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.     

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.     

头颈部岛状肌皮瓣和皮瓣的改良设计及临床应用

目的　探讨制作单一血管为蒂的头颈部局部带蒂肌皮瓣或皮瓣的安全性。方法　解剖学观察20例胸肩峰动脉分支,观察最远入肌点走行特征。通过术前超声观察和术中透视法观察定位最远入肌点,在最远入肌点上方1～2 cm断离肌肉,形成单纯动静脉血管为蒂的胸大肌岛状肌肌皮瓣。利用同样的技术方法,设计岛状的胸锁乳突肌、下位斜方肌的岛状肌皮瓣。结果　解剖学观察胸肩峰动脉分支分为单支型12.5%（5/40）,双支型67.5%（27/40）,多支型20%（8/40）。术前超声定位胸大肌皮瓣的最远入肌点成功率为29.1%（14/48）,DSA成功显影乳内动脉穿支66.7%（12/18）,共完成胸大肌岛状肌皮瓣48例,乳内动脉岛状皮瓣12例,颏瓣18例,下位斜方肌岛状肌皮瓣4例,胸锁乳突肌岛状肌皮瓣4例,颈横血管岛状皮瓣3例,胸肩峰动脉穿支的岛状皮瓣3例。失败2例,1例为胸大肌肌皮瓣的岛状设计中电刀误伤胸肩峰动脉胸肌支;1例为颈横血管浅支,术中修复扁桃体癌咽侧壁缺损。3例胸大肌部分坏死,清理完坏死组织,换药后痊愈。结论　在头颈部设计单一血管为蒂的岛状肌皮瓣（皮瓣）的改良设计安全可行,在受区皮瓣容易塑形固定,供区不仅外形美观且功能保全。     

The rhombotrapezius myocutaneous and osteomyocutaneous flaps

As more radical surgery is being performed for head and neck cancer, an increasing variety of flaps for reconstruction have been developed. The more common myocutaneous flaps for large defects are the pectoralis major, trapezius, and latissimus dorsi flaps. The lower trapezius flap, which is used for reconstruction of large lateral facial defects, is a relatively thin flap. The rhombotrapezius flap described in this article provides bulk for augmentation of facial defects. The flap, which includes the trapezius and rhomboid muscles, also offers a longer pedicle with a greater arc of rotation. This flap may include the medial border of the scapula when bone is necessary. The addition of the rhomboid muscles incorporates the dorsal scapular artery, which gives an additional blood supply to the flap. We believe that the rhombotrapezius, myocutaneous, and osteomyocutaneous flaps have a significant advantage over previously described flaps in the treatment of defects that need greater bulk and length for adequate reconstruction.     

The trapezius myocutaneous flap.

The three trapezius myocutaneous flaps remain valuable adjuncts in head and neck reconstructive surgery. Overall, the lower vertical trapezius flap has the most versatility and reliability, and the least morbidity. There are several advantages of this flap compared to the pectoralis myocutaneous (PMC) flap. It has a thin vascular pedicle, and thus does not add excessive bulk to the neck, as the PMC can. Also, the skin island has less subcutaneous tissue and therefore more pliability than the PMC, which is a definite advantage for oral cavity and oropharyngeal defects. The trapezius flap generally has less hair than the PMC flap, and the donor scar is better hidden.     

10种移植物修复头颈缺损的体会

１９８３年１２月－１９９４年１２月应用１０种组织瓣修复头颈肿瘤切除术后缺损１０３例，其中吻合血管的髂骨游离移植１１例，带血管蒂的上斜方肌肌皮瓣７例，后置舌瓣２例，胸大肌肌皮瓣３０例，舌骨下肌皮瓣２２例，前额皮瓣２０例，外侧斜方肌肌皮瓣４例，胸锁乳突肌肌皮瓣２例，。胸锁乳突肌锁骨瓣２例，颈阔肌肌皮瓣３例。作者对不同移植物的利弊，适应证和临床应用体会进行了讨论。     

Flap Reconstruction of the Upper Face: Free Flaps VS. Lower Trapezius Myocutaneous Flap

ABSTRACT. The immediate one-stage reconstruction of the upper facial cutaneous defects were performed by using two different flaps. In the first representative patient a microvascular free flap was used; in a second case, the lower trapezius myocutaneous flap was used. Free flaps probably are ideal for the correction of such defects in one stage. This procedure requires specially trained surgical teams and longer operative time. A reliable alternative is the lower trapezius myocutaneous island flap. This offers a flap that is thin, hairless and of uniform thickness. The length and thickness of its pedicle allows excellent mobility and leaves no bulky neck deformity. Both these reconstructive techniques satisfy the need for viable replacement in large upper facial and scalp defects coupled with a satisfactory cosmetic outcome.     

