Treatment of head and neck melanoma, lentigo maligna subtype: a practical surgical technique

Melanoma with the lentigo maligna histological pattern often provides a significant and difficult challenge to the head and neck surgeon. The lentigo maligna subtype is the most common type of melanoma on the head and neck. This potentially lethal form of cancer is associated with greater nonvisual lesional extension that is often not clinically apparent. Failure to excise the entire lesion results in a higher risk of local recurrence and a poorer prognosis. The staged excision technique described herein results in histological interpretation of 100% of the peripheral margins using formalin-fixed vertical sections. Definitive local excision and soft tissue reconstruction are performed in a subsequent stage, with an assurance that 100% of the peripheral margins have been evaluated and interpreted as free of disease.     

Cutaneous lesions: benign and malignant

This article reviews the clinical characteristics, histology, biologic behavior, and recommended treatment for several benign and malignant lesions that may arise on the head and neck. Nevus sebaceus and congenital melanocytic nevus are two benign lesions that can present at a size of several centimeters. Surgical excision may be considered for cosmetic purposes and to reduce the small risk for the development of malignancy within each lesion. Basal and squamous cell carcinoma, lentigo maligna and lentigo maligna melanoma, dermatofibrosarcoma protuberans, and Merkel cell carcinoma are malignant lesions for which surgical excision is the recommended treatment. Local flap reconstruction may be used to address the surgical defects resulting from excision of these benign and malignant conditions.     

The role of soft tissue reconstruction after melanoma resection in the head and neck

INTRODUCTION: Reconstruction after wide local excision of melanomas in the head and neck can be formidable. Many tumors lie close to vital structures, and excision must carefully balance preservation of form and function. For small defects, primary closure or skin grafting is satisfactory. However, it has become increasingly evident that more advanced reconstructive procedures can improve the outcome in terms of both function and aesthetics. This study was undertaken to determine the effectiveness of flap closure after wide local excision of melanomas in the head and neck and to develop a set of surgical recommendations on the basis of our experience. METHOD: We reviewed 35 patients who underwent 39 flap closures at The University of Texas, M. D. Anderson Cancer Center after wide local excision of head and neck melanomas. Local flaps were primarily used to close defects after the resection of superficial or intermediate-thickness melanomas. Pedicle and free flaps were used to cover larger defects resulting from the excision of extensive tumors. The flap closures were compared with an analogous database of 560 melanoma resections that underwent primary closure or skin grafting. RESULTS: The mean age of the patient population was 57 years. The most common location for tumor presentation was the cheek, followed by the ear, forehead, and lip. Pathologic findings most commonly demonstrated superficial spreading melanoma, and the average defect size was 30.7 cm2. Local flaps were used most often for reconstruction. The only variable that significantly predicted local recurrence was the depth of the tumor. Local, pedicle, or free flaps did not decrease the ability of detecting local recurrence or increase this number compared with primary closure and skin grafting. Major postoperative complications were detected in seven patients. We found flap closure to achieve excellent functional and aesthetic results. CONCLUSION: Although primary closure is the ideal method of reconstruction for small defects, flap closure provides a versatile and safe alternative when simple closure would yield unsatisfactory results. With careful planning, flap closure offers an exceptional functional and aesthetic result and may even enhance contour defects after extensive neck or parotid dissections. Moreover, our experience with flap closure did not appear to delay the detection of local recurrence and may have even served to decrease the incidence of local failure after wide local excision of head and neck melanomas.     

