Posterior Skin Flap Research Articles

Fifty free flaps from the ear

Reconstruction of facial and intraoral defects is often challenging. Local pedicled flaps may not always be available and distant free flaps usually have suboptimal color match and texture for the facial area. The aim of this study was to assess whether auricular free flaps are a valid reconstructive option. Clinical data and outcomes of patients who underwent reconstruction with microsurgical flaps from the ear between 2011 and 2021 were analyzed. Patient demographic data, type of flaps, etiology, location and size of the defect, features of the pedicle and recipient vessels, complications, and additional surgeries were reviewed. Overall, 48 patients with 50 microsurgical flaps were identified. Thirty-one patients (65%) were men and 17 were (35%) women. The median age was 62 years. Among the 50 flaps, 26 (52%) were helix flaps, 20 (40%) were temporal artery posterior auricular skin flaps, and 4 (8%) were extended helix flaps. The nose was the most frequently reconstructed region (n=32, 64%), followed by the tongue (n=6, 12%), floor of the mouth (n=5%), lower eyelid (n=2%), and in one (2%) patient each, restoration of the upper eyelid, ear, larynx, esophagus, lower lip, and palate. The median follow-up was 74 months. Three flaps (6%) were lost, and the overall rate of complications was 46%. Surgical intervention was required in 7 (14%) cases. All cases healed with acceptable cosmesis. The ear is a valuable source of tissue for complex reconstructions of the face and intraoral regions. However, this technique is surgically demanding and should be reserved for selected cases.

Incidence and Nerve Distribution of Symptomatic Neuromas and Phantom Limb Pain after Below-Knee Amputation.

Patients with major lower limb amputations suffer from symptomatic neuromas and phantom-limb pain due to their transected nerves. Peripheral nerve surgery techniques, such as targeted muscle reinnervation and regenerative peripheral nerve interface, aim to physiologically prevent this nerve-specific pain. No studies have specifically reported on which nerves most frequently cause chronic pain. The authors studied the nerve-specific incidence of symptomatic neuroma formation and phantom limb pain in patients undergoing a below-knee amputation, to better tailor use of targeted muscle reinnervation and regenerative peripheral nerve interface. This was a retrospective review of all patients undergoing a below-knee amputation from January 1, 2013, to December 31, 2018, at MedStar Georgetown University Hospital. All below-knee amputations were performed with a posterior skin flap, myotenodesis, and traction neurectomies of all nerves. Postoperative notes were reviewed for the presence of a symptomatic neuroma, defined as localized pain and a Tinel sign over a known sensory nerve, and nerve-specific phantom limb pain, defined as pain of the missing limb corresponding to a known dermatome. One hundred ninety-eight patients were included in this study. The rate of symptomatic neuroma formation was 14.6 percent (29 of 198), with the superficial peroneal and saphenous nerves most often involved. Diabetes and obesity were protective against symptomatic neuroma formation. The rate of nerve-specific phantom limb pain was 12.6 percent (25 of 198) and highly correlated with the presence of a symptomatic neuroma. To optimize outcomes for amputees, it is critical that surgeons best understand what nerves are more likely to form symptomatic neuromas and lead to nerve-specific phantom limb pain, so that surgeons can best tailor primary or secondary management of the major sensory nerves. Risk, III.

Application of posterior canal skin flap for the repair of large tympanic membrane perforations.

ObjectiveMany methods have been described for the repair of the tympanic membrane, but there is no general consensus as to the standard method. The aim of this study was to evaluate the effect of the inferior base posterior canal skin flap on the graft success rate in large tympanic membrane perforations.MethodsAfter the post‐auricular incision, the posterior canal skin flap with inferior pedicle was created by two vertical and one horizontal incisions. Then the flap was rotated over the temporalis fascia graft. The graft success rate and postoperation hearing test results were evaluated in 52 patients who suffered from large tympanic membrane perforations.ResultsWe achieved a 92.3% total graft success rate with about 9 dB improvement in speech reception threshold (SRT).ConclusionThe rotational inferior base posterior canal skin flap tympanoplasty technique is simple, fast, safe, and effective for the repair of subtotal tympanic membrane perforations.

