Neck bypass modification for inferior trapezius flaps: A discussion of surgical technique and experience

@#<p style="text-align: justify;">The inferior trapezius flap (ITF) is useful as a primary means of head and neck reconstruction or as a salvage flap when a previous flap has failed. This report illustrates a neck bypass modification technique which places the pedicle external and lateral to the neck, thereby 1) increasing the flap's reach and 2) decreasing compression from subcutaneous tunneling. It also describes the authors' experience with this technique.</p>

Pectoralis major myocutaneous flap in head and neck reconstruction: an interesting experience from central India regional cancer center.

Background: Head and neck cancer are sixth most common cancers worldwide with cancer of oral cavity most common. The primary treatment modality for oral cavity cancer has been surgery and defects resulting from the ablation of the tumors require reconstruction. the PMMC flap offer an easy, less time consuming with minimal postoperative complication as a reconstructive option in the hands of reconstructive surgeon. The objective of our study was to give a precise description of our experience with the PMMC flap as a reconstructive option in post-ablative head and cancer surgery. Methods: The current prospective study was conducted in the Department of Surgical Oncology, Regional cancer center, Pt. JNMC, Raipur (C.G.), India from the January 2014 to June 2015. Detailed clinical history and examination of the patients were recorded. All Investigations relevant to the study were done before the surgical procedure. Procedure was performed as per standard protocol and reconstruction was made with PMMC flap. Data was compiled in MS Excel and checked for its completeness and correctness. Then it was analyzed. Results: In the present study male to female ratio was 2:1. Most of the patients belongs to the age group of 41-60 (55.55%) followed by 21-40 (30.15%). In the present study majority of patient of oral malignancy presented with lower alveolus malignancy (36.5%) followed by buccal mucosa malignancy (19.06%). Conclusions: Pectoralis major myocutaneous flap was found to be a versatile flap for reconstruction of large defects in Head and Neck region with minimal complication rate.

Retalho miocutâneo inferior pediculado do músculo trapézio nas reconstruções após cirurgias oncológicas de cabeça e pescoço, e tórax / Lower trapezius myocutaneous pedicle flap in head, neck, and chest reconstructions after cancer surgeries

INTRODUÇÃO: Revisão da literatura sobre o retalho miocutâneo inferior do músculo trapézio, apresentando suas vantagens, técnica cirúrgica e complicações. MÉTODOS: Estudo de 19 casos tratados no INCA, através de técnica específica, e comparação dos dados com a literatura internacional. RESULTADOS: Todas as reconstruções atingiram seus objetivos, com correção dos defeitos em partes moles e pele. O efeito estético foi considerado bom pelos pacientes e pela equipe médica. Foi observada uma taxa de 21% de complicações. Não houve necrose ou infecção nos retalhos. Em relação às funções, 89,5% apresentaram função motora preservada e 10,5%, déficit funcional por acometimento tumoral do nervo acessório. CONCLUSÃO: A despeito do aprimoramento contínuo das técnicas microcirúrgicas, os retalhos miocutâneos pediculados ainda encontram indicações nas reconstruções após ressecções oncológicas alargadas. O retalho miocutâneo inferior do músculo trapézio é uma alternativa segura e aplicável para as reconstruções de partes moles das regiões cervicais lateral e posterior, da região lateral da cabeça, da região do ombro e para as regiões paraespinhal superior e paraescapulares.

INTRODUCTION: In this article, we present a literature review on the lower myocutaneous trapezius flap, and report its advantages, surgical technique, and complications. METHODS: We studied 19 patients treated at INCA with a specific technique, and compared the outcomes with those reported in the international literature. RESULTS: All reconstructions achieved the procedural objectives, and the defects of soft tissues and skin were repaired. The aesthetic outcome was considered satisfactory by the patients and medical staff. The rate of complications was 21%. No necrosis or signs of infection were detected in the flaps. Concerning the functions, 89.5% of patients preserved their motor function, whereas reduced functional movements were observed in 10.5% of the patients due to tumor invasion to the accessory nerve. CONCLUSIONS: Despite the continuous advancements in microsurgical techniques, pedicle myocutaneous flaps are still indicated for reconstruction procedures after extended cancer resections. The use of the lower trapezius myocutaneous flap is safe and represents a suitable option for the reconstruction of soft tissues of the lateral and posterior cervical regions, side of the head, shoulder, and upper paravertebral and parascapular regions.