Total Lower Lip Reconstruction with Innervated Muscle-Bearing Flaps: A Modification of the Webster Flap

BACKGROUND: Mohs surgery and other surgical techniques are used for the removal of squamous cell carcinoma of the lower lip and may leave a large defect in the vermilion and underlying tissue. When nearly the entire lower lip is excised, reconstruction of this defect is a challenge. Repair requires the matching of vermilion color, maintenance of oral sphincter function and mouth opening size, and retention of sensation. Several techniques have been suggested. We present a modification of the Webster flap for total lower lip reconstruction using innervated muscle-bearing flaps. OBJECTIVE: To present a surgical technique for the reconstruction of total lower lip defects after excision of squamous cell carcinoma. METHODS: Innervated muscle-bearing flaps are used and demonstrated in one case. The surgical technique is discussed in detail. RESULTS: The reconstructive results were excellent. There were no postoperative complications. CONCLUSION: The use of innervated muscle-bearing flaps is a useful and effective option for the reconstruction of total lower lip defects.     

Q-switched neodymium:yttrium-aluminum-garnet laser treatment of lentigo maligna.

Lentigo maligna is a premalignant lesion of atypical melanocytes that typically arises on the head and neck of elderly patients. It is considered a melanoma in situ with a significant risk for transformation to invasive lentigo maligna melanoma. Surgery is the preferred method of treatment; however, because of the advanced age of the typical patient with lentigo maligna, the frequency of complicating medical problems, and the cosmetic or functional aspects of treatment, surgical excision is not always feasible. The purpose of this pilot study was to evaluate the efficacy and safety of Q-switched neodymium:yttrium-aluminum-garnet laser treatment of lentigo maligna. Eight patients were treated with 532 and/or 1064 nm wavelengths from the laser. All patients showed a response to laser therapy, and 2 patients treated with 1 treatment from each wavelength had complete eradication of the LM, with no evidence of recurrence in 42 months. Further study is warranted, but Q-switched neodymium:yttrium-aluminum-garnet laser is a promising alternative treatment for lentigo maligna.     

Surgical Management of Melanoma-In-Situ Using a Staged Marginal and Central Excision Technique

Melanoma-in-situ (MIS) represents 45% of all melanomas. The margins of MIS are often poorly defined with extensive subclinical disease. Standard fusiform excision with 5-mm margins results in positive margins in up to a third of cases. To decrease the incidence of involved margins, we use a staged excision approach for MIS. First, patients undergo excision under local anesthesia of a 2- to 3-mm “contoured” rim of tissue optimally 5 mm beyond the visible extent of the lesion. Formalin-fixed paraffin-embedded en face sections from this excision are then evaluated, if necessary with the aid of immunohistochemical stains. Any positive margins are further excised. When all margins are negative, the central area is then excised and reconstructed. A total of 61 patients with MIS or lentigo maligna melanoma underwent staged contoured excisions from 2004 to 2007 at Moffitt Cancer Center. We analyzed data only from patients with MIS of the head and neck. Patients with known invasive melanoma or non–head and neck primary disease were excluded. Demographics, tumor characteristics, margin status, number of stages, and type of reconstruction and recurrences were evaluated. Forty-nine patients with MIS of the head and neck, 28 (57%) male and 21 (43%) female, 42 to 88-years-old (median 72; mean 70), underwent staged contoured margin excision before definitive central tumor excision and reconstruction. The final surgical defect size ranged from 2 to 130 cm² (median 16 cm²). Twelve patients (24%) required reexcision of at least one margin; the median number of reexcisions was 1 (range 1–2). There seemed to be a positive association between lesion size and margin status (as well as number of excisions needed to clear the margin). Unsuspected invasive melanoma was found in the central specimen in six patients (12%). Even small tumors could have unsuspected invasive melanoma: invasive cancer was seen in 4 (21%) of 19 tumors ≤2 cm in greatest dimension and 2 (7%) of 30 > 2 cm, respectively. Surgical defects were reconstructed with flaps in 18 (37%), full-thickness grafts in 20 (41%), and split-thickness grafts in 10 patients (20%). Median time from first margin excision to completion/final reconstruction was 7 days (range 7–63 days). No local recurrences have been reported at a median follow-up of 14 months (range 1–36 months). This technique allows for careful margin analysis and subsequent central tumor excision with simultaneous reconstruction. This approach minimizes the need for a second major operation, which would have been necessary in 24% of our patients if treated by a one-stage excisional approach. It is noteworthy that 12% of MIS patients had invasive melanoma in the final excision specimen. This reinforces the importance of adequate full-thickness biopsies of suspicious pigmented lesions before any type of surgical management. With short follow-up, local control has been achieved by this technique in 100% of cases.     