Long-term outcomes of the surgical treatment of girls with a classical form of congenital adrenal hyperplasia

Introduction. Currently, to study long-term outcomes of feminizing genitoplasty, which is performed to girls with congenital adrenal hyperplasia, is an important step due to the limited data in literature on this topic. The purpose was to assess long-term outcomes of feminizing genitoplasty in congenital adrenal hyperplasia in girls depending on their gender identity, sexual orientation and the anatomy of external genitalia and vagina.Material and methods. A retrospective analysis of 8 case–histories of girls who were operated on at the Arkhangelsk Regional Children’s Hospital in 2001-2004 was made. In 7 of them, who had low urogenital sinus, feminizing genitoplasty included vaginoplasty with a perineal flap; in one patient, who had a high urogenital sinus, the shortened vagina was advanced down to create a missing part with posterior skin (Fortunoff) and anterior mucous (Passerini) flaps. The Prader scores ranged from III to V. Mean age at the time of surgery was 5.6 y.o. (0.5-14). Mean follow-up period was 17.6 (16-18.5) years.Results. All patients had female gender identity. All four sexually active women reported heterosexual orientation. Cosmetic results were good as stated by physicians, parents and patients themselves. Vaginal stenosis was noted only in one patient.Conclusion. The results obtained have shown that the one-stage reconstruction (clitoroplasty and vaginoplasty) for congenital adrenal hyperplasia can be successfully performed in childhood; thus, there is no any reason to refuse of the accepted tactics in treating this group of patients.

Autoaugmentation Brachioplasty: An Arm Contouring Method in Women with Massive Weight Loss.

Brachioplasty of deflated arms following massive weight loss (MWL) often results in too slim arms. These slimmer arms lack the natural proportion and contour. This study presents a novel method for such arms through standard skin excision and autoaugmentation by dermofat flap. During a period of 2 years, 21 women complaining of severe deflation deformity of upper arms following MWL were operated. At time of surgery, the BMI ranged from 20.5 to 33. 4 with a mean of 26.2 kg/m2. The mean value of weight loss was 47.8 kg over a mean period of 18 months. A de-epithelialized dermofat flap was preserved underneath the dissected and advanced anterior and posterior arm skin flaps. The bulk of the flap was tailored as to give an appropriate girth with balanced proportion and contour of the upper arm. During 14 months of follow-up, all patients reported a high satisfaction. Objective evaluation was based on measurement of the mid-upper arm circumferences (MUAC) and its ratio with the mid-forearm circumferences (MFAC) which was compared with those of arms of healthy volunteers with normal BMIs. Augmentation of the upper arm by autologous dermofat flap provides a well arm contour in appropriate balance with the forearm in women having severe arm deflation deformity following MWL. The findings were supported by the objective anthropometric measurements of the MUAC/MFAC of a normal weight healthy women which reached to a mean value of 1.366. The normal girth of upper arm should equal 1[Formula: see text] that of the forearm. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Incision and flap design during total auricular reconstruction using a 2-stage strategy.

BackgroundTotal auricular reconstruction is a challenge for plastic surgeons. Expanded flap method and Nagata’s method with autologous costal cartilage are two leading techniques for ear reconstruction. And a two-stage strategy of expanded flap method received attention. In the present study, we report the incision and flap design of this strategy.MethodsIn the first stage, an 80 mL kidney-shaped expander was inserted in the mastoid region with the larger pole superiorly. The expander pocket was dissected subcutaneously in the scalp area and subfascially in the lower third region. In the second stage, the expander was removed from a Y-shaped lobule incision on the remanent ear. Then the remnant ear was separated into three flaps: the posterior skin flap, anterior skin flap, and lobule flap. When the framework was fabricated, the base frame and the underlying pad, which enhanced the projection, were fixed together as a whole to provide a more prominent appearance. The framework was totally wrapped into the expanded single flap without free skin grafting. Lobule transposition and tragus construction were performed simultaneously instead of a third-stage surgery. The recipient bed of rotated lobule was resected only to the epidermal layer and the subcutaneous layer was preserved to avoid central necrosis.ResultsA total of 21 patients received this strategy to reconstruct ear. With 3 months to 1.5 years of follow-up, 19 patients (90.5%) were satisfied with the reconstructed ears. 3 patients (14.3%) required further modification of reconstructed ear. No serious complications occurred during the procedures.ConclusionsWith a Y-shaped incision, three-flap design of remanent ear and lobule rotation to an epidermal-removal area, tissue expander removal and modification of remanent ear can be performed effectively to avoid necrosis and an extra operation.

