Deltopectoral flap revisited: role of the extended flap in reconstruction of the head and neck.

The extended deltopectoral flap is still the best choice in selected cases. During the period 1987-2004, 34 patients required reconstruction of the head and neck using this flap. Twenty-nine had had one or more failed attempts at microsurgical reconstruction after excision of cancer. Five were treated primarily. The flap was divided at least three weeks after the primary operation. All 34 survived, and there were no donor site complications. Twenty-seven patients had an uncomplicated outcome, but the remaining seven required later closure or skin grafting, usually under local anaesthesia, for complications. The extended deltopectoral flap has been used successfully to provide stable coverage of defects in the head and neck and should remain in the armamentarium of reconstructive microsurgeons.     

Is the deltopectoral flap born again? Role in postburn head and neck reconstruction

After extensive use for head and neck reconstruction, the deltopectoral flap has been supplanted by alternative methods of reconstruction and relegated to historical references. However, it remains a very valuable skin flap and should keep its place in the armamentarium of reconstructive surgeons for postburn head and neck reconstruction. We report here five cases of head and neck reconstruction using the deltopectoral flap: one case of perioral reconstruction after ballistic trauma, one case of nasal reconstruction after burn and three cases of neck reconstruction after burn contracture. Technical simplicity and reliability are the main features of this flap. The skin paddle is thin and pliable, and its surface can be extended after a flap delay. Previous tissue expansion can minimize donor site morbidity. The flap division necessitates a second surgical procedure. The major burn contractures of the neck are, in our opinion, an excellent indication of the deltopectoral flap.     

Major head and neck reconstruction using the deltopectoral flap. A 20 year experience

Six hundred seventy-eight deltopectoral flaps were raised in 604 patients, 125 of which were delayed and 215 of which were used in previously irradiated beds. The rate of major flap necrosis was 16.9 percent and the overall rate of complications, 51.4 percent. Delay in creating the deltopectoral flap had no influence on the risk of complications and necrosis, whereas the use of the flap in a previously irradiated bed was associated with a significantly increased risk of major flap necrosis. The least flap loss occurred when the deltopectoral flap was used without tubulation for skin coverage only. Complications and flap necrosis occurred most frequently when flaps were tubulated in a reversed manner or used for lining of major portions of or for total oropharyngeal and hypopharyngeal reconstruction. The deltopectoral flap remains a useful, reliable, and versatile regional flap that can be used alone or in combination with other flaps in selected circumstances for major head and neck reconstruction.     

Experiences with the deltopectoral flap in reconstructive surgery of the head and neck

Despite the development of many alternative methods of reconstruction in head and neck surgery, the deltopectoral skin flap still remains a useful method in our armamentarium. Its use as a nondelayed procedure in 44 patients with various defects in the head and neck following tumor surgery is discussed. The reliability of the deltopectoral flap is evaluated. Major necrosis of the flap occurred in 6 (13.6%) of our patients. As to the cause of failure, more than one factor could be identified in the individual patient. However, the failure rate was higher when the flap was used in the reconstruction of defects in the anterior part of the oral cavity, particularly the floor of the mouth, than at other sites in the head and neck.     

Salvage for pectoralis major myocutaneous flap failure in head and neck reconstruction by microvascular flap

Abstract

The pectoralis major myocutaneous pedicled flap (PMMPF) – the “workhorse” for head and neck reconstruction – is associated with a high incidence of complications in certain cases. This study presents free tissue transfer as an alternative salvage technique after PMMPF failure in head and neck reconstruction. It includes seven consecutive patients who underwent free tissue salvage after PMMPF failure in head and neck reconstruction from January 2008 to September 2010 at Kaohsiung Medical University Hospital, Taiwan. Four vertical rectus abdominis myocutaneous (VRAM) flaps were applied for tongue and mouth floor defects, while three anterolateral thigh (ALT) flaps were used for mouth floor, buccal, and cheek defects. All flaps survived uneventfully, and normal oral feeding was achieved without major complications. Free tissue transfer has several advantages and can be successfully employed in head and neck reconstruction, and it is also a reliable salvage procedure after PMMPF failure in such cases.     

Pectoralis major musculocutaneous flap: a new flap in head and neck reconstruction.

The pectoralis major musculocutaneous flap described by Ariyan has great potential in single stage reconstructions of the head and neck. The advantages of the flap are greater length, improved vascularity, bulk, and one-stage reconstruction of oropharyngeal defects. The flap was used successfully in eight patients to reconstruct large defects in the head and neck area. Experience to date indicates that this flap has greater versatility than the deltopectoral flap in one-stage head and neck reconstructions.     

