Oral cavity reconstruction using pectoralis major muscle and amnion

The pectoralis major myocutaneous flap has become the mainstay of major oral cavity reconstruction. The flap provides excellent soft-tissue bulk and cavity or surface lining for major defects. There is a high rate of primary take. However, the flap has some deficiencies. A group of patients were identified that are likely to have less than ideal results with the pectoralis major myocutaneous flap technique. In these cases, the flap has been modified and amnion has been added. Initial results indicate enhancement of reconstruction with the modified technique.     

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。     

Skin grafts and flaps in oral cavity reconstruction

Split-thickness skin grafts and regional flaps have been used to reconstruct deficits produced by oral cavity and oropharyngeal cancer resection in 191 patients. The rate of complication, delay in oral alimentation, and the postoperative length of hospitalization was greater for pectoralis myocutaneous and deltopectoral flap reconstructions than for skin grafts, even when comparably sized defects are considered. The adverse effect of weight loss is greater on flap reconstructions than skin grafts and is influenced little by preoperative nutritional therapy. Skin graft reconstruction is recommended for moderate and large defects. The pectoralis myocutaneous flap may be reserved for massive defects or when the anterior part of the mandible has been resected.     

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.     

Reconstruction of the hypopharynx with U-shaped pectoralis major myocutaneous flap after total pharyngo-laryngectomy

Resection of the whole circumference of the pharynx and esophagus is usually reconstructed with gastric pull-up, jejunum free graft or free forearm flap. The aim of this study was to assess the use of pectoralis major myocutaneous flap for closure of total pharyngeal defect. In 11 patients with hypopharynx and larynx cancer, total pharyngo-laryngectomy and excision of the cervical part of the esophagus and neck dissections were performed; the defects were closed with pectoralis major myocutaneous flaps. The skin island was sutured to prevertebral muscles, forming a letter U shape. Good healing was obtained in six patients, and five patients developed fistula that closed spontaneously within 3–4 weeks. The use of U-shaped pectoralis major myocutaneous flap, suturing it to prevertebral muscles, gives good functional results, and it is a simple and time-saving second choice method of reconstruction of the pharynx after total pharyngo-laryngectomy.     

扁桃体癌手术及修复方法的选择

目的 探讨扁桃体癌手术切除入路与组织缺损的几种修复方法及疗效.方法 采用颈前舌骨入路及下颔骨正中裂开外旋入路切除19例扁桃体癌,分别应用舌瓣、颞肌筋膜瓣及胸大肌肌皮瓣修复缺损.结果 1例胸大肌肌皮瓣术后出现皮肤部分坏死,3例颞肌筋膜瓣修复者术后张口轻度受限,其余患者术后呼吸、吞咽、咀嚼和语音功能恢复良好.结论 在选择合适的手术入路彻底切除肿瘤的前题下,熟练地掌握多种修复方法,择优采用,是恢复良好口咽功能,提高患者术后生活质量的重要保证.     

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.     

Free jejunal patch flaps in oral and oro-pharyngeal reconstruction

Free jejunum has been commonly tubed to provide a reconstructive pharyngeal conduit following pharyngolaryngectomy. It is also common practice to repair small oral and oro-pharyngeal defects with skin-lined flaps i.e. radial free forearm or pectoralis major myocutaneous flap. Free jejunal patch flaps can provide cover for large defects, secrete mucus, tolerate radiotherapy well and do not contract. The operation is associated with a low morbidity and early return of swallowing is feasible. Here we describe the functional results of free jejunal patch flap reconstruction of extensive oral and oro-pharyngeal defects.     

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.     

上颌窦恶性肿瘤术后缺损及修复方法

目的探讨上颌窦恶性肿瘤术后缺损的外科重建及贋复体修复。方法60例上颌窦恶性肿瘤术中采用带蒂额瓣、胸锁乳突肌皮瓣、颞肌筋膜瓣、胸大肌皮瓣及腭瓣修复软组织缺损18例,术后选用贋复体修复50例。结果术后语音、吞咽、通气功能及面容恢复良好者占68.3%,一般占20%,较差者占11.7%。胸大肌皮瓣与腭部裂开3例,边缘坏死1例,内眦部皮肤瘘口3例,开口受限8例。结论外科重建与贋复体并用即刻修复上颌窦恶性肿瘤术后缺损,方法简便、经济,贋复体周围软组织良好的固位形和封闭性是功能恢复及面容美观的关键。     

Preliminary results in using the myocutaneous pectoralis major flap

The modified pectoralis major myocutaneous paddle flap has been used in 75 cases since 1982 for the closure of major defects of the oral cavity, oro- and hypopharynx and neck. Although almost all of the patients had a stage IV tumour, we had good aesthetic and functional results. There was no total flap necrosis. Three cases of partial necrosis underwent spontaneous healing. The details of the operative techniques are compared with other reconstructive methods, and the advantage of the pectoralis major flap is discussed.     

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.     

Magnetic sensory cortical responses evoked by tactile stimulations of the human face,oral cavity and flap reconstructions of the tongue

Magnetoencephalography (MEG) is a procedure that analyzes the magnetic responses of neurons. An MEG system with a 37-channel superconductivity quantum interference device (SQUID) was used to record magnetic signals from the human brain in response to tactile stimulations of the face and oral cavity. Six normal individuals were studied as well as three patients who had undergone hemiglossectomies as treatment for carcinoma of the tongue and reconstruction with a pectoralis major myocutaneous flap. When the locations of the magnetic responses having latencies of 40 ms from onset of tactile stimulation were identified, these corresponded to the primary somatosensory cortex. In patients whose tongues had been reconstructed with a pectoralis major myocutaneous flap, the magnetic response upon stimulation of the flap was recorded in a sensory cortical area identical to that corresponding to the tongue. MEG systems such as the one described permit functional mapping of the cerebral cortex on stimulating the face and oral cavity.     

