Tracheal reconstruction with a modified infrahyoid myocutaneous flap

Reconstruction of a tracheal defect is a challenge because it often requires invasive surgery associated with relatively high morbidity. We recently invented a less-invasive method using a modified infrahyoid myocutaneous (IHMC) flap for the reconstruction of a tracheal defect in an 83-year-old male. A tracheal defect, the right half of the cricoid cartilage plus the right three quarters of the I-IV tracheal cartilage (about 3 × 4 cm), was reconstructed with a modified IHMC flap composed of the sternohyoid and platysma muscles and a skin pedicle. Considering the age of patient, we avoided rigid reconstruction and used a soft silicone tracheal opening retainer (Koken Co., Ltd., Tokyo, Japan) as an anterior wall dilator after surgery and waited for the scarring of the flap until it become rigid enough. The postoperative course was uneventful and the trachea was reconstructed safely. Tracheal reconstruction with an IHMC flap is a useful and less-invasive alternative compared to end-to-end anastomosis or reconstruction with a forearm flap, which is currently used as a mainstay.     

Nasalis myocutaneous flap for nasal reconstruction

Eight patients underwent reconstruction of the nasal supratip using nasalis myocutaneous flaps. This flap's blood supply is an axial blood supply from the nasalis muscle. The muscle originates from the piriform aperature and stretches out into an aponeurosis that attaches into the dermis in the nasal supratip and tip areas. Tumor defects 1 to 2 cm in diameter have been reconstructed using this versatile flap. I have been very impressed with natural alar contour, skin texture, and color matching using these flaps. The nasalis myocutaneous flap can be advanced up to 1.5 cm and can be used for lateral nasal wall and central nasal tip defects.     

Sternocleidomastoid myocutaneous flap for intraoral reconstruction

Summary The results of healing of the sternocleidomastoid myocutaneous flap in 22 patients operated upon because of cancer of the tongue and floor of the mouth are presented. An inferiorly based island flap was used in 5 patients. Although total or partial cutaneous necrosis occurred in 4 of the patients, the wound healed without fistula formation in all cases. A superiorly based compound flap was used in 17 patients and in 5 of them the oral part of the skin underwent total or partial necrosis.Presented at the Fourth Symposium of Oncology in Otorhinolaryngology, Pozna, 26 June 1988     

Prevention of hair growth in myocutaneous flap reconstruction

Myocutaneous flaps play a prominent role in the immediate reconstruction of surgical defects following ablative oncologic procedures in the head and neck. Transfer of hair-bearing skin into the reconstructed upper digestive tract can be a major disadvantage associated with the pectoralis major flap. De-epithelialization of skin to the dermal level, removing the majority of skin appendages, can convert a myocutaneous flap to a "myodermal" flap. Platysma myocutaneous and myodermal flaps were grafted into the oral cavity of 13 dogs. Gross and histologic evaluation confirmed decreased hair growth in the experimental myodermal flap. Wound complications and graft survival were similar for both techniques. Diminished hair growth further supports the utility of myodermal flaps in hairy male patients undergoing upper digestive tract reconstruction.     

Pectoralis myocutaneous flap in head and neck cancer reconstruction

This review of 50 consecutive myocutaneous flaps provided an opportunity to assess the value of this particular reconstructive technique in head and neck cancer surgery. There is no question that the flap has certain disadvantages. In this series, it was not found to be a reliable means of one-stage pharyngoesophageal reconstruction. However, its technical ease, versatility, and reliability as a one-stage reconstructive technique strongly outweigh any disadvantages and prove it to be a valuable recent addition to head and neck cancer surgery reconstruction.     

Laryngotracheal reconstruction. Sternohyoid myocutaneous rotary door flap

The vascularized sternohyoid myocutaneous rotary door flap has been used for laryngotracheal reconstruction in ten patients in the past two years. Nine were reconstructed for laryngotracheal stenosis and one for immediate reconstruction after conservation laryngeal surgery for carcinoma. Before reconstruction, the nine patients with stenosis had each undergone a mean of eight surgical attempts at correction. Eight patients were tracheostomy dependent, and only two patients had effective voices. To date, seven patients have been decannulated and all ten have effective voices. No significant complications have been noted. This flap can provide a readily applicable, dependable technique that is useful in management of difficult laryngotracheal stenosis and for reconstruction after conservation laryngeal surgery.     

胸大肌肌皮瓣修复晚期口咽侧壁肿瘤手术缺损

对18例晚期口咽侧壁肿瘤患者的术后缺损，用胸大肌肌皮瓣修复。取瓣面积为15cm×10cm～3cm×3cm；3例发生部分坏死，4例行预防性气管切开；术后外形及口咽功能恢复均满意。术后3年和5年生存率分别为61．5％和40．0％。皮瓣的愈合与本前放疗及术中操作等因素有关。认为晚期口咽侧壁肿瘤术后缺损应首选胸大肌肌皮瓣作一期修复，以提高患者生存质量，延长其生命。     

The pectoralis major myocutaneous flap in head and neck reconstruction

The pectoralis major myocutaneous flap (PMMC flap) represents a landmark in the development of head and neck reconstructive surgery. After Stephan Ariyan first described its use for head and neck reconstruction in 1979, it has become tremendously popular and has revolutionised head and neck cancer surgery. Here, we present our initial experience with fourteen PMMC flaps in head and neck reconstruction. In most of the instances it was used for oral or oropharyngeal reconstruction. It was used for five other reconstructive tasks as well. Wound infection was the most common complication. There was no case of total flap loss. It has proven to be a reliable method of reconstuction in the head and neck.     

