin
undergoes expansion, even though the technique can be
complicated by skin necrosis. After establishing that the
anterolateral neck skin has axial blood supply, the medial
contracture can be released with neck split flaps from the
neck lateral surfaces. Stable blood circulation allows mobili-
zation of healthy skin that does not damage axial vessels and
transposition on the anterior neck with tension.
Anatomy of Midline Neck Contracture
In this group of patients, the contracture was caused by scars
located along the medial line of the anterior surface of the
neck (Fig. 10.1). Scars spread from the chin to the manu-
brium and can cover the lower face and chest wall (Fig. 10.2).
The shape of the scars differs from case to case; they may be
wider in the submental region and narrower closer to the
manubrium, or vice versa (Figs. 10.3 and 10.4). The width of
the scar strip is on average 5–7 cm. The scars protrude for-
ward and often restrict head motion. The skin on the neck
lateral surfaces remains healthy.
10

94
a
b
c
d
Fig. 10.1  Medial neck scar
contracture anatomy and
treatment with lateral cervical
split flaps. (a, b) Protruded
forward scar (SCAR) strip
spreads from the chin to the
middle neck region and
covers the sternum zone.
Lateral neck surfaces are
undamaged; planning of
operation: trapezoid flap (FP)
on each neck side and borders
of scar excision; (c) scar
removed, neighboring
adipose-cutaneous layer on
the chest and split neck flaps
on both sides of the wound
elevated and extended with
tight gauze tamponing of
sub-flap space; (d) flaps
counter-transposed, good
functional and cosmetic
outcomes
a
b
Fig. 10.2  Medial neck
contracture treatment with
lateral split neck trapezoid
flaps. (a) Pre-surgery: Medial
segment of the neck and
submandibular region covered
scars (SCAR); planning of two
lateral split neck flaps (FP);
(b) mobilized split neck flaps
counter-transposed with
tension, restored neck and
submandibular region; left
lower face scar deformity
removed, wound skin grafted.
Ten days after reconstruction,
the flap and skin transplant
are alive and contracture is
eliminated
10  Medial Neck and Submandibular Scar Contractures: Anatomy and Treatment

95
a
b
c
d
Fig. 10.3  Treatment of
severe medial neck
contracture: contracted scars
took a butterfly shape. (a, b)
Pre-surgery view, planning:
boundary of scars (SCARS)
for removal and flaps (FP)
marked; (c, d) scars excised,
contracture released,
neighboring tissues elevated
widely and displaced on the
wound; neck and chest wall
scar deformity and
contracture eliminated, neck
contours restored; flaps alive
a
b
Fig. 10.4  Variant of medial
neck, submandibular zone,
and sternal contracture
elimination and scar
resurfacing with split
cervico-thoracic trapezoid
flaps. (a) Before surgery,
planning of trapeze-flap plasty
(SCAR, FP); (b) 10 days after
reconstruction, the flaps are
alive and contracture is
eliminated
Anatomy of Midline Neck Contracture

96
Contracture Treatment with Split Neck Flaps
In all cases, the aim of reconstruction is contracture elimina-
tion, scar excision, and skin restoration, with the neighboring
healthy skin located laterally to the scars (Figs.  10.1 and
10.2). The edge of the scar to be removed and the borders of
two neck split flaps are outlined. The exit of the perforators
is marked; it should be located on the flap borders. See Chap.
6 for details of split neck flap mobilization. The scars are
removed and the flaps are mobilized with a thin fat layer
(split flap); platysma stays in situ. The space under the mobi-
lized flap on the chest wall and neck can be extended with
gauze tamponing (Fig. 10.1c). If the neck’s split flaps are
insufficient for wound covering, the thoracic adipose-­
cutaneous layer is involved (cervico-thoracic split flap); the
flap is detached from the clavicles, manubrium, and pectora-
lis major muscle fascia (Figs.  10.1, 10.3, and 10.6). The
mobilized flap on the chest wall and neck can be extended
with gauze tamponing. If necessary, the trapezoid flaps are
formed from the healthy skin by incising along the mento-
cervical angle projection and upper clavicles (Fig. 10.2). The
flaps are counter-transposed and placed on the wound, one
above the other, with tension (Figs. 10.1, 10.2, and 10.4).
If a wound is large and the flap is transposed with severe
tension, the inner flap’s surface should be fixed with sutures
to the fascia of the major pectoralis muscle and to the man-
dible (Figs. 10.3 and 10.5). The line of the flap’s connection
is passed oblique on the anterior neck surface; the location of
upper and lower suture lines depends on the scar form and
the borders of their excision. Simultaneously, the scars on
the lower face and chest wall can be excised. The sub-flap’s
space is actively drained.
a
b
Fig. 10.5  Lateral
submandibular contracture
and deformity elimination by
cervico-thoracic split
ascending flap. (a) Pre-­
surgery marking of scars to be
removed and boundaries of
flap elevation; “+” perforator
exit. (b) Follow-up result:
deformity and contracture are
eliminated
10  Medial Neck and Submandibular Scar Contractures: Anatomy and Treatment