Magnetic sensory cortical responses evoked by tactile stimulations of the human face, oral cavity and flap reconstructions of the tongue

Magnetoencephalography (MEG) is a procedure that analyzes the magnetic responses of neurons. An MEG system with a 37-channel superconductivity quantum interference device (SQUID) was used to record magnetic signals from the human brain in response to tactile stimulations of the face and oral cavity. Six normal individuals were studied as well as three patients who had undergone hemiglossectomies as treatment for carcinoma of the tongue and reconstruction with a pectoralis major myocutaneous flap. When the locations of the magnetic responses having latencies of 40 ms from onset of tactile stimulation were identified, these corresponded to the primary somatosensory cortex. In patients whose tongues had been reconstructed with a pectoralis major myocutaneous flap, the magnetic response upon stimulation of the flap was recorded in a sensory cortical area identical to that corresponding to the tongue. MEG systems such as the one described permit functional mapping of the cerebral cortex on stimulating the face and oral cavity.     

Immediate reconstruction of pharyngoesophageal defects. Preference or reference

In this era of development in reconstruction, interest in searching for the most appropriate procedure for replacing the pharyngoesophageal defect is intense. The type of defect, depending on the level of invasion by the cancer, should be classified as partial pharyngeal, circumferential pharyngeal, or pharyngoesophageal. Within each class, the surgeon can have his preference for a reconstructive procedure according to available expertise and familiarity. In our series of 97 patients with pharyngoesophageal defects resulting from resection of laryngeal, hypopharyngeal, and cervical esophageal cancers, the patch-on pectoralis major myocutaneous flap, the tubed pectoralis major myocutaneous flap, and the stomach were used for the three types of defects, respectively. Mortality and morbidity, while kept at an acceptable level, appear to rise as the complexity of the procedure increases. This supports the argument that the reconstructive method should be selected with reference to the type of defect, which is in turn dependent on the site and behavior of the tumor. The reconstructive procedure is to fit the defect, and not vice versa.     

Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis

Objectives: The free radial forearm flap has replaced the pedicled pectoralis major myocutaneous flap and it has become the ‘workhorse flap’ used by many head and neck reconstructive surgeons for soft tissue reconstructions. Cost implications of radial forearm flap reconstruction within the context of the overall health care in a particular system need to be investigated particularly before it is labelled as ‘costly only’. Design and Setting: Forty patients who underwent immediate free radial forearm flap reconstruction for oral or oropharyngeal soft tissue defects were matched with patients who underwent pectoralis major myocutaneous flap reconstruction for similar defects. The 2 years of which the overall management costs according to the hospital perspective were calculated were divided into four periods: operative period, the postoperative phase, follow‐up during first year and follow‐up during second year after discharge. Results: The total costs within the first 2 years were comparable at ∼50 000 euros. The lower costs of hospital admission (24 days versus 28 days; P = 0.005) in the postoperative phase outweighed the higher costs of the surgical procedure (692 min versus 462 min; P < 0.005) in radial forearm flap patients when compared with pectoralis major flap patients. Conclusions: Oral and oropharyngeal reconstruction with radial forearm flap is not more costly than pectoralis major flap reconstruction. Given the better functional outcome and the present cost analysis, reconstruction of oral and oropharyngeal defects is preferably performed using free tissue transfer.     

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.     

下咽颈食段食管环周缺损修复方法的探讨

目的探讨不同手术方法修复重建下咽颈食管环周缺损的适应证，对不同方法的优缺点进行比较。方法对1993年6月至2006年6月期间收治的72例下咽颈食管区肿瘤进行手术切除，并根据肿瘤切除术后缺损的范围，采用胸大肌肌皮瓣、喉管、游离空肠、游离前臂皮瓣和胃上提咽胃吻合5种方法对肿瘤切除术后所致的下咽颈食管环周缺损进行一期修复重建，并重点对所有患者术后的吞咽功能恢复情况进行观察和客观评估。结果胸大肌肌皮瓣修复重建31例，喉管代下咽颈食管8例，游离空肠移植12例，游离前臂皮瓣移植4例，胃上提咽胃吻合术17例。其中15例患者出现了不同程度的并发症，包括创口感染、咽漏、皮瓣部分坏死、胃壁部分坏死和食管吻合口狭窄等，除1例死亡外，其他患者经处理全部治愈。本组患者术后吞咽功能恢复满意，除2例食管吻合口狭窄患者可以进半流食外，其余患者均恢复了正常的进食功能。平均随访时间为1．6年，术后2年生存率为45．3％。结论下咽颈段食管癌切除术后所致的环周缺损可依据缺损的范围和患者的情况选择不同的修复方法，只要适应证掌握得当均可获得满意的修复重建效果。     

Repair of head and neck defects with thin and double-lined pectoralis flaps

The evolution of nondelayed , single-stage repairs of extensive ablative defects of the upper aerodigestive tract with thin, skin-lined pectoralis myogenous and myocutaneous flaps is described, with particular emphasis on technique and applicability. To date, 15 such modified flap reconstructions of the oral cavity, oropharynx, and pharyngoesophagus have been performed. Other than one instance of flap failure, no significant short- or long-term complications were noted. The functional results of these repairs are equivalent to other, less convenient or technically more difficult methods of reconstruction.     

Compound pharyngeal myocutaneous flap

Rehabilitation of major palatal ablative defects associated with lateral composite resection of the tonsil, base of tongue, and/or hemimandible is a difficult problem. Palatal reconstruction is described with emphasis on the compound medially based posterior pharyngeal, pectoralis major myocutaneous flap, which we have found to be an effective and reliable means of reconstructing these defects.