MANAGEMENT OF NECROTIC NECK WOUNDS WITH A “SANDWICH” PECTORALIS MYOCUTANEOUS FLAP

A modified pectoralis major myocutaneous flap was used to stabilize necrotic neck wounds rapidly in irradiated patients. The flap was a “sandwich” flap that included an overlying “parasternal” pectoral skin paddle for pharyngeal reconstruction, the pectoralis muscle for carotid protection, and a meshed skin graft applied to the undersurface of the muscle to replace cervical skin. This flap has been used to reconstruct seven patients with severe wound necrosis from pharyngeal fistula and infection. All patients had carotid exposure in the infected wound. Reconstruction in all patients accomplished restoration of pharyngeal continuity, carotid protection, and cervical skin replacement. Some patients required more than one procedure for closure. There were no carotid “blowouts” in any of the patients. This technique enables the head and neck surgeon to stabilize these contaminated wounds rapidly and to reconstruct complex defects of the pharynx and cervical skin.     

胸大肌肌皮瓣与中厚皮片修复颈部咽瘘

目的探索以胸大肌肌皮瓣及中厚皮片联合修复颈部咽瘘的方法。方法对因头颈部恶性肿瘤术后与放疗后形成颈部的咽瘘,应用胸大肌肌皮瓣与中厚皮片联合修复咽食管黏膜及颈部皮肤缺损。结果本组11例皮瓣术后全部存活,术后5d去除中厚皮片之缝线包扎敷料,术后12~14d拆线,其中2例皮瓣边缘部分愈合不良,经换药后愈合。术后随访全部皮瓣及中厚皮片存活良好,患者吞咽功能恢复,外形良好。结论胸大肌肌皮瓣与中厚皮片联合用于颈部咽瘘的修复可获得良好的临床效果。     

改良胸大肌肌皮瓣在晚期头颈肿瘤手术中的应用

目的探讨一种保留胸大肌功能的改良胸大肌肌皮瓣的制作方法。方法根据胸大肌肌皮瓣的解剖学特点设计皮岛，将胸大肌肌皮瓣的血管蒂完全解剖出来而不携带肌肉，使肌皮瓣成为名副其实的岛状瓣，从而完整保留了胸大肌的锁骨部分以及胸大肌外侧大部分肌纤维。结果2002至2005年采用该方法制做改良胸大肌肌皮瓣29例，其中20例修复口内缺损，4例修复颈部缺损。3例修复腮腺区缺损，2例修复下咽部缺损。术后皮瓣全部成活，随访6个月至2年，所有患者术后进食、吞咽功能良好，语言功能大多恢复良好。结论改良胸大肌肌皮瓣应用于头颈外科克服了传统的胸大肌肌皮瓣的缺点，提高了肌皮瓣血供的可靠性，最大程度地保留了胸大肌的功能和胸部的外形。     

Combined use of free jejunum and pectoralis major muscle flap with skin graft for reconstruction after salvage total pharyngolaryngectomy

Salvage total pharyngolaryngectomy after failed organ‐preserving therapy often results in composite defects involving the alimentary tract, trachea, and neck skin. This retrospective study examined combined use of the free jejunum flap and the pectoralis major muscle flap with skin graft for such a complex reconstruction. We reviewed 11 patients who underwent free jejunum transfer for alimentary reconstruction and pedicled pectoralis major muscle flap transfer with a skin graft on the muscle for simultaneous neck skin resurfacing after salvage total pharyngolaryngectomy from 2005 through 2010. The operative morbidity rate was 27.3%. No pharyngocutaneous fistula developed in this series. Oral intake could be resumed within 3 weeks after surgery in all patients. Seven of 11 patients had a functional tracheostoma with adequate stomal patency. Combined use of free jejunum and pectoralis major muscle flap with skin graft provided secure wound closure even for complicated cases. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Pectoralis major musculocutaneous flap with nipple-areola complex in head and neck reconstruction: preliminary results of a new modified method

Pectoralis major musculocutaneous flap remains the workhorse tool for head and neck reconstruction. Flap failure in head and neck reconstruction is a devastating complication with a high morbidity and mortality. Inclusion of nipple-areola complex on the skin paddle stabilizes the blood circulation in the skin island of the pectoralis major musculocutaneous flap. A modified use of pectoralis major musculocutaneous flap with nipple-areola complex on the skin island was performed in 11 male patients in head and neck reconstructions with success without partial or total skin island necrosis.We recommend the inclusion of nipple-areola complex on the skin island of the pectoralis major musculocutaneous flap in head and neck reconstructions to increase the blood supply of the skin paddle. We concluded that the skin island of the pectoralis major musculocutaneous flap might include the areola and nipple complex in patients with large defects of the head and neck, which stabilize the blood circulation in the skin island.     