Revisiting the temporal artery posterior auricular skin flap with an anatomical basis stepwise pedicle dissection for use in targeted facial subunit reconstruction

This study demonstrates the anatomy of the pedicled temporal artery posterior auricular skin (TAPAS) flap, its variable arc of rotation based on stepwise dissection, and case reports demonstrating clinical use. This flap provides excellent color match and ultrathin tissue for targeted reconstruction of small- to medium-sized facial subunit defects. Twenty-six cadaver dissections were performed. The authors measured the reach and rotation limits of the flap in a pedicled fashion depending on a stepwise approach for vascular pedicle dissection. Two clinical cases demonstrating maximum arc of rotation are seen. The pedicled TAPAS flap maximal rotation limits allow for reconstruction of facial subunits encompassing nearly the entire ipsilateral face. No venous congestion, wound complications, or partial/total flap loss were encountered with extreme clinical applications. The pedicled TAPAS flap has extensive versatility for reconstruction of a variety of facial subunit defects. The flap also has, in theory, multiple applications for intraoral reconstruction.

Revisiting the temporal artery posterior auricular skin (TAPAS) flap: an anatomical basis for stepwise pedicle dissection for use in targeted facial subunit reconstruction

Background: Anatomical study and cases series to evaluate the pedicle TAPAS flap reliability in hemifacial and intraoral reconstruction.

Gluteal region spindle cell variant embryonal rhabdomyosarcoma in infant treated with buttockectomy

IntroductionRhabdomyosarcoma (RMS) is a soft tissue tumor developed from immature mesenchymal cells and accounts for about one-half of soft tissue sarcomas in children. However, it is very rare in infants and so, little is known about. Spindle cell variant of embryonal RMS is a rare and a better differentiated variant of embryonal RMS, having a better prognosis compared to other types of rhabdomyosarcomas. So, it needs to be distinguished from classical forms of the neoplasm. Its morphological resemblance to spindle cell neoplasms like leiomyosarcomas and fibrosarcomas may pose diagnostic difficulties for the pathologist. Gluteal region is a rare site for RMS. We report an infant with embryonal spindle cell variant RMS in the gluteal region. Case reportA one-year-old infant appeared with a history of a two-month lump on the right buttock. Her mother started to notice asymmetry on her child's buttock when she was bathing him. She noticed a lump with the size of a ping-pong ball. The patient could still crawl as usual and walk with aid. Two months later, the lump grew to the size of a tennis ball. In spite of this condition, there was no complaint of fever, weight loss or signs of pain. On the MRI, the mass appeared hypo-intense at muscle on T1-weighted images and hyper-intense on T2-weighted images. Following the administration of dimeglumine-gadopentetate contrast, T1-weighted fat-saturated scans showed intense enhancement with interspersed non-enhancing areas. We decided to do a buttockectomy followed by an adjuvant chemotherapy. Results and discussionInitially, the incision was performed from the posterior iliac crest curving distally following the gluteus maximus muscle until the 2 cm distal of greater trochanter. The incision was curved slightly posterior back to the medial aspect of the thigh to the gluteal fold to form a large posterior skin flap. Sciatic nerve had been identified and preserved. The entire gluteus maximus muscle with the mass has been removed. After 6 months of follow-up treatments, the patient is able to walk in normal gait and accordance with his mileage. ConclusionThe spindle cell embryonal rhabdomyosarcomas is a rare variant of embryonal subtype of RMS, occurring more commonly in children and adolescents. Its less aggressive sarcoma and better prognosis in children or adolescents, establish the correct diagnosis crucial using combination of clinical finding, histopathology and Immunohistochemistry.