The superior trapezius myocutaneous flap in head and neck reconstruction.

The superior trapezius myocutaneous flap, based on the paraspinous perforating branches of the intercostal vessels, is generally not a first-line choice for reconstruction of head and neck defects. However, after wound breakdown following radical neck dissection and radiation therapy, the superior trapezius flap is extremely reliable for coverage of exposed major neck vessels. The flap was used in 30 patients undergoing lateral neck reconstruction. All 30 patients had undergone prior neck dissection and all but two had undergone prior radiation therapy. There were no flap failures. The superior trapezius flap is unique among other regional myocutaneous flaps presently in use in that it has a superiorly based pedicle, which reduces the problem of gravitational pull on the suture lines of severely unfavorable recipient beds. Another advantage of using the denervated muscle of this flap is that it imposes no additional functional loss. The deficiencies of this flap are primarily related to its limited arc of rotation, thereby precluding its use when resurfacing defects that extend beyond the midline of the neck. The reliability of the superior trapezius flap after neck dissection can be explained by the angiosome concept. Based on that concept, previous ligation of the transverse cervical vessels during a neck dissection serves to simultaneously stage this flap, thereby improving its reliability and potential surface area available.     

Pectoralis major myocutaneous flap reconstruction of the laryngopharynx and cervical esophagus

Advanced carcinoma of the hypopharynx and cervical esophagus is a formidable challenge to the skills of the head and neck surgeon. Radiation therapy is valuable as adjunctive therapy when combined with curative surgery, which is the primary treatment modality. The extent of anatomical disease associated with extensive neoplasia of the hypopharynx and cervical esophagus is frequently not amenable to total laryngectomy with local tissue repair. Surgical ablation usually requires an extended laryngectomy, which does not permit primary local repair. A previous report by this author, comparing all techniques historically and chronologically, indicated that the present impetus is toward procedures characterized by a one-stage primary repair with shorter completion times. Presently, the three most promising procedures that meet these criteria are the gastric transposition, free microvascular bowel transfer, and regional myocutaneous flap repair. Theogaraj, et al. reported the use of a partially tubulated pectoralis muscle flap over preserved posterior wall cervical esophageal mucosa in cases of short segment stenosis. Encouraged by these results, a technique using partial tubulation for long-segment stenosis was reported. The use of this technique was expanded to include the repair of the defect left after total ablation of the laryngopharynx and cervical esophagus. Over the past 40 months, 22 patients have undergone repair using partial tubulation of the pectoralis myocutaneous flap. This paper will discuss the technical aspects of the procedure and analyze the procedure as it relates to mortality, morbidity, and completion time. Low morbidity and a completion time of 18 days competes favorably with gastric transposition and free jejunal transfer. A rational approach to reconstruction using all procedures will be discussed.     

Latissimus dorsi myocutaneous flap for secondary head and neck reconstruction.

PURPOSE: To review our experience and results with the use of pedicled latissimus dorsi myocutaneous flap (LDMF) for secondary reconstruction in head and neck surgery. METHODS: Twenty-two patients had LDMF, 17 of them for secondary reconstruction. Data were collected regarding the primary surgery, primary method of reconstruction, indication for secondary reconstruction, and outcome. RESULTS: Seventeen LDMF procedures were performed for secondary reconstruction. Flap success rate was 100%. Reconstructive goals were achieved immediately in 16 (94.1%) patients. CONCLUSION: LDMF is a thin flap with a large surface area and a long pedicle that allows it to reach any region in the head, neck, and scalp. Its main disadvantages are the need for lateral positioning of the patient and the fact that its pedicle is not protected with muscle. In our experience, LDMF provides an excellent reconstructive option especially in complicated cases of secondary reconstruction. It may be used in cases where a free flap is usually used, but with significantly reduced surgical time.     