Closure of infected sternal wounds with a unilateral rectus abdominis muscle flap in addition to bilateral pectoralis major myocutaneous advancement flaps

We have recently added to our regimen a unilateral rectus abdominis muscle flap to cover the lower sternum and adjacent soft tissues, in addition to bilateral pectoralis major myocutaneous advancement flaps for closure of infected sternal wounds. Twenty patients underwent this procedure for closure of infected sternal wounds after initial débridement at our institutions. There were no intraoperative deaths in this series, but three patients died of other medical conditions. Two patients developed hematomas and one developed recurrent sternal wound infection after surgery; two had superficial wound infections and five had minor wound problems (i.e., skin edge necrosis). All surviving patients (17/20, 85%) had healed sternal wounds with normal chest contour and there were no instances of flap necrosis, sternal wound dehiscence, or abdominal wall hernia during the follow-up (18–60 months). Based upon our experience, we recommend a unilateral rectus abdominis muscle flap in addition to bilateral pectoralis major myocutaneous advancement flaps for selected patients with infected sternal wounds. This approach provides reliable soft tissue coverage with acceptable morbidity and mortality in this high-risk patient population. Received: 29 July 1998 / Accepted: 1 March 1999     

Reconstruction of posterior neck and skull with vertical trapezius musculocutaneous flap

The vertical trapezius musculocutaneous flap has been successfully utilized for reconstruction in 13 patients with complex posterior skull and neck defects. This flap based on its vascular pedicle, the descending branch of the transverse cervical artery, provides well-vascularized tissue for coverage of defects related to chronic osteomyelitis, tumor extirpation, osteoradionecrosis, and dehisced cervical laminectomy wounds. Emphasis on flap design, including the location of the skin island, allows adequate wound coverage, direct donor site closure, and muscle function preservation. With its large size and wide arc of rotation, the vertical trapezius musculocutaneous flap provides reliable coverage for posterior trunk, cervical, and skull defects.     

Reconstruction of the infected median sternotomy wound

Infection of a median sternotomy incision may result in a large, unsightly, unstable, and potentially fatal wound. We report on a series of 18 patients who were treated during the past six years with muscle flap closure for this difficult wound problem. We describe the evolution of our current preferred techniques and the results we have achieved with them. Patient risk factors and hospital course are discussed. Before definitive flap closure, all patients were treated with aggressive debridement of the bone and cartilage involved. Our first 4 patients were treated with pectoralis major myocutaneous rotation flaps. Since 1982, our procedure of choice has been to use a rectus abdominis muscle flap covered with either chest skin advancement flaps or, for deeper wounds, bilateral pectoralis major myocutaneous advancement flaps. The current technique makes possible an excellent cosmetic result with no functional deficit, and it lends good stability to the chest wall. We continue to use pectoralis flaps if there is reason to believe the blood supply to the rectus has been compromised.     

岛状胸大肌肌皮瓣修复颌颈部电烧伤

目的 了解应用岛状胸大肌肌皮瓣修复颌颈部高压电烧伤组织缺损的效果.方法 2001年8月-2007年12月,笔者单位对18例高压电烧伤患者的颌颈部软组织大面积缺损创面,应用岛状胸大肌肌皮瓣修复.早期扩创后移植皮瓣8例、感染创面移植皮瓣10例,皮瓣面积12 cm×10cm～16 cm×13 cm,供区移植自体大张中厚皮.结果 所有皮瓣均成活,4例皮瓣远端创缘表皮出现坏死带(长2～5 cm、宽1～2 cm),创缘局部裂开2例,经换药或再次缝合治愈.术后随访6个月～3年,患者颌颈部外观和功能恢复较满意.结论 岛状胸大肌肌皮瓣具有组织量大、肌腹扁平、血供丰富的优点,能够较好修复颌颈部较大面积深部组织裸露创面.     

经胸骨正中手术切口感染创面的修复

目的对比观察不同方法修复经胸骨正中手术切口感染创面的治疗效果。方法1997年12月～2006年12月,分别用胸大肌内侧头肌瓣、胸大肌瓣、上蒂腹直肌瓣及大网膜移位修复经胸骨手术切口感染创面13例。男8例,女5例;年龄28～72岁,平均52岁。合并糖尿病8例,肺炎及心力衰竭4例,脓胸3例,慢性肺功能不全4例,恶性肿瘤1例,严重肥胖6例。11例为较新鲜裂开创面,2例为慢性创面。创面范围10cm×5cm～22cm×10cm。结果3例分别于术后3d因血管吻合处破裂大出血、肺炎及癌转移死亡。其余10例伤口期愈合6例,随访6个月～5年,均无复发;2例切口皮肤拉拢缝合处部分皮肤坏死,经再次手术扩创植皮后愈合;2例创口引流处感染,经换药愈合。结论创面较小且位于手术切口上端者适合用胸大肌内侧头肌瓣修复;创面较大且位于切口上端者适合用全胸大肌瓣修复;创面较小且位于切口下端的适合用上蒂腹直肌瓣修复;创面较长可联合应用胸大肌瓣、上蒂腹直肌瓣修复创面;创面巨大合并重要脏器外露时,可用大网膜移位修复创面。残余创面可经植皮及换药愈合。     