Repair of a Large Wound of the Back, Post-Mohs Micrographical Excision, Using Chronic Skin Expansion

BACKGROUND: Large defects not otherwise closed primarily may be closed after chronic skin expansion. OBJECTIVE: If chronic expansion were deemed indicated for the closure of a proposed defect expected to result from Mohs micrographic surgery, can it be performed before Mohs surgery, avoiding the increased chance of expander extrusion via the defect when done postoperatively? METHODS: A team approach of a Mohs surgeon and a plastic surgeon coordinated scheduling an insertion of and staged infiltration of a tissue expander before Mohs surgical removal of a large basal cell carcinoma on the back of a young woman. The reconstruction after Mohs surgery was scheduled for the immediate postoperative period. RESULTS: The Mohs surgery completed removed the carcinoma, and the expander was removed, enabling the surgeon to perform a side-to-side closure. CONCLUSION: Provided that there is not a great probability of the neoplasm extending significantly deeper or wider than expected and that the skin expander is placed so as not to disturb the plane of Mohs excision, this is a useful technique to close large Mohs defects.     

Staged Cheek-to-Nose and Auricular Interpolation Flaps

Background. Staged interpolation flaps are priceless options in skin cancer reconstruction. Their value lies in their flexibility, reach, reliability, and ability to repair distant, complex facial defects. Familiar interpolation flaps to dermatologic surgeons include the paramedian forehead flap, cheek-to-nose interpolation flaps, and auricular staged flaps.
Objective. In this special reconstructive issue, the paramedian forehead flap is discussed separately. This article highlights the cheek-to-nose and auricular interpolation flaps as applied to skin cancer defects. Design considerations, anatomic basis, execution, and the distinctions of each repair are presented.
Materials and Methods. Patients with facial defects from Mohs micrographic surgery serve to illustrate the surgical techniques of each repair.
Results. With meticulous planning and thoughtful execution, cheek-to-nose and auricular staged flaps are capable of restoring both function and cosmesis. Several surgical stages are necessary, and an adequate supporting infrastructure is essential for an optimal outcome.
Conclusion. Skin cancer patients with complex facial wounds from Mohs micrographic surgery may be assured of the highest possible cure rate. Further, their esthetic and functional reconstructive goals may be achieved with staged flaps for the nose and ear.     

Experience with 998 cutaneous melanomas of the head and neck over 30 years

Between 1960 and 1990, a total of 998 patients were treated at the Sydney Melanoma Unit for cutaneous melanoma of the head and neck. There were 595 male and 403 female patients, with a median age of 53 years. The most common primary lesion site was the face (47%), followed by the neck (29%), scalp (14%), and ear (10%). Histologic types were as follows: superficial spreading 30%, nodular melanoma 28%, lentigo maligna melanoma 16%, and other 26%. All patients underwent surgical treatment. Primary closure of wounds was achieved in 52% of patients, and excision margins were 2 cm or less in 45%. A total of 152 patients had therapeutic neck dissections, and 234 had elective neck dissections. The overall local recurrence rate was 13%, and this was significantly influenced by increasing tumor thickness and Clark level. The recurrence rate in the neck after neck dissection was 24%, and the rate of parotid recurrences was 14%. Melanoma-specific survival was 77% at 5 years and 66% at 10 years for the entire group. By univariate analysis, survival varied significantly with age, tumor thickness, ulceration, anatomic sub-site, histologically positive nodes, and the presence of distant metastases. A diagnosis of lentigo maligna melanoma and elective lymph node dissection both appeared to improve survival. With multivariate analysis, all of these factors remained significant prognostic factors except elective node dissection, which lost its beneficial influence.     