Association between crural vessel patency and successful transmetatarsal amputation: a single centre experience

Transmetatarsal amputation (TMA) has a reputation for failure, centred around wound breakdown. No study has looked at the direct association between the patency of individual crural arteries and the healing of TMA. TMA relies on a posterior skin flap which derives its blood supply from the posterior tibial (PT) artery. We investigated the association between PT patency and achievement of successful TMA. A retrospective review of all patients undergoing TMA for complications of peripheral arterial occlusive disease in a regional vascular tertiary referral centre over a 9 year period (2006-2015). TMA was considered successful by the absence of a higher-level amputation. Follow-up was for a minimum of 12 months. 24 patients (21 male; mean age 64 years) were studied. TMA was successful in 16 (67%). On statistical analysis, successful TMA was not significantly associated with vessel patency in either superficial femoral artery (SFA), or any single or combination of named crural artery. TMA healing can be achieved in the absence of a patent posterior tibial artery. We support the role of TMA in selected patients, given its benefits compared to transtibial amputation.

Choosing of the posterior lateral leg pedide skin flaps supplyed by different blood repair of foot and ankle soft tissue defect

Objective According to the characteristics of skin defects in ankle and foot select the posterior lateral leg pedide skin flaps supplyed by different blood to repair, providing advice and reference. Methods Between January, 2001 and December, 2015, 163 cases of soft tissue defects at the foot and ankle were treated in our department. ①The sural neurovascular flap was used in 93 cases in ankle and foot defect. ②The sural nerve nutritional vessel flap pediele with the perforating branch of the peroneal artery in 36 cases in ankle and foot defect. ③The sural nerve nutritional vessel flap pediele with the perforating branch of the peroneal artery including sensory reconstruction in 16 cases in heel rejion defect. ④Peroneal artery perforator flap in 10 cases in anterior ankle, lateral malleolus and posterior malleolus defect.⑤The use of the sural fasciocutaneous flap alonged with peroneal artery and perforators in 8 cases in dorsal foot defect. The donor site with skin graft. Results Of the 93 sural neurovascular flaps, 8 had partial loss, which were cured after dressing. All the sural nerve nutritional vessel flaps pediele with the perforating branch of the peroneal artery survived. Sensory grading standard by UK Medical Research Council was used to evaluate the recovery of sensory function on the last follow-up. The sensory function recovery of heel region flaps with reconstruction of the sensory was between S0 and S1. All peroneal artery perforator flaps survived. One of the sural fasciocutaneous flap alonged with peroneal artery and perforators occurred distal epidermis, which were cured after dressing. All patients were followed up 6-50 months (mean 20 months). All patients had recoveryed walking function, and infection wound had no recurrence after surgery. Conclusion According to the location, size, severity and the injury of peripheral vascular, select the most simple, safe, minimal damage flap for the soft tissue defects at the foot and ankle. The right choice and the exact design can improve flap survival rate, and recieve good clinical results. Key words: Foot and ankle; Soft tissue defect; Surgical flap; Repair; Sense reconstruction

Free temporal artery posterior auricular skin (TAPAS) flap: A new option in facial and intra-oral reconstruction.

There is a limited availability of suitable microvascular free flap options for the reconstruction of small to medium-sized facial and intraoral defects. The purpose of this report is to present a new free temporal artery based posterior auricular skin (TAPAS) flap in facial and intraoral reconstruction. Four patients were deemed suitable for TAPAS flap reconstruction and consisted of two males and two females with a mean age of 43 years (range 22-66). Defect aetiology and location comprised of post-traumatic lower eyelid scarring, late lower lip scarring post tumour resection, and floor of mouth and tongue defects following tumour resection. The dimensions of the resultant defects ranged from 25 × 50 mm (smallest) to 40 × 70 mm (largest). All patients underwent microvascular reconstruction using a free fasciocutaneous TAPAS flap raised from the retroauricular region based on the superficial temporal vessels. The maximal pedicle length was 60 mm and the maximum flap size measured 40 mm by 70 mm. The latter patient required skin grafting of the postauricular donor site. Postoperatively, there was one case of mild transient venous congestion that spontaneously resolved after 2 days and one case of minor partial flap dehiscence that required re-suturing. Follow-up time ranged from 6 to 14 months. Overall, all flaps survived with good aesthetic and functional outcome. The TAPAS flap is a small flap with exceptional qualities and may be a useful addition to the armamentarium of free flaps in facial and oral reconstructions. © 2016 Wiley Periodicals, Inc. Microsurgery 37:525-530, 2017.

Sebaceous Carcinoma of the Ocular Region: The 2014 Professor Winifred Mao Lecture.

