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Case Report
Expediting venous drainage in large anterolateral thigh flaps for scalp electrical burns in India: two case reports on the use of primary vein grafts for second vein anastomosis
Jyotica Jagadish Chawaria, MChorcid, Parvati Ravula, MChorcid, Nazia Tabassum, MSorcid, Srikanth Rangachari, MChorcid
Journal of Trauma and Injury 2023;36(4):404-410.
DOI: https://doi.org/10.20408/jti.2023.0054
Published online: November 30, 2023
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Department of Plastic and Reconstructive Surgery, Nizams Institute of Medical Sciences, Hyderabad, India

Correspondence to Srikanth Rangachari, MCh Department of Plastic and Reconstructive Surgery, Nizam’s Institute of Medical Sciences, Punjagutta Rd, Punjagutta Market, Punjagutta, Hyderabad 500082, India Tel: +91-40-2348-9049 Email: drsrikanthr@gmail.com
• Received: August 11, 2023   • Accepted: August 29, 2023

© 2023 The Korean Society of Traumatology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

  • Large scalp defects resulting from high-voltage electrical burns require free flaps, preferably skin, to permit optimal coverage and enable future or simultaneous cranial vault reconstruction. The anterolateral thigh permits the harvest of a large area of skin supplied by a reliable perforator. The superficial temporal vessels offer the proximate choice of recipient vessels to enable adequate reach and coverage. The lack of a second vein at this site implies the inability to perform a second venous anastomosis; however, this obstacle can be overcome by using an interposition vein graft, to the neck veins primarily. This assures adequate venous drainage and complete flap survival.
High-voltage electrical burns of the scalp can result in large areas of skin loss and the exposure of skull bones. The nature of the thermal insult implies the possibility of full-thickness skull bone loss with a risk of dural infection and future calvarioplasty. The probability of multiple burn sites and other injuries consequent to a high-voltage electrical injury may preclude the ideal of primary debridement and definitive flap coverage, as treating these other problems may be potentially lifesaving.
Free flaps are a single-stage solution for adequate wound coverage. Historically, muscle flaps (especially the latissimus dorsi) were preferred, but the availability of the anterolateral thigh (ALT) flap has allowed the replacement of lost skin with skin, which would also be advantageous for second-stage calvarial reconstruction where indicated.
We present two such clinical situations where the elective use of an interposition vein graft from the second accompanying vein of the ALT flap to a second recipient vein in the neck enabled complete flap survival.
Case 1
A 25-year-old man sustained a high-voltage electrical burn at work 6 months earlier, with approximately 25% mixed thermal burns involving the back, gluteal region, face, neck, and scalp. He lost vision in both eyes. He underwent primary management with debridement and airway support with a tracheostomy, followed by split-skin grafting of raw areas over the neck, right hand, and forearm. He was referred with a large area of scalp skin loss with exposed dead calvaria. Both eyelids on the right side were destroyed. The left lower eyelid was present, and since there was some perception of light, a future keratoplasty was planned. On examination, a 19×16-cm area of scalp was bereft of skin, extending from the bregma to the root of the nose anteroposteriorly and from one temporal line to the other transversely (Fig. 1). The exposed frontal and temporal bones were desiccated.
Under general anesthesia, the margins of the wound were freshened (Fig. 2A), the dead frontal bone was removed without any dural breach (Fig. 2B), and the supraorbital bandeau was retained after burring the surface. A 22×18-cm ALT flap was planned from the right thigh to permit inset into unscarred skin (Fig. 2C). Because the lesser scar was on the right side, the right superficial temporal vessels were chosen as the recipient. The flap was a musculocutaneous type with one artery and two accompanying veins. Since there was only a single superficial temporal vein, the other flap vein was anastomosed to the external jugular vein in the neck by using a 17-cm great saphenous vein interposition graft electively (Fig. 2D). The flap was inset around all edges of the freshened skin defect, and the anterior edge of the flap on the left side was sutured to the lower lid remnant margin.
Subsequently, the patient underwent three sittings of flap thinning and adjustment. A further attempt was made to recreate a semblance of the left upper eyelid to permit future keratoplasty (Fig. 3).
At the 3-year follow-up, he was provided with a wig to conceal the alopecic flap as well as dark glasses. The keratoplasty was not successful, but he is presently able to move around with a walking aid for the blind and has been trained in Braille to permit him to seek a job (Fig. 4).
Case 2
A 33-year-old man sustained a high-voltage electrical burn to the scalp and upper limb 7 months earlier. He also sustained a spinal injury with his fall from the overhead transformer, which was treated conservatively and resulted in mild weakness of both lower limbs and an altered gait. He was referred with a 14×22-cm scalp skin defect and exposed dead calvaria (Fig. 5).
The resected full-thickness calvaria consisted of the superior frontal bone, both temporal bones, and both parietal bones (Fig. 6A, B). Although there was no dural breach, dural hitching sutures were used around the entire defect after debridement. The ALT flap was harvested from the right thigh, as exploration of the left thigh was negative for a suitable perforator (Fig. 6C), and anastomosis was done to the superficial temporal vessels. The second venous anastomosis was done to the ipsilateral common facial vein in the neck using a 12-cm cephalic vein interposition graft primarily (Fig. 6D). The flap was completely inset with a split-skin graft applied over the recipient pedicle to prevent compression. The incision in the neck was closed primarily.
We scheduled a follow-up of not more than 9 weeks for this patient, at which time the flap was found to be completely viable, and all donor and recipient wounds were healed (Fig. 7). The patient discontinued follow-up, likely because he was from a broken home with multiple socioeconomic issues.
In both cases there was no reexploration, no loss of vascularity in any part of the flap, and no infection. The second case had a 15-mL seroma under the flap, detected on the 9th day and drained under local anesthesia with no further consequence. In both cases, a split-skin graft for the large donor defect was harvested from the opposite thigh to expedite uneventful healing.
