Lateral Intercostal Microvascular Flap for Release of Neck Scar

EDITORIAL COMMENT

This is another alternative that would be far down on the editors’ list of recommendations because of the difficult dissection and the poor color match for neck skin. In severely burned patients with only selected areas that are free of scarring, however, this flap might prove useful.

This is a sizable neurovascular skin flap from the anterolateral abdomen, based on the lateral cutaneous branch of any one of the lower three posterior intercostal vessels or the subcostal artery. It can have varying forms and a wide spectrum of applications, including use for posttraumatic scarring of the face, neck, and extremities, to correct facial contour deformities, and in breast and penile reconstruction (Fig. 137.1).

INDICATIONS

Lateral intercostal flaps share indications with other upper-quadrant flaps (1, 2, 3, 4, 5, 6, 7, 8) but without the need for delay or the inclusion of intercostal or abdominal musculature. The flaps are innervated by the lateral cutaneous nerve, which contains between two and four fascicles for total flap supply. A vascularized rib segment may be incorporated for an osteocutaneous flap (9), and the flap may be deepithelialized (10). Other advantages of the flap include its large size (up to 25 × 20 cm), its long pedicle (8-15 cm), easy anastomosis of relatively large-diameter intercostal vessels (1.5-2.0 mm), and relative thinness. There is a choice between several pedicles, and the flap can be defatted and beveled without compromising its vascularity; primary tailoring minimizes the need for future revisions. The donor defect is closed directly, even in larger flaps, because of the redundancy of the abdominal skin.

ANATOMY

For purposes of description, the posterior intercostal artery, which is a branch of the thoracic aorta, can be divided into four segments: vertebral, costal groove, intermuscular, and rectus sheath segments (7). The vertebral segment gives off a nutrient branch to the rib, a spinal branch, and a collateral branch. In the intermuscular segment, the artery gives off mainly muscular and intermuscular branches. In the rectus sheath segment, the vessel terminates by anastomosing with the epigastric system. In the costal groove segment, the vessel gives off the following branches.

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