Utilizing Pedicled Muscle Flap for Defect Coverage after External Auditory Canal Cancer Resection

PURPOSE: Cancer arising from the external auditory canal is a rare disease. A lesion that seems harmless in someway, can be lethal when inadequately excised, the tumor may infiltrate nerves, the parotid and auditory tissues before re-invading the skin. Wide resection of the lesion surrounding the structure and reconstruction with an adequate plan is crucial for the treatment of this disease. METHODS: Two patients with external auditory canal cancer were treated with muscle flaps and skin grafts. Lateral temporal bone resection (LTBR) was performed for complete resection of the cancer. The defect cavity was obliterated with highly vascularized tissue using pedicled sternocleidomastoid muscle, and temporalis muscle individually, combined with full thickness skin graft for covering the skin defect of the ear. RESULTS: Clear resection margin was obtained, and both patients showed disease free survival during the follow up. There was no complications of hematoma, infection, flap loss, or wound problem in both patients. Both patient received radiation therapy, there was no osteoradionecrosis or any other complication related to radiation therapy. CONCLUSION: Utilizing pedicled muscle flaps for managing defects after wide resection of the external auditory canal cancer is an effective method for managing this difficult disease.

Anatomy of tensor fascia latae perforator flap and its clinical significance in reconstruction of head and neck defects / 基础医学与临床

Objective To study anatomy of the tensor fascia latae perforator flap (TFLP flap) and explore its clini-cal application in reconstruction of head and neck defects. Methods Five fresh cadavers were prepared, and mor-phology and blood supply of TFLP flap were examined by microsurgery anatomy. During dissections, the following parameters were recorded: number and type of perforators vessels, diameter of perforators, pedicle length, diameter of the original vessels, course (infra fascia and supra fascia) ,and its position was located by anatomical landmark. Results There were 41 TFLP flap perforators in all specimen with 35 musculocutaneous perforator and 6 septocuta-neous perforator. Original vessel was ascend branch of lateral circumflex femoral artery/vein with average diameter of (3.01±0.49) mm/(3. 28±0.57) mm. The mean pedicle length was (9. 1±0.79) cm. The surface location was (4. 22± 1. 37) cm laterally and (8. 73±2.72) cm beneath to anterosuperior iliac spine. Conclusion With the characteristics of constant position, large caliber and convenient preparation, TFLP flap is useful for operation andoption in reconstruction of head/neck defects and considered as backup of anterolateral thigh flap. The disadvantage of this flap is its short vascular pedicle.

Perforator Flaps in Head and Neck Reconstruction / 한양의대학술지

Basic requirements of head and neck reconstructions are thin resurfacing, a long vascular pedicle, 3-dimensional and well customized reconstruction with a team approach. Ideal reconstruction methods were thought to be free tissue transfer including radial forearm flap, latissmus dorsi or rectus abdominis myocutaneous flap. But recently, there has been concerns about sacrifice of donor structures in these conventional flaps. For minimal sacrifice of donor structures, there has been much evolution in flap concepts, which lead to the introduction of perforator flaps. They are popular in every region for reconstruction. Anterolatral thigh, latissmus dorsi or deep inferior epigastric artery perforator flaps are commonly used. Perforator flaps could also be applied to head and neck reconstructions, because they could be used for the controlled resurfacing of scalp, cheek, neck, oropharynx, and for customized 3-dimensional reconstructions, including diverse components according to each perforator, which may result in more comfortable handling and less restricted access to the defect. The perforator flaps also have long vascular pedicles compared to conventional myocutaneous flaps, which can lead to less restriction in choosing recipient vessels. Perforator flaps have known to have many advantages as described and they give one more option in head and neck reconstruction.