Ethics statement
Written informed consents for publication of the research details and clinical images were obtained from the patients.
McLean and Buncke [1] and Chavoin et al. [2] described the earliest use of free flaps for scalp electrical burns using the superficial temporal vessels. The omentum was used in one case by McLean and Buncke [1], and Chavoin et al. [2] used groin flaps in two cases after preliminary debridement. The superficial temporal vessels were used as recipient vessels.
In 1994, Shen [3] presented six cases of electrical burns of the scalp, for which musculocutaneous latissimus dorsi flaps were used, and the author cited a preference for the neck vessels as they were away from the zone of thermal trauma. Though the article does not state explicitly whether two veins were anastomosed, it mentions the use of vein grafts to neck veins in two of six cases.
Lutz et al. [4] described 30 scalp reconstructions, four of which were for large electrical burns (120–420 cm2). One of those four reconstructions failed because of venous congestion. The superficial temporal vessels were the vessels of choice, but the series had three cases where vein grafts had to be used, presumably for venous anastomosis.
Imanishi et al. [5] highlighted the lack of consistency in the nomenclature of veins in the temporal region. There is the superficial temporal vein as well as deep veins (the latter being of small caliber), which do communicate with each other.
The need to avoid using the superficial temporal vessel as the recipient vessel in five moderate scalp defects compelled Hashem and Al Qattan [6] to artificially lengthen the pedicles of the rectus abdominis and latissimus dorsi flaps to enable anastomosis with neck vessels and avoid the use of vein grafts.
Calikapan et al.[7] reported a series of seven consecutive cases with simultaneous duraplasty in four. They specified the use of the two concomitant temporal veins and the need for a vein graft to the neck veins in one case with postoperative venous congestion.
Forty-five free flaps, specifically referring to the use of the superficial temporal vessels as recipient vessels, were first reported by Hansen et al. [8], 19 of which were for scalp defects with an average defect size of 140 cm2; none were ALT flaps. They saw that three of 43 flaps had a >2:1 discrepancy in vein size and elected to use the retromandibular, external jugular, or contralateral facial vein; the latter two cases needed vein grafts. Interestingly, they made a distinction between the superficial temporal vein and the venae comitantes of the superficial temporal artery.
Use of the superficial temporal vein remains a matter of debate. Ausen and Pavlovic [9] stated that the course of the superficial temporal vein is not as predictable as the artery and often does not follow the artery except in the most proximal portion. Whereas the artery almost always bifurcates into two major branches, the vein presents more anatomical variability; it may remain as one vessel or divide into two or three major branches. Therefore, when the two venae comitantes are being anastomosed, it is very likely that the proximal drainage is into the same vein.
Sudirman et al. [10] reported an interesting use of the retrograde and antegrade limbs of the superficial temporal vessels in a cohort of 60 patients with recurrent reconstructions following tumor excisions in the presence of frozen neck. The retrograde route was preferred over the antegrade when the flow or drainage was inadequate and relied on anastomosis across the midline of the scalp. They reported no statistical significance in loss of flap regardless of the direction of the anastomosis. All defects were in the middle or upper third of the face and ALT flaps were used in most cases.
Maricevich et al. [11], in a systematic review of more than 3,000 cases, reported an increased risk of free flap compromise and loss with the use of vein grafts (7.4% vs. 3.4%). Despite this statistic, they found that eight of 16 such failures were not directly related to the technical use of vein grafts but were caused by other factors such as dressing pressures and tracheostomy ties. Furthermore, they agreed that the use of such a vein graft is likely to be of benefit in large free flaps for scalp reconstructions where the superficial temporal pedicle was questionable.
In 2019, Daya and Pillay [12] used this concept to perform double venous anastomosis for the cut ends of the superficial temporal vein in six cases of facial and temporal defects, with no complications.
Kumbla and Myers [13] described the empiric use of a preliminary arteriovenous loop with the superficial temporal vessels in two stages for a large post–neoplasia excision scalp defect needing a latissimus dorsi flap. They justify the use of vein grafts to overcome the issue of arterial spasm, especially in the setting of prior radiation to the area.
The availability of the distal end of the superficial temporal vein and putative drainage pathways across the midline may not be a given in the setting of large scalp defects. We believe that large flaps as described in our report need the anastomosis of a second vein to eliminate any chance of postoperative venous compromise. The anatomical compulsion of a single sizable superficial temporal vein forces the surgeon to opt for a second venous anastomosis using the veins in the neck, even at the cost of adding an interposition graft.
The debate over a single versus double venous anastomosis continues. It is pertinent that in a meta-analysis by Chaput et al. [14] of 16 articles and 3,684 flaps with an overall success rate of 96.15%, they reported a failure rate of 1.51% in the group with two anastomoses versus 5.03% in the group with single anastomoses. There were also more surgical revisions in the single venous anastomosis group (11.87%) than in the double anastomoses group (6.04%). They further stated that, since the ALT flap does not offer the luxury of a superficial and deep venous system like the radial forearm or the deep inferior epigastric artery flap, performing a second venous anastomosis for the ALT flap is mandatory.
In conclusion, the reconstruction of large scalp defects following electrical burns has improved with the advent of the ALT flap. Using the superficial temporal vessels permits optimal flap size and reach for defects that reach from ear to ear. Since the superficial temporal vessels do not consistently allow a second venous anastomosis, primary vein grafts from the second venae comitantes to neck veins ensure a favorable flap outcome.