Surgical techniques and results of lateral thoracic cutaneous, myocutaneous, and conjoint flaps for head and neck reconstruction

BACKGROUND: This paper aims at presentation of our surgical techniques and results of the lateral thoracic (LT) flaps for head and neck reconstructions. METHOD: There were seven LT cutaneous, seven LT myocutaneous, and two LT conjoint myocutaneous flaps for reconstruction of head and neck mucosal or cutaneous defects. RESULTS: The largest flap size was 22 cm x 13 cm. All donor sites were closed primarily. The highest point of reconstruction was in the nasopharynx internally and zygoma externally. All flaps survived without major complication. CONCLUSIONS: The LT flap has the versatility of cutaneous, myocutaneous, and conjoint flaps with pectoralis major or latissimus dorsi myocutaneous flaps to reconstruct large surgical defects. It has a large, reliable surface area, a long pedicle to reach nasopharynx and zygoma, and has less bulky muscle to facilitate tubular reconstruction of circumferential pharyngeal defect, one-stage operation, esthetic hidden donor site scar in axillary region, and minimal donor site morbidity. It is an additional reliable pedicle flap in our armamentarium for reconstruction of both cutaneous and mucosal defects in the head and neck region.     

Improving outcomes of locoregional flaps: an emphasis on anatomy and basic science

PURPOSE OF REVIEW: There has been renewed interest by surgeons in locoregional flaps for facial renconstructive problems previously thought to be optimally managed by microvascular tissue transfer. Complication rates of locoregional flaps are similar to those of free flaps. Successful reconstruction using local flaps is largely based on an understanding of regional vascular anatomy. RECENT FINDINGS: Sternocleidomastoid and trapezius muscle flap studies have elucidated patterns of arterial and venous anatomy to allow for improved flap design. Perioral vascular studies in cadavers demonstrate consistent and reliable patterns of blood supply. The terminal vascular anatomy of the submental island flap has been recently studied. The reverse-flow submental artery flap has been used to reconstruct periorbital soft tissue defects. Preliminary studies show that a full-thickness forehead flap can be utilized to simultaneously reconstruct both the external and internal surfaces of the nose. Basic fibroblast growth factor has been found to have a protective effect on random skin flap viability. SUMMARY: Locoregional flaps remain a useful tool for head and neck reconstruction, and often provide unique characteristics not available with free flap reconstruction. A sound understanding of vascular anatomy and recent basic science discoveries will significantly improve success of locoregional reconstruction.     

下斜方肌皮瓣修复头颈部肿瘤术后组织缺损

目的 探讨下斜方肌皮瓣的解剖基础和该皮瓣在头颈部肿瘤切除术后大型组织缺损修复重建中的作用.方法 回顾性分析中山大学附属第二医院颅颌面外科2000年1月-2004年1月间应用下斜方肌皮瓣对头颈部恶性肿瘤根治性切除后的缺损进行同期修复患者24例,男14例,女10例;年龄35～76岁,中位年龄54岁.其中舌癌10例,颊癌4例,口底癌2例,腮腺癌1例,口咽癌2例,牙龈癌3例,上颌窦癌1例,右颧、额部恶性肿瘤1例;15例为初发恶性肿瘤,9例为复发恶性肿瘤;皮瓣最小为8 cm×7 cm,最大为12 cm×10 cm.结果 21例患者术后皮瓣全部存活,3例皮瓣远端部分坏死,供区Ⅰ期愈合.术后随访6～24个月,全部皮瓣无坏死,头颈部形态功能满意.结论 下斜方肌皮瓣具有血管蒂长、旋转度大,皮瓣薄而柔软,操作简便,适合同期修复头颈部术后较大的缺损.     

