Free Tissue Transfer in the Reconstruction of Neck Contractures after Burn Injury: A Case Series

Round 1

Reviewer 1 Report

The issue of colour mismatch between the free flap skin paddle and surrounding burn scars should be highlighted as a significant disadvantage in choosing free flap reconstruction over local/regional flap options or non-surgical scar modulation eg. with laser for neck burn contracture resurfacing. I do note the comment that imperfect colour match was 'easily concealable with make up or clothing' however I think this point downplays the main cosmetic disadvantage of free flap reconstruction within a diffuse area of burn scar as opposed to alternative measures. I agree with the statement later in the paper that ''Adequate contour and color is 194 also difficult to achieve with grafting (5).'', however I believe skin graft colour match generally does blend better longer term to surrounding burn scar/graft in diffuse neck burn scars (as in the cases described in this series) compared with free flap skin colour mismatch.

I think it would be prudent to mention non free flap surgical reconstruction options for neck burn scar resurfacing as part of the discussion such as supraclavicular artery based or transverse cervical artery based flaps, trapezius and parascapular flaps. It is likely these were not available in many of the cases listed in this series given the diffuse nature of the neck scars presented and this information further justifies the indications for free flap neck scar resurfacing described.

Case 1 - Could the authors include any measurements of mentosternal distance pre and post-operatively recorded that could be used as an objective measure of neck contracture release in this case? Alternatively are there any longer term clinical photographs to demonstrate maintenance of the excellent result beyond the 2 month follow-up picture shown? Can the authors comment on skin paddle contraction following inset of the pre-expanded free flaps in this series?

Case 2 shows a very nice result with congratulations to the authors. Slightly blurry pictures in the series accompanying this case and also in Figure 4. Perhaps higher resolution images are available for the final publication?

I appreciate the inclusion of post-operative physiotherapy protocols in this paper. Could the authors expand on this with description of details regarding splint type (hard/soft/Watusi collar) and duration of post-op splint usage?

Can the authors comment in more detail on their operative set up in terms of patient positioning - any specific techniques to maximise neck extension at the time of neck scar release. Can the authors further describe how many patients underwent platysmectomy and how many did not in this series and what factors affected that operative decision?

 

 

Author Response

Reviewer 1

The issue of colour mismatch between the free flap skin paddle and surrounding burn scars should be highlighted as a significant disadvantage in choosing free flap reconstruction over local/regional flap options or non-surgical scar modulation eg. with laser for neck burn contracture resurfacing. I do note the comment that imperfect color match was 'easily concealable with make up or clothing' however I think this point downplays the main cosmetic disadvantage of free flap reconstruction within a diffuse area of burn scar as opposed to alternative measures. I agree with the statement later in the paper that ''Adequate contour and color is 194 also difficult to achieve with grafting (5).'', however I believe skin graft colour match generally does blend better longer term to surrounding burn scar/graft in diffuse neck burn scars (as in the cases described in this series) compared with free flap skin color mismatch.

We appreciate the points made by the reviewer and agree over time skin graft color mismatch can improve. The important benefit of free tissue transfer in the neck is that it gives relief of contractures far superior to skin grafts and the texture of the skin in the neck much more closely resembles the normal skin in the neck with its smoothness, pliability and elasticity. In many cases the color match was very good and in only a minority was a color mismatch a concern. When our female patients wanted to use makeup to improve this, the amount of makeup required was similar to what was used on the normal facial regions because the contour, relief and contractures were minimal whereas with skin grafts it was very difficult to give the smoothness as well as colour desired with makeup.  

 

I think it would be prudent to mention non free flap surgical reconstruction options for neck burn scar resurfacing as part of the discussion such as supraclavicular artery based or transverse cervical artery based flaps, trapezius and parascapular flaps. It is likely these were not available in many of the cases listed in this series given the diffuse nature of the neck scars presented and this information further justifies the indications for free flap neck scar resurfacing described.