The Safety of Microsurgical Head and Neck Reconstruction in the Elderly Patients

By means of microsurgical free-tissue transfer providing a large amount of required tissue, the surgeon can resect tumoral tissue more safely, which allows tumor-free margins and enhances the reliability of the ablative surgery that otherwise could not be performed radically. The morbidity of elective free-tissue transfer seems to be quite low, carrying acceptable risks for most patients. But the elderly patients are at risk for cardiac and respiratory problems, deep vein thrombosis, pulmonary emboli and infection merely as a function of age. This study was undertaken to define further risks of the elderly population with regards to free-tissue transfer. We retrospectively reviewed our experience with 110 microsurgical free-tissue transfers for head and neck reconstruction in patients greater than 60 years of age. Microsurgical procedures in all cases were preformed by the plastic and reconstructive department at Yonsei medical center. The investigated parameters were patient demographics, past medical history, American Society of Anesthesiologists(ASA) status, site and cause of defect, the free tissue transferred and postoperative complication including free-flap success or failure. There were 46 patients in the age group from 60 to 64 years, 34 patients from 65 to 70 years, and 30 patients 70 years or older. There happened 3 flap losses, resulting in a flap viability rate of 97%. Patients with a higher ASA designation experienced more medical complication(p=0.05, 0.01, 0.03 in each age group I, II, III) but not surgical complication p=0.17, 0.11, 0.54 in each age group I, II, III). And the relationship between postoperative complication and age groups was not significant. These observations suggest that major determinant for postoperative medical complication be the patient's American Society of Anesthesiologists score, and chronologic age alone should not be an exclusion criterion when selecting patients for free-tissue transfer.

Head and neck reconstruction using free flaps

BACKGROUND: Free flap reconstruction was first introduced in 1959 and has since been used for reconstruction of various defects in the head and neck. It has been shown to be the most reliable and efficient way of restoring tissue in the head and neck region secondary to surgical or traumatic defects. It has allowed single stage reconstruction of even complex defects with high flap viability rates. Here in the Philippine setting, free flaps have not been the reconstructive option of choice. It is viewed as a special option for selective cases not amenable to pedicled reconstruction. OBJECTIVE: To describe the experience of one microvascular team in head and neck reconstruction using free flaps from 1996 to March 2004. DESIGN AND SETTING: Retrospective chart review of all patients who underwent free flap reconstruction of head and neck defects from 1996 to March 2004 at six tertiary hospitals in Manila. PATIENTS AND METHODS: Atotal of 69 patients who underwent 71 free-flap reconstructions of the head and neck for various pathologies and with a range of bony and soft tissue defects from 1996 to March 2004 were included in the study. All free flap reconstructions were done by only one microvascular team. The success and viability of free tissue transfer, length of hospital stay, length of operation, complications and morbidities encountered and functional outcome based on length of time to removal of the nasogastric tube and decannulation were reviewed. RESULTS: Of the 71 free flap reconstructions that were performed, 64 flaps were viable leading to an overall success rate of 90 percent. The first 36 cases had a success rate of 86 percent while the subsequent 35 cases had a success rate of 94 percent. Average length of hospital stay was 24 days and the average length of operation was 13 hours 40 minutes. There were 6 mortalities secondary to medical problems and 7 patients had major surgical complications. Twenty-one patients (29 percent) did not have any complication post-operation. Average time post-operation to decannulation was 14 days while return to oral diet was noted at 17 days post-operation. There were 8 patients who were discharged with either a nasogastric tube or percutaneous endoscopic gastrostomy. The results are at par with the review of literature reviewed. CONCLUSIONS: The success of the use of free flaps in head and neck reconstruction was demonstrated in this series. There were minimal complications noted. All patients were decannulated with majority able to return to an oral diet. (Author)