Oropharyngeal reconstruction: current state of the art

Oropharyngeal reconstruction represents one of the greatest challenges in the surgical rehabilitation of patients with head and neck cancer. This article reviews several reconstruction methods, starting with the primary closure and healing by secondary intention all the way to the complex sensate microvascular flap reconstructions. Small defects such as tonsillar, small tongue base, and partial palatal defects may be closed primarily or left to granulate. This is assuming that there is no communication with the neck or bone exposure. Local flaps such as the palatal island, submental, and buccal mucosal flaps are used to close small to moderate-sized defects. Split-thickness skin grafts are also appropriate for small to moderate-sized defects. Larger defects such as total palatal, more than 50% of the tongue base, and composite tongue base/palatal/pharyngeal defects may be closed with regional myocutaneous pedicled flaps such as the pectoralis major, lower trapezius, or latissimus dorsi pedicled flaps. Microvascular tissue transfer is an excellent alternative for closure of moderate to large-sized defects. Free tissue transfer includes the radial forearm and the lateral arm free flaps. Both of these can have a sensory component. Free jejunal flaps are used for total or subtotal hypopharyngeal defects. Free gastro-omental flaps may be used for oropharyngeal and hypopharyngeal reconstruction as well. For defects involving bone, fibular flaps are an excellent option and can provide sensation. The scapular free flap may be used as well and offers the advantage of having two skin paddles (scapular and parascapular) for internal and external lining. Following a reconstructive ladder is extremely important in ensuring good function and, hence, improved quality of life.     

Lower trapezius myocutaneous island flap

Resurfacing of the floor of the mouth and buccal region of the oral cavity and the tonsillar region of the oropharynx may be accomplished with many variations of regional and distant vascularized flaps. Our experiences in the use of 14 lower trapezius myocutaneous island flaps are described with respect to the unique application and suitability of this flap to resurface defects in these areas, as well as the contraindications, both relative and absolute, to the use of this particular method of resurfacing. In addition, the intraoperative technique and attendant problems, as well as postoperative complications, are presented. The overall advantages and disadvantages of this flap as compared with the more traditional pectoralis myocutaneous flap are outlined. It is our belief that because of the distinct qualities of this flap, including extended scope and flap thinness, this method of reconstruction merits consideration in the preoperative planning process.     

Use of the latissimus dorsi myocutaneous flap in cervico-maxillofacial surgery. Study carried out in 32 cases

The authors report their experience about 32 cases of island latissimus dorsi myocutaneous flaps used in Head and neck reconstruction: 29 where concerning cancer surgery, 3 traumatic after gun shots wounds. The advantages retained for explaining their use of this flap are discussed. The quality of the functional results, the versatility of its use and viability allow them to prefer it to any other one for reconstruction of large head and neck defects.     

Role of the island deltopectoral flap in contemporary head and neck reconstruction

OBJECTIVES: The deltopectoral flap (DP) was originally described 40 years ago for head and neck reconstruction. Since that time, use of pedicled myocutaneous flaps and free tissue transfer has supplanted the DP flap as a first-line reconstructive tool. The island DP flap, a variation of the DP flap wherein the skin bridge is de-epithelialized, provides a source of thin and pliable tissue that can be useful for select head and neck reconstruction. The purpose of this review is to assess the utility of the island DP flap in contemporary head and neck reconstruction. METHODS: A retrospective review of 16 consecutive cases utilizing the island DP flap was performed. Indications, complications, and outcome were reviewed in an effort to determine the role of the island DP in contemporary head and neck reconstruction. RESULTS: Sixteen island DP flap procedures were successfully performed in 16 patients for a variety of reconstructions, including esophageal, laryngeal, cutaneous, and pharyngeal defects. The donor skin paddles averaged 22.4 cm2 (range, 14 to 40.8 cm2). There were no recipient site complications; however, there was 1 donor site hematoma that was managed with drainage. In all 16 cases, the island DP flap provided an appropriate source of donor tissue for reconstruction of limited defects of the pharynx, esophagus, and skin of the neck. CONCLUSIONS: The island DP flap is a reliable donor site that provides an excellent source of thin and pliable tissue for limited defects of the head and neck.     