 

The senior author has used the supraclavicular artery flap expanded and non-expanded for these types of burn deformities but it requires non-injured skin in the region which did not exist for the cases we describe. Free flaps from the back contain very thick skin of different color to face and again were not available in our cases due to the size and location of the burns.

 

Case 1 - Could the authors include any measurements of mentosternal distance pre and post-operatively recorded that could be used as an objective measure of neck contracture release in this case? Alternatively are there any longer term clinical photographs to demonstrate maintenance of the excellent result beyond the 2 month follow-up picture shown? Can the authors comment on skin paddle contraction following inset of the pre-expanded free flaps in this series?

 

Case 1 was a five year old child who is now a 28year old mother of two children who also had a DIEP flap for breast reconstruction. She was last seen more than five years ago and at that time the surrounding scars of the neck burn have remodelled and she has a good aesthetic result. For these reasons we do not have measurements or additional photos.  Although 10-15% contraction was encountered at the time of inset, normal only the superior scar release incision is madein most cases and the microvascular anastomosis successfully achieved before remove of the scar skin and inset performed to avoid mistakes in excessive resection. This also allows us to back out of the free tissue transfer in case of difficulties of any kind, however we have not as yet had to do this.

 

Case 2 shows a very nice result with congratulations to the authors. Slightly blurry pictures in the series accompanying this case and also in Figure 4. Perhaps higher resolution images are available for the final publication?

 

Thank you for the comment. I apologize for the less sharp photos submitted but they are the only photos I have which display the defatting approach and I think the general approach is still displayed by their inclusion but they could be omitted if desired.

 

I appreciate the inclusion of post-operative physiotherapy protocols in this paper. Could the authors expand on this with description of details regarding splint type (hard/soft/Watusi collar) and duration of post-op splint usage?

 

Immediately post-operatively, a soft bulky dressing is used.  Once the flap is healing nicely a soft collar could be used but these patients started physiotherapy at one week and their splinting requirements were minimal. None of our patients wore a splint at the time of discharge from hospital.

 

Can the authors comment in more detail on their operative set up in terms of patient positioning - any specific techniques to maximize neck extension at the time of neck scar release. Can the authors further describe how many patients underwent platysmectomy and how many did not in this series and what factors affected that operative decision?

Patients were supine with a roll behind their shoulders for neck extension and a donut gel head rest which allow some side to side movement for access to the side of the neck for micro-anastomosis.

Although the platysma was certainly divided at the time of inset, in many of the cases the resected skin graft had been placed on debrided wounds that involved the platysma so that little undamaged platysma remained after free tissue coverage.

 

Reviewer 2 Report

Thank you for the opportunity to review this manuscript.  It is very interesting with wonderful case examples and photographs.  It will add a lot to the literature on this topic. My suggestions for revision include the following:

General:

1.) I think the title and introduction are too ambitious and should be revised.  When I started reading based on the title and the intro I thought you were going to give me evidence as to why free tissue transfer has better outcomes when compared to other methods of neck reconstruction.  However, none of your results were compared to other methods in this study so essentially this is a well-done case series describing your success with the technique, but this is not obvious until the last sentence of the introduction.  

2.) Did you consider comparing your free tissue transfer results to other methods of reconstruction with respect to the need for re-operation, improvement of airway issues, cosmesis, ROM, etc.? This would make your argument stronger.

Discussion:

3.) Your discussion needs to include a discussion of the limitations of your study.

Author Response

Reviewer #2

 

1.) I think the title and introduction are too ambitious and should be revised.  When I started reading based on the title and the intro I thought you were going to give me evidence as to why free tissue transfer has better outcomes when compared to other methods of neck reconstruction.  However, none of your results were compared to other methods in this study so essentially this is a well-done case series describing your success with the technique, but this is not obvious until the last sentence of the introduction.  