Sebaceous carcinoma is a malignancy arising in the periocular region that can lead to blindness and tumor-related metastases. This study is a review of published literature and personal experience. This malignancy can arise from the sebaceous units in the tarsus (meibomian glands), in association with the cilia (Zeis glands), in the brow, and in the caruncle. There is a tendency for diffuse intraepithelial growth (pagetoid spread) that can be clinically invisible. Detection before lymph node metastasis is critical. This malignancy often masquerades as chronic unilateral conjunctivitis or blepharitis, typically in older patients. Management includes a 2-step approach with step 1 focused on eyelid and conjunctival map biopsies to determine the full extent of solid deep tumor and pagetoid spread. After complete review of all biopsies, step 2 is performed using local resection for all deep tumor, cryotherapy to pagetoid disease, and reconstruction. In most cases, the posterior lamella of eyelid is sacrificed with tumor removal, whereas the anterior lamella of the eyelid can be saved. After removal and cryotherapy, immediate reconstruction, using clean instruments, with buccal membrane graft for the posterior lamella and skin flap for the anterior lamella, is developed. For persistent or recurrent pagetoid disease, cryotherapy, topical mitomycin C, or plaque radiotherapy is provided. Exenteration is sometimes necessary. Sebaceous carcinoma, if detected early, can be managed with carefully planned map biopsy to determine tumor extent, followed by local resection, cryotherapy, and eyelid reconstruction. Orbital exenteration is occasionally necessary.

Meatoplasty in a CWD Procedure Using an Endaural Approach: A Case Series of 31 Cases.

A canal wall down, inside outside mastoidectomy requires an adequate meatoplasty for a dry outcome of the procedure. For an inside outside CWD procedure an endaural route is the best procedure. However the limitation in this approach is the meatoplasty. Thirty-one cases of unsafe disease with a sclerotic mastoid were taken up for an inside outside mastoidectomy using an endaural route. A procedure is described for the creation of a large adequate meatoplasty raising a posterior skin flap and removing the conchal cartilage via endaural route and the results discussed here.

A new skin flap method for total auricular reconstruction in microtia patients with a reconstructed ear canal: Extended scalp and extended mastoid postauricular skin flaps

Before visiting a plastic surgeon, some microtia patients may undergo canaloplasty for hearing improvement. In such cases, scarred tissues and the reconstructed external auditory canal in the postauricular area may cause a significant limitation in using the posterior auricular skin flap for ear reconstruction. In this article, we present a new method for auricular reconstruction in microtia patients with previous canaloplasty. By dividing a postauricular skin flap into an upper scalp extended skin flap and a lower mastoid extended skin flap at the level of a reconstructed external auditory canal, the entire anterior surface of the auricular framework can be covered with the two extended postauricular skin flaps. The reconstructed ear shows good color match and texture, with the entire anterior surface of the reconstructed ear being resurfaced with the skin flaps. Clinical question/level of evidence; therapeutic level IV.

Parálisis del nervio mediano secundaria a lipofibrohamartoma en el túnel carpiano

IntroductionThe lipofibrohamartoma is a rare entity of unknown origin that can affect any peripheral nerves, but mainly being found in the median nerve within the carpal tunnel. The lipofibrohamartoma is frequently associated with other conditions such as macrodactyly, the Proteus and Klippel-Trenaunay-Weber syndromes and multiple exostosis, among others. Clinical casesTwo cases of lipofibrohamartoma in the carpal tunnel with associated median nerve palsy are described in the present article. They were treated by simple decompression of the median nerve by releasing the transverse carpal ligament and a palmaris longus tendon transfer to improve the thumb abduction (Camitz procedure). In one of the cases (a previously multi-operated median nerve entrapment at the carpal tunnel), a posterior interosseous skin flap was employed to improve the quality of the soft tissues on the anterior side of the wrist. DiscussionA review of the literature is also presented on lipofibrohamartoma of the median nerve, covering articles from 1964 to 2010. The literature suggests that the most recommended treatment to manage this condition is simple release of the carpal tunnel, which should be associated with a tendon transfer when a median nerve palsy is noticed.