Various Utility of Perforator Flaps in Head and Neck Reconstruction

There are various types of flap in head and neck reconstruction. We chose the appropriate flap considering the indication and patient's condition. In case of conventional flaps, its type is decided according to the reconstruction site. In other words, the types of considerable flaps are limited in a way. But, perforator flaps can reduce donor limitation and harvest flaps depending on the condition of the recipient. Therefore, the flap is very useful for the head and neck reconstruction needed for 2-dimensional or 3-dimensional reconstruction. We report the 29 cases of perforator- based flap including 8 cases of latissimus dorsi perforator free flap, 5 thoracodorsal perforator free flap, 4 anterolateral thigh perforator free flap, 3 peroneal osteocutaneous perforator free flap and 9 submental perforator island flap for the head and neck reconstruction. Free flaps include 2 cases of chimeric pattern, 7 controlled resurfacing pattern, 4 3-D pattern, 3 dermoadiposal pattern, 1 folded pattern and 3 osteocutaneous pattern. The flaps were successfully used for the head and neck reconstruction. But one patient died during a follow up period because of the recurrence of tumor. Various perforator flaps(island/free pattern) can be highly competitive to the conventional flaps in the head and neck reconstruction, considering a thin character for resurfacing, more flexible and versatile option, variable composition, long pedicle with donor structures saved, and less prominent donor morbidity.

Analysis of 180 Head and Neck Reconstructional Cases with Free Flap Transfer

Microvascular surgery now plays an increasingly important role in head and neck reconstruction. When compared to local or regional flaps, free flaps are more effective in complex or extensive defects, have better blood supply and are not restricted by the territory of the pedicle. Recently, not only coverage of the defect but restoration of both function and aesthetics with rapid recovery and minimal morbidity have become the interest of many surgeons. A retrospective study was conducted including 180 microvascular free tissue transfer for reconstruction of surgical defects in the head and neck region by the plastic & reconstructive surgery department at Yonsei Medical Center. The flap survival rate was 95.5 percent. Complications developed in 46 cases(25.5%). In our study, the radial forearm free flap was most commonly used(75%) and the primary location of tumors were the tonsils(18.3%), oral tongue(17.8%) and pyriform sinus (17.2%). Analysis in this study shows obesity as the only independent factor for development of complications while the number of risk factors of the patient were associated with an increased risk. With our analysis, many factors were found not to have a significant effect on flap outcome, including flap transfer in smokers, diabetics and preoperative radiation status. In our opinion, accumulation effect of the risk factors seems to be more important in determining the flap outcome and complications than that of independent risk factors.

True island pectoralis major myocutaneous flap: its advantages / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Pectoralis major myocutaneous flap(PMMCF) is a workhorse flap of head and neck reconstruction and it has four types depending on its nature of vascular pedicle. True island type PMMCF has many advantages over conventional muscular type, but reports on this type of flap and its advantages are lacking. Material and METHOD: Fifty two PMMCF(50 patients) used for head and neck reconstruction between 1992 and 1998 were reviewed retrospectively. There were 16 muscular type and 36 true island type PMMCF. We compared the incidence of complication between two groups. RESULT: Six marginal necrosis(less than 20%) and 1 major necrosis(more than 50%) developed in 16 muscular type PMMCF. However in 36 true island type PMMCF, 1 marginal necrosis and 2 major necrosis developed. CONCLUSION: True island type PMMCF has the following advantages over muscular type. 1. True island type has 3-4 cm gain in length. 2. Flap could be harvested at more cephalic portion of the chest. 3. Unwanted tension of the flap could be avoided. 4. Vascular pedicle is not compressed between skin and clavicle. 5. The rotation of vascular pedicle is natural without kinking. 6. Ugly bulge over clavicle is absent postoperatively. 7. This type could be used regardless of types of neck dissection.