Thank you for the comments.  We have changed the title to reflect the fact that the manuscript is a case series as requested.  As the reviewer knows, in clinical medicine it is not easy to design and conduct a controlled trial of skin grafts versus free flaps for neck release in burn patients as alluded to by the reviewer.  Also based on our experience, we would question the ethics of using inferior techniques such as skin grafts when we are aware of the significant benefits offered the patient by free tissue coverage.  However, we contend that the manuscript presents objective evidence for significant improvement in range of motion after free flaps and subjective information comparing the appearance of skin grafted necks prior to surgery and after free flap reconstruction.

 

2.) Did you consider comparing your free tissue transfer results to other methods of reconstruction with respect to the need for re-operation, improvement of airway issues, cosmesis, ROM, etc.? This would make your argument stronger.

In our experience, it was only after suboptimal results were achieved by less complex methods including split and full thickness skin grafts for burn neck contractures that we had developed the technique of free tissue transfers for neck reconstruction. Thereafter,  we began to measure range of motion and determine Mallampati scores before and after surgery in a subset of more recent cases. As suggested by the reviewer, measurement of neck range of motion was significantly improved and Mallammpati scores (which are determined in part by measuring Mentosternal distances) also were improved but did not reach statistical significance. Importantly, after free tissue transfer,  our patients could undergo further endotracheal intubation and general anesthesia without the need for awake fibreoptic intubation which is stressful and traumatizing for the patient.  

Discussion:

3.) Your discussion needs to include a discussion of the limitations of your study.

 As requested this section was added to the manuscript:

 

Limitations of the Study

                                        

The numbers of patients in our study is small and the subset of patients who were studied in a prospective fashion was limited.  Patients described in the study included individuals first operated on more than twenty years ago which made follow up difficult.  Larger numbers of cases in a controlled trial with further measurements range of motion, color matching and Mallampatti scores would improve the strength of the findings of this case series of patients.  

 

Reviewer 3 Report

Thank you for sending in your manuscript to this journal.

This is a case history of 9 cases with a burn related contracture of the neck and a solution of that by free flap technique.

however only nine cases in 10 year is a very limited series, and also when you consider that you used several harvesting locations and techniques.That makes it difficult to draw firm conclusions.

How many times did you apply an other technique like a split skin graft or a z-plasty in this period?
To do a statistical analysis in only 4 cases is in my opinion not done.

please remove that part out of your manuscript because it makes no sense.

The conclusion you made to harvest ,in future cases, from the thigh is not argumented well enough ,please explain why, over the other locations , the thigh should be the favorite..Allthough you describe no recurrencies, you still did a z-plasty as a reoperation :why?

 

Author Response

Reviewer #3

This is a case history of 9 cases with a burn related contracture of the neck and a solution of that by free flap technique.

however only nine cases in 10 year is a very limited series, and also when you consider that you used several harvesting locations and techniques.That makes it difficult to draw firm conclusions.

We agree that the number of cases is limited but as burn surgeons caring for the entire spectrum of injury the number of times we felt free tissue transfer was appropriate was limited and other less complicated techniques were used including split thickness and full thickness grafts, Integra artificial skin, local and distant flaps.  As we improved our technique and recognized the limitations of other methods, we used  free tissue transfer more frequently. Although different types of free flaps were included in our series, the control of contractures and improvement and function occurred independent of the type of flap selected.  We agree with Desmouliere et al , that flap coverage of the open wound inhibits wound contracture and hypertrophy likely through the induction of apoptosis in the underlying fibroblasts and myofibroblasts and enhanced remodeling of granulation tissue in the wound bed.

Ref:  S Garbin, Pittet,B, Montandon D, Gabbiani G Desmoiliere A.  Covering by flap induces apoptosis of granulation tissue myofibroblast and vascular cells.  Wound Repair Regen. 1996 Apr-Jun; 4(2) 244-51.

 

This information has been added to the revised manuscript.

 

How many times did you apply an other technique like a split skin graft or a z-plasty in this period?

Although we have no record of the exact number of other techniques used to address neck contractures after burns, we did and continue to do a broad range of other techniques including split and full thickness grafts, Integra, local flaps including expanded supraclavicular artery flaps.