Complications of the pectoralis major osteomyocutaneous flap used for head and neck reconstruction

The analysis of the complications of the pectoralis major osteomyocutaneous flaps used for head and neck reconstruction and how to prevent them is the subject of this report. Ten patients with squamous cell carcinoma of the floor of the mouth who had undergone segmental glossectomy and mandibulectomy, radical uni- or bilateral cervical lymphadenectomy, and immediate reconstruction with the pectoralis major osteomyocutaneous flaps were evaluated. Neither partial nor total necrosis of the myocutaneous segment occurred in any patient but rib necrosis developed in five. An oral fistula occurred in four patients exposing the junction of the rib with the mandible. There were three cases of flap necrosis of the neck dissection. Two patients developed pneumothorax. The overall complication rate was 66.7%. Although this surgery requires major intraoral excision, the tumor is exophytic with previous infection and the patients' general condition debilitated, the incidence of complications is high. Despite the high morbidity, the pectoralis major myocutaneous flap remains a useful adjunct for head and neck reconstruction. The flap is versatile and for many patients repair with a free flap is impossible because of contraindications such as previous irradiation, problems with the vascular anastomoses, advanced age and poor general condition. It also aids in the surgical training of new specialists.     

Internal mammary artery perforator flap for head and neck reconstruction

Background: The internal mammary artery perforator (IMAP) flap is a useful modification of the classic deltopectoral flap that has a number of important roles in head and neck reconstruction. Methods and results: In this report, we describe the technique used to plan and raise the flap and demonstrate its use in three different clinical scenarios. Results and conclusions: The IMAP flap is a pedicled fasciocutaneous flap that is based on single or multiple internal mammary artery perforators. As such, it provides thin pliable tissue with a wide arc of rotation that is suitable for cutaneous, pharyngeal and tracheostomal reconstruction. Moreover, the flap is well‐vascularised, reliable and the donor site can be closed primarily.     

扩张后胸三角皮瓣修复面颈部瘢痕的护理

目的：探讨扩张后胸三角皮瓣修复面颈部瘢痕的护理要点。方法：回顾分析102例采用扩张后胸三角皮瓣修复烧烫伤后颈面部瘢痕的患者的护理过程。结果：102例中12例扩张器自切口处外露,但未影响手术效果。皮瓣转移后7例单侧尖端皮瓣血运障碍,自行愈合后色素减退;1例单侧转移,皮瓣坏死;其余效果良好。结论：术前进行心理护理至关重要;术后加强基础护理,积极预防并发症的发生,注意观察皮瓣血运是皮瓣转移成活的关键。     

A clinical experience of the supraclavicular flap used to reconstruct head and neck defects in late-stage cancer patients

The supraclavicular island flap has been widely used in head and neck reconstruction, providing an alternative to the traditional techniques like regional or free flaps, mainly because of its thin skin island tissue and reliable vascularity. Head and neck patients who require large reconstructions usually present poor clinical and healing conditions. An early experience using this flap for late-stage head and neck tumour treatment is reported. Forty-seven supraclavicular artery flaps were used to treat head and neck oncologic defects after cutaneous, intraoral and pharyngeal tumour resections. Dissection time, complications, donor and reconstructed area outcomes were assessed. The mean time for harvesting the flaps was 50?min by the senior author. All donor sites were closed primarily. Three cases of laryngopharyngectomy reconstruction developed a small controlled (salivary) leak that was resolved with conservative measures. Small or no strictures were detected on radiologic swallowing examinations and all patients regained normal swallowing function. Five patients developed donor site dehiscence. These wounds were treated with regular dressing until healing was complete. There were four distal flap necroses in this series. These necroses were debrided and closed primarily. The supraclavicular flap is pliable for head and neck oncologic reconstruction in late-stage patients. High-risk patients and modified radical neck dissection are not contraindications for its use. The absence of the need to isolate the pedicle offers quick and reliable harvesting. The arc of rotation on the base of the neck provides adequate length for pharyngeal, oral lining and to reconstruct the middle and superior third of the face.     