Superior based trapezius flap

The most revolutionary innovation in reconstructive surgery of the past decade is the development of the musculocutaneous flaps. These flaps permit the reconstruction of large head and neck defects in one stage. They carry on excellent reliable blood supply and the inclusion of the underlying muscle adds sorely needed bulk to the resected area. The trapezius musculocutaneous flap is one of the most versatile. Its color and texture match for facial reconstruction is excellent. Moreover, the pliability of the cutaneous component lends itself well to lining the oral cavity ond the oropharynx. The trapezius musculocutaneous flap is an outstanding advance in head and neck reconstructive surgery. The discovery that it can be successfully pedicled superiorly greatly enhances its versatility.     

Reconstruction After Temporal Bone Resection

Reconstruction of soft tissue defects after temporal bone resection can vary from simple closure of the external auditory canal to complex flap coverage of extensive defects. Between 1987 and 1996, 34 patients underwent lateral skull base resections and reconstruction for invasive carcinoma of the temporal bone. Seven underwent sleeve resection and/or radical mastoidectomy. Sleeve resection was managed with tympanoplasty, canalplasty, or obliteration of the external auditory canal (10). There were 24 lateral temporal bone resections and four subtotal temporal bone resections. Larger defects created by lateral and subtotal temporal bone resections required closure with a combination of temporalis flaps and local rotational cutaneous flaps (13). Lower island trapezius flaps (five), free flaps (four), and pectoralis major flaps (two) were also used. Indications and efficacy of each method are discussed, and treatment outcomes are presented.     

Platysma myocutaneous flap revisited

The platysma myocutaneous flap has seen limited application in the reconstruction of head and neck defects over the past decade. There are anatomical and physiological reasons for this. There has been an emphasis on the anatomical vascular supply and method of preparation of the platysma myocutaneous flap and its use in the oral cavity. This article emphasizes the use of this flap for reconstruction of defects of the base of tongue, hypopharynx, lateral pharyngeal wall, and supraglottis. The criteria for selection of the platysma myocutaneous flap as a method of reconstruction, and the limitations, are outlined. New variations of harvesting the flap based on randomized muscular support are described. Specific complications as seen in our group of patients add certain precautions in the use of the platysma myocutaneous flap.     

Pectoralis major muscle flap in head and neck reconstruction

Pectoralis major muscle flaps have rarely been used on their own for head and neck reconstruction. Some of the problems experienced with myocutaneous flaps can be avoided by the judicious use of muscle flaps. These include suture line separation, excessive bulk, hair growth from the flap, and alteration of breast position. In contrast to the pectoralis major myocutaneous flap, the pectoralis major muscle flap is light and pliable. When it is employed for reconstruction in the oral cavity, oropharynx, or hypopharynx, it can be covered by a "quilted" skin graft or used on its own. We believe that pectoralis major muscle flaps provide a valuable alternative to the more bulky myocutaneous flaps in head and neck reconstruction.     

双岛胸大肌皮瓣在头颈肿瘤切除、重建术中的应用

目的 探讨双岛胸大肌皮瓣在头颈肿瘤术后组织缺损修复重建应用的效果及优点。方法 应用双岛胸大肌皮瓣,对头颈肿瘤术后组织缺损的8例患者进行修复重建。结果 重建后的咽腔无狭窄,颈部皮肤均成活。皮瓣I期愈合7例;皮瓣重建颈部皮肤面边缘轻度坏死1例,经处理后愈合。患者于术后8～12d(平均10d)开始进食;术后14～20d(平均16d)出院。结论 双岛胸大肌皮瓣血供丰富,组织量多,是同时修复头颈肿瘤术后皮肤、黏膜双重缺损的优选方法。     

The lower trapezius island musculocutaneous flap revisited. Report of 45 cases and a unifying concept of the vascular supply

The lower trapezius island musculocutaneous flap is valuable in head and neck reconstruction. It offers thin, pliable tissue and a long arc of rotation to reach virtually any defect in the head and neck. Recent reports have shown unacceptably high rates of failure and have questioned the reliability of the vascularity. We report our experience with 45 reconstructions using the lower trapezius island musculocutaneous flap. The literature is reviewed and the vascular anatomy is described in detail. The concept of angiosomes is applied to the trapezius muscle to help explain the reasons for flap failure and to provide guidelines for flap design and harvest.