To do a statistical analysis in only 4 cases is in my opinion not done.

please remove that part out of your manuscript because it makes no sense.

The measurements of improvements in range of motion were performed in our latest cases as discussed and by comparing before and after function in the same patient one could analyze within subjects the change in ROM to limit variability.  This approach allowed us to see significant improvements in ROM which fit with our clinical experience.  As requested by other  reviewers, this is a more objective analysis of our findings we feel is important and we would like to retain it.

The conclusion you made to harvest ,in future cases, from the thigh is not argumented well enough ,please explain why, over the other locations , the thigh should be the favorite..

We favor the thigh as a source of free flap because usually one can closure the donor site wound and leave a linear scar as the only donor site deficit which is preferable to the radial forearm donor site where the skin grafted donor site is a negative feature of selecting this donor site. We have tried to illustrate that with pictures of both donor sites and illustrate our commitment to the thigh as a donor site in future planning by avoiding skin graft harvest where possible in cases where we anticipate that burns to the face and neck will result in significant deformity that would benefit from free tissue transfer.

Allthough you describe no recurrencies, you still did a z-plasty as a reoperation :why?

We have had very few if any recurrences but one or two cases where the size of the flap was insufficient to remedy all of the tightness the patients complained of and in those cases smaller split skin grafts at the base of the neck was sufficient to resolve the residual contractures. 

We still frequently employ Zplasty for smaller, localized neck contractures and bands as well as laser, skin grafts and tissue engineered skin where applicablefor smaller more localized contractures and bands.  However, all our burn surgeons are trained to do microsurgery and this technique has become more routine for us and has greatly expanded our ability to assist our patients with difficult, large scale neck contractures / wounds as we have tried to illustrate.

 

 

Reviewer 4 Report

The manuscript is not well-structured and requires extensive revision. Here are some comments that I believe could assist the authors in improving the manuscript's quality:

 

1. The references are not up-to-date. The most recently published articles should be used to provide background on each subject investigated and to discuss the results obtained.

 

2. Many statements in the manuscript require citations.

 

3. On page 2, lines 46-48, "Multiple methods have been applied when … skin substitutes and lasers," it would be helpful if the authors provided more information about the advantages and limitations of the methods mentioned.

 

4. The ages of the cases have been reported to be between 18 and 59 years old (line 70), but case 1 is a 5-year-old girl.

 

5. On page 3, line 102, The soft tissue expander device information should be included.

 

6. The manuscript lacks coherence. The subsection "3.2. Case 2" should come before the subsection "3.3. Case 3."

 

7. Why did the authors only report three cases in the section "3. Case Reports"?

 

8. The authors have not provided much information about the operations.

 

9. All of the provided figures should have detailed captions.

 

10. Each figure should be labeled with a letter and thoroughly explained in the caption.

 

11. Figure 4 is of poor quality.

 

12. On page 8, line 186-188, "One patient suffered … and intravenous antibiotics." More information about this specific case should be provided. The antibiotic-based therapy should also be explained.

 

13. The "5. Discussion" section is poorly written. The manuscript falls short of providing a more immersive critical analysis of the advantages/disadvantages, potentials/limitations, and opportunities/challenges of the various subjects investigated.

 

14. "Staphylococcus aureus" (on page 8, line 187) and "et al" (on page 9, line 216) should be written in italics.

Author Response

 

Reviewer 4

The manuscript is not well-structured and requires extensive revision. Here are some comments that I believe could assist the authors in improving the manuscript's quality: 

1. The references are not up-to-date. The most recently published articles should be used to provide background on each subject investigated and to discuss the results obtained.

We accept this criticism and have reviewed the literature again and added five more recent citations to update our reference list.

 

2. Many statements in the manuscript require citations.

I have reviewed the manuscript in attempt to reduce the number of unsupported statements.  I have added five more recent support references, changed the title and added a section on limitations of our study.   