Modified bilobular (“gemini”) pectoralis major myocutaneous flap

The bilobular or gemini type of pectoralis major myocutaneous flap evolved from a desire to simplify the closure of large surgical defects of both mucosa and skin that could not be satisfactorily closed primarily. Previously, such defects often required combined or multiple reconstructive procedures such as myocutaneous and deltopectoral flap operations. The mucosal and skin defects are closed by two skin paddles supported by a single muscular vascular pedicle.The skin paddles are fashioned side by side and separated from each other as the muscle is folded between them parallel to the vascular axis. All of the defects were successfully closed and the major portion of all grafts survived. This operation permits single-stage reconstruction after ablation of tumors or treatment of complications which produce large through-and-through mucocutaneous defects of the head and neck area.     

Internal mammary artery perforator (IMAP) flap for tracheostoma reconstruction

BACKGROUND: Tracheostoma reconstruction requires a thin flap to avoid occlusion. Although the deltopectoral flap has been used as a rotational flap for decades, clinical use of a true internal mammary artery perforator island flap has not been reported. METHODS: In two cases, tracheostoma and anterior neck reconstruction were performed by use of an internal mammary artery perforator flap as a pedicled island flap. One flap was based on the perforator vessels in the second intercostal space and, the other, on the third. Donor sites were closed primarily in both patients. RESULTS: The internal mammary artery perforator flaps were well perfused in both cases. Both flaps healed uneventfully, with reliable reconstruction of the tracheal stoma and coverage of the anterior neck, although overall prognoses were poor. CONCLUSION: The internal mammary artery perforator flap is a relatively thin and reliable flap for tracheostoma and lower neck reconstruction.     

Surgical treatment of tracheocutaneous fistula and tracheostomy scars using a hinged flap and local myocutaneous flap

Tracheocutaneous fistula and tracheostomy scar are complications associated with the prolonged use of tracheostomy tubes. They have functional and cosmetic problems owing to tracheal tugging during swallowing and easily visible scars. Although many procedures exist to correct this issue, there is no consensus on the optimal surgical technique. Therefore, an ideal surgical procedure was devised. The study was performed on 12 patients between September 2016 and May 2021. All patients had persistent tracheocutaneous fistulas or hypertrophic scars on the neck after tracheostomy. All procedures were performed using a hinged flap and two myocutaneous local flaps. All patients had no complications, and their aesthetics were excellent in postoperative photographs. The scar was better on the straight scar when the flap's skin is denuded than on the VY advancement flap. It should be noted, however, that this procedure can cause the flap to become congested in a short period after head and neck surgery. This procedure is safe, reliable and simple for surgical closure. This was found to produce excellent cosmetic results with no major complications.     

Experience with the forearm septofascial flap

Summary Fascia has a well vascularized surface, and when it is covered with a split skin graft, it provides the thinnest possible flap. The authors present their own experience with the use of the forearm septofascial flap in 23 patients. A free septofascial flap was used in 15 patients and an island flap in 8 patients. Seven days later, only 25% of the patients had complete take of the split skin graft, while in 60% of the cases, there was only partial take of the graft. The results at 6 months, regarding appearance of the flap and donor site, were good. In 2 patients, a composite osteofascial flap was used for reconstruction of the mandible. In those patients, the viability of the bone was assessed with scintigraphy. There were no significant complications with the donor site. The forearm septofascial flap proved to be a good and reliable method of reconstruction in those parts of the body where thin cover was required. Constant anatomy and minimal postoperative complications are great advantages of the forearm septofascial flap when compared with other fascial flaps.     

Clinical outcome of reconstruction of the lateral oropharyngeal wall with an anterolateral thigh free flap

The anterolateral thigh (ALT) free flap is widely used for various reconstructions in the head and neck. However, its use in the oropharynx has not been widely evaluated, so we have reviewed our experience. We retrospectively reviewed the medical records of 28 patients with oropharyngeal cancer, who were treated with immediate reconstruction with an ALT free flap after excision. We recorded history, stage of tumour, course of operation, postoperative period, oncological treatment, clinical outcome, and follow-up. The mean age of the patients was 61 years (range 44-83). Ten of the patients had clinically relevant coexisting conditions. Most of the patients had T3-4 tumours and involved neck nodes. The operations included resection of the tumour, neck dissection, and reconstruction of the oropharynx with an ALT free flap. All donor sites were closed primarily. Eight patients (29%) developed early local complications that required reoperation. Ten patients (36%) had postoperative cardiopulmonary problems. Twenty-seven flaps succeeded; one was lost. There were no other complications or late problems of the donor site except one seroma. Twenty-one patients were given postoperative radiotherapy. After the mean follow-up period of 40 months (range 13-68) 20 patients (71%) were disease-free. Three patients required a permanent gastrostomy and one a permanent tracheostomy. We conclude that the ALT free flap can be used successfully for reconstruction of a lateral oropharyngeal defect with manageable postoperative morbidity.     