Paralysis of the median nerve due to a lipofibrohamartoma in the carpal tunnel

IntroductionThe lipofibrohamartoma is a rare entity of unknown origin that can affect any peripheral nerves, but mainly being found in the median nerve within the carpal tunnel. The lipofibrohamartoma is frequently associated with other conditions such as macrodactyly, the Proteus and Klippel–Trenaunay–Weber syndromes and multiple exostosis, among others. Clinical casesTwo cases of lipofibrohamartoma in the carpal tunnel with associated median nerve palsy are described in the present article. They were treated by simple decompression of the median nerve by releasing the transverse carpal ligament and a palmaris longus tendon transfer to improve the thumb abduction (Camitz procedure). In one of the cases, (a previously multi-operated median nerve entrapment at the carpal tunnel), a posterior interosseous skin flap was employed to improve the quality of the soft tissues on the anterior side of the wrist. DiscussionA review of the literature is also presented on lipofibrohamartoma of the median nerve, covering articles from 1964 to 2010. The literature suggests that the most recommended treatment to manage this condition is simple release of the carpal tunnel, which should be associated with a tendon transfer when a median nerve palsy is noticed.

Correction of the Bilateral Question Mark Ear Deformity Using Double-Opposing Z-Plasty and a Chondrocutaneous Flap

To describe an alternative technique for correcting a rare and complex ear deformity. The question mark ear deformity has been described as a congenital cleft between the helix and the lobule in addition to a prominent ear. Here we describe a novel technique using double-opposing Z-plasty and a chondrocutaneous flap to correct the deformity without significant reduction in auricle height or creation of a donor-site defect. An anterior/posterior double-opposing Z-plasty and a superiorly based chondrocutaneous flap were designed at the level of the cleft. Flaps were raised full thickness, and Mustarde and Furnas sutures were placed to reduce the prominence. The flaps were then transposed and reapproximated. Of note, all anterior and posterior skin flaps were used in the repair to minimize diminution of ear height. Pre- and postoperative measurements and photographs of the ears were taken. Postoperatively, all flaps were viable, and there was no evidence of skin necrosis. The total length of the left ear was reduced by only 3 mm (53 to 50 mm), and the right ear was reduced by 1 mm (52 to 51 mm). The patient's pain was successfully managed as an outpatient, and there were no infectious complications. The resultant scars healed aesthetically and are minimally visible. The patient and her parents are satisfied with the results. Our technique addresses all components of the question mark ear deformity and does not create a visible donor-site deformity.

The Surgical Correction of Urogenital Sinus in Patients with DSD: 15 Years after Description of Total Urogenital Mobilization in Children

Total urogenital sinus mobilization has been applied to the surgical correction of virilized females and has mostly replaced older techniques. Concerns have been raised about the effect of this operation on urinary continence. Here we review the literature on this topic since the description of the technique 15 years ago. Technical aspects and correct nomenclature are discussed. We emphasize that the term “total” refers to an en-bloc dissection and not to the extent of the proximal dissection. No cases of urinary incontinence have been reported following this operation. It is yet too early to evaluate results regarding sexual function but it is likely that the use of a posterior skin flap to augment the introitus will minimize the development of introital stenosis.

Experience in the management of axillary post-burn scar contractures

Background: Axillary post-burn scar contracture is a challenging problem to the reconstructive surgeon owing to the wide range of abduction that should be achieved. The aim of this paper is to highlight the various management options used in managing axillary contractures in our hospitals and to itemize the complications commonly encountered.Method: This is a retrospective study of cases of axillary contractures managed at the Komfo Anokye Teaching Hospital, Global Evangelical Mission Hospital and South Tongu District Hospital all in Ghana, from 2003 – 2007.Result: Sixteen patients made up of 10 males and 6 females presented with axillary contractures that involved 25 axillae. The mean age of the study was 25.2 years. Injuries involved the anterior axillary fold in seven (28%), posterior fold in nine (36%), both folds in five (20%) and both folds plus axillary dome in four (16%) axillae. Surgical treatment included split-thickness skin graft in seven (28%), random pattern local skin flaps in five (36%) including z-plasties, parascapular flaps in six (24%), while scapular flaps and posterior trunk skin flap were used in two (8%) and one (4%) axillae respectively.Conclusion: The choice of surgical procedure for reconstruction of post-burn axillary contractures can be made according to the pattern of scar contracture and the state of surrounding skin. The choice of a flap should have priority over skin graft because of the superior functional and cosmetic results of flaps. Keywords: Axillary contracture; Skin grafting; Parascapular flap; Z-plasty; Physiotherapy.