Background: The webbed neck is a unique congenital deformity that is easily identified by its appearance. The neck skin webs are associated with widening of the trapezius muscle as well. It can be debated as to whether the neck webs represent an excess of tissue or normal tissue that is abnormally displaced to the side. My observation is that is an excess of skin and muscle tissue which must be factored into his the repair is done.
The classic technique for webbed neck correction is skin transposition flaps (e.g., z-plasties) along the outer lines of the webs. While effective it does create scarring that is noticeable and most patients do not usually see that as a good aesthetic tradeoff. For this reason I have always used a posterior approach where the scar line is in the midline of the posterior neck which for women hides it completely and it is single scar as opposed to bilateral lateral neck scars.
Posteriorly based webbed neck surgery takes an indirect approach to addressing the problem using a midline pull. Using a large skin excision, neck muscle fascial plication and weed muscle resection the neck webs are reduced albeit not completely eliminated. The immediate and short term results are usually quite good but there is always going be some partial relapse as the tissues relax a bit over time. Better long-term results should be able to be achieved if there was a better method to treat the wide muscle bands.
Case Study: This female had congenital neck webbing although she did not have Turner’s syndrome by genetic testing or having any other of its associated findings.
Under general anesthesia and in the prone position a midline diamond pattern of skin excision was marked on the back of her neck. It is important to have the apex of the diamond’s side right angles to be in line with where the maximum inward pull of the neck is needed. A full-thickness resection of the skin and fat down to muscle fascia is initially done. On the back of the neck this tissue thickness is remarkably thick, often being 1” to 2” thick.
Skin flaps were then raised on the muscle fascia all the way out to the edge of the webbing. The fascia was vertically incised and the trapezius muscle exposed. A wide strip of muscle was dissected out and released superiorly. The muscle flaps were then turned 90 degrees other bases and brought to the midline and sewn to the fascia, creating a very visible inward pulling effect on the webs.
The skin flaps were advanced inward by quilting sutures and a midline skin closure done on the back of the neck. The immediate effects of the change in the shape of the neck could be appreciated.
When seen the next day the improvement in the shape of the neck could be appreciated from the frontal view.
The traditional posterior approach to neck web surgery relies on a medial pull towards the midline from fascial plications and skin flap advancements/closures. It is effective but some partial relapse is seen in the first few months after the surgery. It is always better than before surgery but not as good as seen immediately after surgery. This trapezius muscle flap transposition technique may change that as muscle from the outer webs is moved inward as well. It is not just pulled but actually released and transposed. The superior release and inward movement allows the widest part of the web to be pulled inward.
Case Highlights:
1) The webbed neck is a finding seen in numerous congenital syndromes of which Turner’s is the most common. But it can also occurs in non-syndromic patients.
2) The posterior approach to webbed neck correction is the most acceptable to most patients who are understandably averse to scars along the side of their neck/webs.
3) The trapezius muscle flap technique is a new cmomponent of the posterior approach which I believe will have better and more sustained results in webbed neck corrections.
Dr. Barry Eppley
Indianapolis, Indiana