 

3. On page 2, lines 46-48, "Multiple methods have been applied when … skin substitutes and lasers," it would be helpful if the authors provided more information about the advantages and limitations of the methods mentioned.

 

We have modified the manuscript to address the request of the reviewer:

Multiple methods have been applied when a contracture is limited to a small area including partial and full-thickness skin grafts, Z-plasties, local flaps, tissue expanders, skin substitutes and lasers (3). These techniques are less time consuming, technically easier to perform and offer quicker recovery.  However their disadvantages are primarily limited to large burns where recurrence remains frequent and success with grafted materials is less reliable. Moreover, when the contractures are extensive and the adjacent area is burned, when large donor areas available microsurgical reconstruction of the neck has been shown to offer better functional results and reduce morbidity (4).

 

4. The ages of the cases have been reported to be between 18 and 59 years old (line 70), but case 1 is a 5-year-old girl.

Thank you for pointing this out.  The statistical cohort was what being referred to but the manuscript has been corrected.

 

5. On page 3, line 102, The soft tissue expander device information should be included.

At the suggestion of the reviewer we have provided the following information:

The expander was a 100 cc total volume rectangular expander with a self-contained port placed under the forearm fascia via an ulnar based incision.

 

6. The manuscript lacks coherence. The subsection "3.2. Case 2" should come before the subsection "3.3. Case 3."

Thankyou.  We noticed that with type setting the order of the cases changed and have tried again to correct it in the revised manuscript.

 

7. Why did the authors only report three cases in the section "3. Case Reports"?

We chose one male patient, one female patient and one child to illustrate the range of patients which could be cared for and to show various flaps used where the reader could examine the various donor sites and the morbidity encountered in attempt to illustrate the advantage of ALT when it is available.

 

8. The authors have not provided much information about the operations.

We appreciate the comment and have added the following additional information:

 

After completion of recipient vessel exposure and flap harvesting, surgical anastomoses of one artery and vein were performed with microsurgical techniques using coupling devices on the venous anastomosis.  Flap monitoring was assisted by implantable doppler devices around the arterial pedicle and venous monitoring visually by experienced nurses in the burn intensive care unit.

 

 

9. All of the provided figures should have detailed captions.

 The figure legends have been reviewed and revised as requested.

 

10. Each figure should be labeled with a letter and thoroughly explained in the caption.

The figure legends have been reviewed and revised as requested.

 

11. Figure 4 is of poor quality.

As discussed earlier the figure illustrates the planes involved and the technique for defatting despite it suboptimal focus. Unfortunately, we have no substitute so It can be removed if desired by the editor.

 

12. On page 8, line 186-188, "One patient suffered … and intravenous antibiotics." More information about this specific case should be provided. The antibiotic-based therapy should also be explained.

 As request we have modified the information.  One patient who was poorly compliant with dressings and wound care developed an infection in the soft tissue expander site.  It was debrided and the expander removed and he received intravenous Vancomycin.  After several months, he returned for surgical release and reconstruction with an unexpanded radial forearm flap from the same donor area. 

 

13. The "5. Discussion" section is poorly written. The manuscript falls short of providing a more immersive critical analysis of the advantages/disadvantages, potentials/limitations, and opportunities/challenges of the various subjects investigated.

 As discussed earlier, the manuscript has been reviewed, revised and additional information provided to support the ideas presented. Limitations  have been acknowledged and advantages/disadvantages discussed.

 

 

14. "Staphylococcus aureus" (on page 8, line 187) and "et al" (on page 9, line 216) should be written in italics.

Thank you these errors have been corrected.

Round 2

Reviewer 1 Report

Thank you for your responses and edits. I believe this to be publishable in its current form.

Author Response

Thankyou 

Reviewer 3 Report

The manuscript has been improved

Caused by the corrections there are a few typo s and bad sentence constructions in the red text. Please correct.

Author Response

Thankyou will correct the sentence

Reviewer 4 Report

The manuscript could be accepted for publication.

Author Response

Thank you