向颈、肩、背扩展的胸三角皮瓣的解剖学研究与临床应用

在30例成人新鲜尸体上,采用手术显微镜下解剖、钼钯 X 线照像、碳素墨汁动脉灌注等方法,调查向颈、肩、背扩展的胸三角皮瓣的皮动脉来源及其分支的外径、长度、走行方向,及该皮瓣各皮动脉之间吻合支的外径、数目。并通过临床实践,讨论了该皮瓣的实用价值及推广前景。     

向颈、肩、背扩展的胸三角皮瓣的解剖学研究与临床应用

在３０例成人新鲜尸体上，采用手术显微镜下解剖、钼耙Ｘ线照像、碳素墨汁动脉灌注等方法，调直向颈、肩、背扩展的胸三角皮瓣的皮动脉来源及其分支的外径、长度、走行方向，及该皮瓣各皮动脉之间吻合支的外径、数目。并通过临床实践，讨论了该皮瓣的实用价值及推广前景。     

游离股前外侧皮瓣与改良胸大肌皮瓣在修复头颈肿瘤术后缺损中的选择与改进

目的探讨游离股前外侧皮瓣与改良胸大肌皮瓣在头颈肿瘤术后缺损修复中的应用及效果。方法2011年11月至2016年11月湖南省肿瘤医院头颈外科收治头颈部肿瘤患者394例,男性286例,女性108例,年龄25~79岁。分别采用游离股前外侧皮瓣(306例)、改良胸大肌皮瓣(88例)修复头颈肿瘤术后缺损。采用t检验法分析不同方法修复的效果及患者生存质量,总结2种皮瓣修复的优缺点及适应证。结果本组394例,游离股前外侧皮瓣组皮瓣成活率97.1%(297/306),改良胸大肌皮瓣组成活率97.7%(86/88);手术总时间2组相近,游离股前外侧皮瓣组3~4 h,改良胸大肌皮瓣组1.5~2.5 h;术后1年,UW-QOL评分游离股前外侧皮瓣组与胸大肌皮瓣组相比,在外观、言语功能及肩部运动方面有显著优势,差异有统计学意义(P<0.05)。结论头颈部肿瘤术后缺损修复中,游离股前外侧皮瓣及改良胸大肌皮瓣都具有较高的成功率,游离股前外侧皮瓣适用于复杂缺损的修复,改良胸大肌皮瓣对血管条件、全身状况不佳的患者,更具有安全性。     

Contiguous cervical and deltopectoral flaps for skin lining and replacement with en bloc resection of cancer of the head and neck

Contiguous cervical and deltopectoral flaps have several advantages in reconstruction of the head and neck after extirpation of cancer. The cervical skin provides an excellent color match for facial skin, and nonhair-bearing skin is available if lining of the oral cavity is required. The deltopectoral flap provides superior coverage for the carotid artery.     

Clinical outcome of reconstruction of the lateral oropharyngeal wall with an anterolateral thigh free flap

Abstract

The anterolateral thigh (ALT) free flap is widely used for various reconstructions in the head and neck. However, its use in the oropharynx has not been widely evaluated, so we have reviewed our experience. We retrospectively reviewed the medical records of 28 patients with oropharyngeal cancer, who were treated with immediate reconstruction with an ALT free flap after excision. We recorded history, stage of tumour, course of operation, postoperative period, oncological treatment, clinical outcome, and follow-up. The mean age of the patients was 61 years (range 44–83). Ten of the patients had clinically relevant coexisting conditions. Most of the patients had T3-4 tumours and involved neck nodes. The operations included resection of the tumour, neck dissection, and reconstruction of the oropharynx with an ALT free flap. All donor sites were closed primarily. Eight patients (29%) developed early local complications that required reoperation. Ten patients (36%) had postoperative cardiopulmonary problems. Twenty-seven flaps succeeded; one was lost. There were no other complications or late problems of the donor site except one seroma. Twenty-one patients were given postoperative radiotherapy. After the mean follow-up period of 40 months (range 13–68) 20 patients (71%) were disease-free. Three patients required a permanent gastrostomy and one a permanent tracheostomy. We conclude that the ALT free flap can be used successfully for reconstruction of a lateral oropharyngeal defect with manageable postoperative morbidity.