Systematic review of the platysma myocutaneous flap for head and neck reconstruction

OBJECTIVES: To systematically review and quantify complication rates and to identify preoperative factors among patients who underwent platysma myocutaneous flap reconstruction for head and neck cancer. DESIGN: This study analyzed 190 patients in 16 case series published between 1982 and 2002. Funnel plots, contingency tables, and chi(2) analyses were used to minimize bias and heterogeneity among the studies. Logistic regression models were used to quantify the associations between preoperative factors (age, sex, T stage, prior radiation therapy, and recipient site) and complications (skin loss or necrosis, fistula, dehiscence, hematoma, and infection) at different recipient sites (floor of mouth, alveolar ridge, pharyngeal wall, buccal mucosa, tongue or tongue base, and tonsil). SETTING: Academic research. PATIENTS: Patients described in the literature with head and neck surgery who underwent platysma flap reconstruction. MAIN OUTCOME MEASURES: Results of logistic regression analyses. RESULTS: Seventy-one patients (37%) developed a complication, ranging from 20% at the buccal mucosa to 55% at the tonsil and at the alveolar ridge. Major complications (ie, those requiring further surgery) occurred in 5% of patients. The most common complication was skin loss or necrosis, occurring in 25% of patients. Postoperative complications were not associated with age or sex but were associated with recipient site and tumor stage. Overall, complications were 0.3 (95% confidence interval [CI], 0.1-1.1) times less common at the buccal mucosa than at other recipient sites. Hematomas were 18.8 (95% CI, 1.6-217) times more common at the buccal mucosa. Infections were 20.0 (95% CI, 1.1-350) times more common at the pharyngeal wall. Major complications were 4.6 (95% CI, 0.9-23.5) times more likely, and fistulas were 9.2 (95% CI, 2.0-43.1) times more likely in patients with stage T3 or T4 oral cancer than in patients with lesser grades. CONCLUSIONS: Postoperative complications were not associated with age, sex, or preoperative radiation therapy, but they were associated with recipient site and tumor stage. These results may guide surgeons considering the platysma flap to reconstruct head and neck cancer.     

Sternocleidomastoid myocutaneous flap

The sternocleidomastoid myocutancous flap has several applications for reconstruction of defects about the head and neck. It is used for augmentation of facial defects, carotid artery protection, and repair of oral cavity defects. Additional reconstructive efforts suggest the sternocleidomastoid myocutancous flap can be used for facial reanimation and as an osteomyocutaneous flap incorporating the clavicle for mandibular reconstruction. Reports of unreliable viability and resection of the sternocleidomastoid muscle during neck dissection decreases the applicability of the flap. Twenty-seven sternocleidomastoid flaps were used in 26 patients for head and neck reconstruction. In contrast to the reported 40% to 50% incidence of superficial slough or total flap necrosis, three (11%) flaps developed superficial (cutaneous) slough while two patients developed inclusion cysts. The technique includes elevation of the sternocleidomastoid muscle with the overlying platysma and skin originally described by Owens. The procedure is modified by removing the epithelium on the tunneled portion of the flap. This allows the flap to be used as a one-stage method of reconstruction without sacrificing the additional blood supply from the platysma and overlying dermis.     

Parietal occipital nape of neck flap. A myocutaneous flap for selected head and neck reconstruction

Reconstruction in head and neck surgery has been greatly advanced with the use of the pectoralis major and trapezius myocutaneous flaps. Most surgical defects can be repaired with one of these flaps alone, or in conjunction with cutaneous flaps. Specific problems, however, occur that cannot be successfully reconstructed by these standard flaps. The traditional scalp flaps are cutaneous flaps. Use of these flaps is limited because of their shortened arc of rotation and accompanying forehead deformity. Three patients underwent reconstruction with a parietal occipital nape of neck myocutaneous flap. Its advantages include the following: large segments of hairless skin from the contralateral side of the neck can be used, an extensive arc of rotation and distance can be achieved with excellent vascularity in the overlying skin, and cosmetic results are superior. Angiographic studies were used to demonstrate the vascular pattern and supply to this flap. Cadaver dissections were performed to determine the pattern of distribution of the perforating vessels to the skin from underlying muscle.     

胸大肌肌皮瓣卷筒在下咽颈段食管环周缺损修复中的应用

目的 探讨胸大肌肌皮瓣卷筒在晚期喉咽及颈段食管肿瘤切除术后环周缺损修复中应用的可行性及远期疗效.方法 回顾性分析2004年12月至2008年10月对30例头颈鳞癌原发灶肿瘤切除后出现下咽和颈段食管环周缺损的患者选择行胸大肌肌皮瓣卷筒修复的临床资料.其中下咽癌22例,颈段食管癌7例,喉癌术后放疗后复发累及下咽1例.术前接受放疗者5例,外院手术后复发者3例.采用全喉全下咽切除者12例,全喉全下咽切除颈段食管切除者18例,均行胸大肌肌皮瓣卷筒修复.结果 术后咽瘘4例,其中2例有术前放疗史,2例有糖尿病史,均换药治愈.2例患者出现吻合口狭窄,均位于口咽部上吻合口处,经反复扩张后缓解,术后吞咽功能均恢复.全部患者均进行随诊,术后随访时间8～56个月,中位随访时间18个月.以Kaplan-Meier法计算生存率,1年及3年生存率分别为71.4%及42.5%.结论 胸大肌肌皮瓣卷筒修复晚期咽喉及颈段食管肿瘤切除后的下咽和颈段食管环周缺损效果可靠.可用于放疗及手术后复发肿瘤切除后环周缺损的修复.