Author contributions

Conceptualization: JJC; Methodology: PR; Investigation: all authors; Writing–original draft: PR; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no any financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.
High-voltage electrical burn of the scalp with exposed dead frontal bone (case 1). (A) Vertex view showing dead frontal bone. (B) Complete loss of both eyelids. (C) Right lateral view. (D) Left lateral view with scar over region of temporal vessels. The patient provided written informed consent for publication of the clinical images.
jti-2023-0054f1.jpg
Fig. 2.
Images of case 1. (A) The debrided wound. (B) The dead frontal bone. (C) The harvested flap. (D) The vein graft (arrows) for the second vein of the anterolateral thigh flap.
jti-2023-0054f2.jpg
Fig. 3.
Appearance after second flap thinning in case 1. (A) Frontal view. (B) Vertex view. (C) Left lateral view. (D) Right lateral view. (E) Right oblique view. (F) Left oblique view. The patient provided written informed consent for publication of the clinical images.
jti-2023-0054f3.jpg
Fig. 4.
Appearance after rehabilitation at 30 months with the use of a camouflaging wig (case 1). (A) Frontal appearance. (B) Dark glasses. (C) Wig to enable social acceptance. (D) He is able to independently navigate using a stick. The patient provided written informed consent for publication of the clinical images.
jti-2023-0054f4.jpg
Fig. 5.
Exposed frontal and parietal bones and large skin defect (case 2).
jti-2023-0054f5.jpg
Fig. 6.
Images of case 2. (A) The debrided wound. (B) The dead calvaria. (C) The harvested flap. (D) The vein graft for the second vein to the neck veins. The patient provided written informed consent for publication of the clinical images.
jti-2023-0054f6.jpg
Fig. 7.
Follow-up images at 9 weeks with uneventful wound healing (case 2). (A) Frontal view. (B) Left lateral view. (C) Vertex view at follow-up showing completely healed flap. The patient provided written informed consent for publication of the clinical images.
jti-2023-0054f7.jpg
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