Cosmetic outcomes following head and neck melanoma reconstruction: The patient’s perspective

BACKGROUND:While studies have compared aesthetic outcomes following wide local excision of head and neck melanoma, none have evaluated this important outcome from the patient’s perspective. Indeed, one could argue that the psychosocial impact of head and neck melanoma excision and reconstruction is more accurately assessed by deriving patient-based as opposed to surgeon-based outcome measures.OBJECTIVE:To evaluate aesthetic outcomes following wide local excision of head and neck melanoma from the patient’s perspective.METHODS:Fifty-one patients who underwent excision of 57 head and neck melanomas followed by immediate closure by primary repair, skin grafting, local flap coverage or free tissue transfer were asked to complete a written survey at least six months after their surgery. A visual analogue scale (VAS) was used to assess the patient’s perception of appearance alteration, satisfaction with his or her appearance, and emotional impairment. An ordinal scale was used to evaluate several criteria of the reconstructive outcome (pain, itching, colour, scarring, stiffness, thickness and irregularity).RESULTS:Forty-two patients (82.4%) completed the survey. There were significant correlations between VAS scores reported for appearance alteration, satisfaction with outcome and emotional impairment (P=0.001). Patients who received skin grafts reported significantly unfavourable VAS scores compared with other methods of reconstruction (P=0.046). Moreover, skin grafts received significantly worse ordinal scale ratings for itching (P=0.043), colour (P=0.047), scarring (P=0.003) and stiffness (P=0.041) compared with other methods of reconstruction. Both skin grafts and free flaps were reported to have significantly less favourable thickness (P=0.012) and irregularity (P=0.036) than primary closure or local tissue transfer. There was no significant difference between patients undergoing primary closure with local tissue transfer (P>0.413). Other factors related to the patient’s VAS scores included location of the melanoma (P=0.033), size of defect (P=0.037) and recurrence of melanoma (P=0.042).CONCLUSION:The degree of emotional impairment following reconstruction of head and neck melanoma excision defects was correlated with the patient’s perception of appearance alteration. From the patient’s perspective, primary closure and local tissue transfer appeared to result in the highest aesthetic satisfaction.     

Radiation therapy for melanomas of the head and neck

This report reviews experience with radiation therapy in 77 patients with melanoma of the head and neck, a lesion traditionally but incorrectly considered to be radiation-resistant. Thirteen patients with lentigo malignum and 18 patients with lentigo malignum melanoma have been primarily irradiated. In 11 of the 13 patients, the lentigo malignum has been locally controlled with no recurrence from 6 months to 5 years following treatment. One patient had a local recurrence and was salvaged with further radiation therapy, and one patient had residual tumor after irradiation and was salvaged with simple excision. Seventeen of 18 patients primarily irradiated had lentigo malignum melanomas that have been locally controlled from 6 months to 6 years after irradiation. One patient had a local recurrence and was salvaged by excisional surgery. There have been no deaths from lentigenous melanoma, and the cosmetic results of treatment are excellent. We concluded that radiation therapy is a simple, effective out-patient treatment for lentigo maligna and lentigo maligna melanoma. Nonlentigenous melanoma was irradiated after incisional biopsy in 6 patients; local control was obtained in 4 patients although 1 died of distant metastases. Fifteen patients were irradiated after excisional biopsy (margins inadequate); 14 of 15 had local control although 6 died of metastases. Only 2 of 16 patients irradiated for recurrent melanoma were controlled. Analysis of local control versus irradiation fraction size revealed that 17/24 (71%) achieved local control with a dose per fraction of greater than 400 rad as compared with 3 of 12 (25%) in those being irradiated with a dose of less than 400 rad per fraction. We concluded that nonlentigenous melanoma is not radiation resistant and that local excision followed by radiation therapy with a large dose per fraction deserves further study, particularly in melanomas of the head and neck where wide local excision is not possible due to age of the patient or location of the tumor. Nine mucosal melanomas have been primarily irradiated and four have been locally controlled.     