Fracture of the Clavicle after Radical Neck Dissection, Pectoralis Major Myocutaneous Flapand Postoperative Radiotherapy / 대한이비인후과학회지

The treatment of head and neck cancer with radiotherapy and radical neck dissection has many well recognized complications. Radiotherapy in therapeutic doses can produce devascularization and weakening of bone. Radical neck dissection results in altered mechanics of the shoulder girdle and a normally balanced forces acting on the clavicle. However, there are no reports elaborating on the unusual case of clavicle fracture which is considered to have resulted from pectoralis major myocutaneous flap (PMMCF). We reviewed 169 cases treated with radical neck dissection and 45 patients treated with PMMCF between 1992 and 1998, retrospectively. We could find three cases of clavicle fracture all of whom underwent radical neck dissection, PMMCF and postoperative radiotherapy on the side of fracture. The type of PMMCF was island PMMCF. Fractures were noted 1-3 years postoperatively and all fractures were noted on medial portion of the clavicle. Island type PMMCF was considered as one of the predisposing factors of clavicular fracture. Devascularization after stripping of periosteum and altered mechanics of the clavicle following resection of clavicular head of pectoralis major muscle may contribute to developing a rare complication in addition to the effect of radiotherapy and radical neck dissection.

Free Flap Reconstruction in the Head and Neck Regions: A Review of 40 Cases / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: With the advent of free flap reconstruction techniques, several free flaps were used for a variety of head and neck defects. The objective of this study was to review our experience during 3-year period in performing 40 microvascular free flaps for head and neck defects. Materials and Method: A review of 40 microvascular free flaps performed in 38 patients between April 1995 through August 1998 was undertaken. Patient's age, sex, stage of disease, types of free flaps, short-term postoperative outcome including the flap success rate, postoperative complications, effect of preoperative irradiation on the development of the wound complications such as fistula were evaluated. RESULTS: 36 (90%) of 40 free flaps were successful with 4 failures resulting from 3 venous thromboses and 1 infection. Emergent reexploration was done in 2 patients, none of whom were successfully salvaged. The postoperative surgical complications including donor site complications and medical complications were seen in 17 flaps (47%) and in 8 flaps (22%), with multiple complications seen in several patients. The preoperative radiotherapy did not affect the incidence of the postoperative surgical complications (p=0.273). CONCLUSION: In review of our experience, we believe that free flap reconstruction in head and neck regions has become a useful procedure with acceptable outcome and complication rates and has surpassed conventional techniques cosmetically and functionally.

Reconstruction of Defects in the Head and Neck Using Pedicled or Free Flaps: A Review of 112 Cases / 대한이비인후과학회지

BACKGROUND: Despite recent advances in radiation therapy and chemotherapy, surgical procedures remain the primary modality of head and neck cancer therapy. Adequate surgical resection frequently requires the removal of significant amounts of tissue. In addition to the prolongation of life, the restoration of a functional aerodigestive tract is the primary concern of the reconstructive surgeon. OBJECTIVE: With the above in mind, we have evaluated our experience with head and neck reconstruction using various flaps. MATERIALS AND METHODS: The medical records of 95 patients who underwent 112 reconstructive surgeries in the head and neck area from 1983 to 1996 in Seoul National University Hospital were reviewed. Results were evaluated with emphasis on the functional aspect and postoperative course. RESULTS: Successful transfer using PMMC flaps were achieved in 100%, 93% in skin defect and oral/oropharyngeal defect, respectively. In pharyngoesophageal reconstruction, free and visceral flaps had higher success rates and lower complication rates than pectoralis major myocutaneous(PMMC) flaps(75% vs. 64%, 64% vs. 25%). The average completion time to oral intake in pharyngoesophageal reconstruction was within 2 weeks using free and visceral flaps, but within 29 days using PMMC flaps. CONCLUSIONS: PMMC flap is still a workhorse for head and neck reconstruction. Reconstruction with PMMC flap is adequate for skin, oral or oropharyngeal reconstruction, but inadequate for pharyngoesophageal reconstruction especially for circumferential defect. Those patients reconstructed with visceral flaps were able to tolerate oral feedings sooner and were less likely to have local complications than those with PMMC flaps. Thin myocutaneous flaps such as platysma flap can be used for myomucosal defect of oral cavity as adequately as free flaps.