Head and neck reconstruction: a review of 117 cases

The reconstruction of defects of the head and neck, no matter the cause, begins with a careful assessment of the patient and the defect. Ideally, it ends with the successful execution of the reconstructive procedure that optimally restores form and function with minimal morbidity. There are several treatment possibilities that differ in their indications, technical difficulty, safety, and incidence of complications. This is a review over a period of 13 years of 117 cases of head and neck reconstruction performed by the author. Sixty-eight patients were treated with five different musculocutaneous pedicled flaps, mainly during the first half of the 13-year period. Those based on the pectoral major and latissimus dorsi were the most frequently utilized, mainly in pharyngolaryngeal reconstructions and sometimes as osteomyocutaneous flaps for oromandibular defects. Forty-nine patients had microvascular reconstructive procedures with 12 different types of free flaps. The latissimus dorsi flap was used for reconstruction of the scalp and after excision of intracranial lesions, whereas the serratus anterior or rectus abdominis free flaps were utilized for reconstruction of complex defects of the middle-third of the face. The radial forearm flap and the free jejunum have become the choice for intraoral and pharyngoesophageal reconstruction, respectively. Good results were obtained in both functional and social rehabilitation of the patients. There were three flap losses due to thrombosis of the microvascular anastomosis. There was no surgical mortality. The indications for each pedicled and free flap are discussed. Received: 27 October 1999 / Accepted: 22 June 2000     

Refinements in free flaps for head and neck reconstruction

The decade of adolescence of microsurgical techniques of head and neck reconstruction has led to a further clarification of the indications and methods for microsurgical reconstruction of head and neck defects. A review of the defects and the variety of flaps available for reconstruction leads to an increased understanding of the advantages and disadvantages of these various methods. When assessing a defect in the head and neck for microsurgical reconstruction, the surgeon should consider the various advantages of the flap to be used and weigh them against the disadvantages. The specialty has long since passed the point when one or two donor flaps could be considered to answer all of the reconstructive questions. We must now thoughtfully consider all the available options before settling on a course of treatment.     

Lentigo Maligna and Lentigo Maligna Melanoma in Young Adults

BACKGROUND: We observed two young women with skin types II to III according to Fitzpatrick's classification who developed pigmented macules in the face that were histologically diagnosed as lentigo maligna melanomas. OBJECTIVE: The objective of this study was to examine lentigo maligna melanoma in young adults. METHODS: According to private photographs of one of those patients a precursor lesion was clinically apparent as early as in her 26th year. Ten years later, the diagnosis of a lentigo maligna melanoma was made. The other patient was diagnosed with lentigo maligna at the age of 37. After excision, a relapse occurred in her 39th year. At this time histopathology revealed an early invasive lentigo maligna melanoma. RESULTS: These case reports demonstrate that the diagnosis of both lentigo maligna and lentigo maligna melanoma cannot be dismissed because of young age or well-tanning skin types. CONCLUSION: We conclude that owing to changes in social behavior and sporting activities with high short-term ultraviolet exposures, one must be aware of the possibility of an unusual early onset of lentigo maligna and lentigo maligna melanoma already in the third and fourth decade of life. Furthermore, our observations support the effectiveness of dermatoscopy in diagnosing ambiguous pigmented skin lesions in sun-exposed skin.     

Internal mammary artery and vein: recipient vessels for free tissue transfer to the head and neck in the vessel-depleted neck

BACKGROUND: Microvascular free tissue transfer is a standard reconstructive option for postablative defects of the head and neck. However, the success of this surgery requires suitable recipient vessels in the cervical region. This form of reconstruction can be particularly challenging in the vessel-depleted neck. While the internal mammary artery and vein (IMA/V) have been used extensively in breast reconstruction, there are few reports describing their use in head and neck reconstruction. We report the first case series of the use of the internal mammary vessels for head and neck microvascular reconstruction. METHODS: We reviewed 5 cases of free tissue transfers to the head and neck in which extensive prior treatment precluded the use of more traditional recipient vessels in the neck or upper chest. RESULTS: A variety of free flaps were transferred for different reconstructive problems which included: chin/lower lip (n = 2), closure of widely patent tracheoesophageal puncture sites (n = 2), and pharyngoesophageal reconstruction following staged repair of a severe stenosis (n = 1). The radial forearm free flap was transferred in 4 patients and the rectus abdominus free flap in 1 patient. The IMA/V on the right side was prepared in all cases. All free flaps were successfully revascularized without the need for vein grafts and without the need for any microvascular revision procedures. CONCLUSION: The internal mammary artery and vein provide reliable, easily accessible recipient vessels for microvascular reconstruction in the vessel-depleted neck. The selection of free flap donor sites with long donor vessels facilitates the microvascular repair.     

Utility of Rush Paraffin-Embedded Tangential Sections in the Management of Cutaneous Neoplasms

BACKGROUND: Mohs micrographic surgery (MMS) modified by the use of tangential, formalin-fixed, paraffin-embedded histologic specimens is advantageous in treating selected skin neoplasms. OBJECTIVE: To review the use of our experience with a modification of MMS to treat lentigo maligna melanoma (LMM), lentigo maligna (LM) and other melanoma in situ (MIS) lesions, dermatofibrosarcoma protuberans (DFSP), atypical fibroxanthoma (AFX), and angiosarcoma. METHODS: Our experience utilizing a modification of MMS in the treatment of 77 patients with LM or other MIS, 23 patients with LMM, 11 patients with DFSP, 1 patient with AFX, and 1 patient with angiosarcoma was reviewed. Length of follow-up and rate of recurrence were examined. A literature review of this pertinent modification of the Mohs technique was performed. RESULTS: One hundred fourteen patients underwent MMS for melanocytic (LM, MIS, LMM), spindle cell (DFSP, AFX), and vascular malignant neoplasms. One patient developed locally recurrent LM and one patient with LMM developed satellite metastasis. Regional lymph node metastasis occurred in one patient with LMM and in a patient with angiosarcoma. CONCLUSION: The use of Mohs micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential histologic sections provides the accuracy and tissue conservation of the Mohs procedure while ensuring more confident interpretation of histology in cases of lentigo maligna, lentigo maligna melanoma, dermatofibrosarcoma protuberans, atypical fibroxanthoma, and angiosarcoma.     

Plantar flap reconstruction for acral lentiginous melanoma

Background: Acral lentiginous melanoma continues to be difficult to diagnose despite an overall trend toward early identification of smaller and thin lesions. The insidious nature of this lesion often precludes primary closure of the surgical defect once it is excised, adding to the reconstructive complexity. Local flaps on the plantar foot offer an option for reconstruction when the defect is of intermediate size. Methods: Eight patients (5 men and 3 women, with an average age of 58 years) who underwent plantar flap reconstruction for defects isolated to the weight-bearing heel were retrospectively reviewed. Results: The average depth of the melanoma was 2.82 mm. Surgical margins were 2 cm or less in seven of the eight patients. Partial flap necrosis occurred in one patient, and loss of part or all of the skin grafts was noted in two patients. Currently five patients are alive with no evidence of disease. Conclusion: The plantar flap can provide local well-vascularized tissue for weight-bearing areas where skin grafting alone may not be appropriate. Coverage of these areas with well-padded flaps led to ambulation in all of the patients studied. We believe this flap offers durable coverage for medium-sized defects in acral lentiginous melanoma.     

Reconstructive indications of simultaneous double free flaps in the head and neck: A case series and literature review

Extensive and complex defects of the head and neck involving multiple anatomical and functional subunits are a reconstructive challenge. The purpose of this study is to elucidate the reconstructive indications of the use of simultaneous double free flaps in head and neck oncological surgery. This is a retrospective review of 21 consecutive cases of head and neck malignancies treated surgically with resection and reconstruction with simultaneous use of double free flaps. Nineteen of 21 patients had T4 primary tumor stage. Eleven patients had prior history of radiotherapy or chemo‐radiotherapy. Forty‐two free flaps were used in these patients. The predominant combination was that of free fibula osteo‐cutaneous flap with free anterolateral thigh (ALT) fascio‐cutaneous flap. The indications of the simultaneous use of double free flaps can be broadly classified as: (a) large oro‐mandibular bone and soft tissue defects (n = 13), (b) large oro‐mandibular soft tissue defects (n = 4), (c) complex skull‐base defects (n = 2), and (d) dynamic total tongue reconstruction (n = 2). Flap survival rate was 95%. Median follow‐up period was 11 months. Twelve patients were alive and free of disease at the end of the follow‐up. Eighteen of 19 patients with oro‐mandibular and glossectomy defects were able to resume an oral diet within two months while one patient remained gastrostomy dependant till his death due to disease not related to cancer. This patient had a combination of free fibula flap with free ALT flap, for an extensive oro‐mandibular defect. The associated large defect involving the tongue accounted for the swallowing difficulty. Simultaneous use of double free flap aided the reconstruction in certain large complex defects after head and neck oncologic resections. Such combination permits better complex multiaxial subunit reconstruction. An algorithm for choice of flap combination for the appropriate indications is proposed. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

The Dog-Ear Rotation Flap for the Repair of Large Surgical Defects on the Head and Neck

BACKGROUND: The Mohs micrographic surgeon is often faced with the daunting challenge of having to repair very large surgical defects on the head and neck where cosmesis and maintenance of normal function are of paramount importance. OBJECTIVE: We describe a novel flap, the dog-ear rotation flap, for the repair of such defects. We will demonstrate that this flap offers superior cosmetic and functional results to many other closure options, particularly for extensive defects of the cheek, temple, forehead and scalp. METHODS: The dog-ear rotation flap is a combination repair. It is executed by first closing one end of the surgical defect in a primary side-to-side-fashion, to a point at which tension across the wound precludes any further closure. A rotation flap is then developed to close the remaining defect, using tissue from the large dog-ear created at the distal end of the wound. RESULTS: In our experience, the dog-ear rotation flap is able to close substantial head and neck defects with less tension across the wound edges when compared to other closure types, resulting in diminished scarring and little to no distortion of surrounding anatomic structures. It also provides an excellent tissue match, is relatively quick and easy to perform, and has an extremely low incidence of flap necrosis. CONCLUSIONS: The dog-ear rotation flap is an excellent choice for the repair of very large surgical defects on the head and neck, particularly the cheek, temple, forehead and scalp, and, in our experience, provides a superior cosmetic and functional result to other closure options.     

Parascapular free flaps for head and neck reconstruction

We report our experience with single-stage, primary reconstruction of the head and neck in 29 consecutive patients using parascapular free flaps. The commonest indications were for craniofacial defects (9), oropharyngeal soft tissue defects (10), and combined mandibular and soft tissue losses (4). Ablative surgery was performed for squamous carcinoma (22), melanoma (2), and malignant fibrous histiocytoma (2). Seven patients died of recurrent disease during a 3 1/2 year follow-up. Seven patients are alive with recurrence. Flap complications included total loss (2) due to unsalvageable microvascular thrombosis, wound breakdown with oropharyngeal fistula (2), mandibular osteomyelitis (1), trismus (2), neck contracture (1), and donor site wound dehiscence (1). The overall success of this reconstruction was 93%. Primary wound healing was the general rule with lower morbidity than with other reconstructive techniques. The flap is thin, pliable, and conforms well to three-dimensional defects. The lateral border of the scapula can be incorporated on the same vascular pedicle for single-stage mandibular reconstruction. No muscle is sacrificed, and the posterior donor defect is an added advantage. The parascapular flap is our first choice for reconstruction of major defects in the head and neck.