The pectoralis major muscle in head and neck reconstruction

From June 1980 to June 1985 51 pectoralis major muscle flaps have been used for one-stage reconstruction of extensive defects in the head and neck following cancer surgery. The pectoralis major muscle was used as a myocutaneous flap on 28 occasions, as a muscle covered with split thickness skin on 17 occasions, and as a muscle-only flap six times. The muscle, in its various forms, was used for reconstruction of the pharyngooesophageal segment, the tongue, floor of the mouth and oropharynx, to replace the skin of the face and neck, and to provide a well vascularized recipient bed for a split-rib graft, used to replace a defect of the anterior arch of the mandible. Many of the problems associated with the use of a pectoralis major myocutaneous flap can be avoided by the judicious use of a muscle flap on its own or covered by a split thickness skin graft.     

Use of free-tissue transfer in the treatment of median sternotomy wound infections: retrospective review

The incidence of sternal wound infection following median sternotomy is 0.4 to 5 percent. Debridement and closure of the wounds with local and regional muscles, such as a pectoralis or a pedicled rectus abdominis, have been the mainstay of surgical treatment. Often, both pectoralis major muscles and the superior portion of a rectus abdominis muscle must be used to close large sternal wounds. Loss of these major muscles can be both debilitating and cosmetically disfiguring. Free-tissue transfer can be employed to limit the amount of tissue needed to fill the sternal defect. The authors present a series of 12 free-tissue transfers used in 11 patients to close large sternal defects in this subset of patients. Total flap loss occurred in one patient. Partial loss of the skin island was noted in three patients. Two patients developed abdominal hernias after rectus abdominis free flaps. Free-tissue transfer offers the ability to close these large wounds, using one muscle, in those patients where pedicled rectus abdominis flaps are not available.     

面颈部严重缺损畸形的皮瓣修复

目的：探讨对严重面颈部缺损的修复，在局部功能恢复的同时，如何使其外观与正常相近似，才能让患者和社会予以接受。方法：依据缺损创面的部位、形状、缺损面积的大小、受区和供区色泽反差等，选择吻合血管的皮瓣或真皮下血管网皮瓣、传统皮瓣或带蒂的真皮下血管网皮瓣、岛状皮瓣和扩张后皮瓣转移，修复面颈部各种不同的皮肤软组织缺损。结果：对鼻、眼睑、眉毛的再造效果较佳；对颏颈Ⅲ－Ⅳ度粘连者，被修复区的皮肤柔软，颜色与周围皮肤色泽相近；对肿瘤切除或深度烧伤创面修复，皮瓣外观平整，不显臃肿。结论：应用外科皮瓣在不同部位进行修复，能取得良好的临床效果。     

Infected carotid pseudoaneurysm and carotid-cutaneous fistula as a late complication of carotid artery stenting

Carotid stenosis after neck irradiation is a well-described entity. A 78-year-old man presented with left eye amaurosis fugax 11 years after radical neck dissection and neck irradiation for mucoepidermoid carcinoma. The patient underwent carotid artery stenting for a high-grade stenosis of the left internal carotid artery. Twenty months after the procedure, a pulsatile neck mass developed with intermittent arterial bleeding. After control of the bleeding, he underwent resection of the left carotid bifurcation, including the indwelling stent and reconstruction with a saphenous vein interposition graft. A pectoralis myocutaneous flap was used for wound closure. In this case, localized infection of the stented carotid artery led to mycotic degeneration, pseudoaneurysm formation, and erosion to the skin surface. As carotid artery stenting becomes more widely used, previously unreported late complications associated with this procedure are likely to become apparent, and continued close follow-up is warranted.     

Carotid Artery Reconstruction Combined with Myocutaneous Flap Coverage: A Complex and Durable Rescue Operation

Carotid reconstruction combined with myocutaneous flap coverage is a rare and challenging operation. We reviewed our experience to define the indications and outcome of this complex procedure. Clinical data and neurologic, wound, and vascular complications of all patients who underwent carotid artery reconstruction combined with myocutaneous flap coverage over a 17-year period were retrospectively reviewed. Results from this procedure indicate that pectoralis major myocutaneous flap is a safe and durable option for wound coverage in patients who undergo carotid endarterectomy, resection, and/or reconstruction for neck malignancy, previous irradiation or graft infection. Late outcome is favorable with low neurologic, vascular, and wound complication rates.     

Sternal osteomyelitis: use of vacuum-assisted closure device as an adjunct to definitive closure with sternectomy and muscle flap reconstruction

OBJECTIVES: Sternal osteomyelitis following cardiac surgery often requires debridement and flap coverage. The VAC (vacuum-assisted closure) device has been useful in complex wound coverage. A retrospective review of a single surgeon's experience with sternal reconstruction using the VAC device as an adjunct to debridement and muscle flap reconstruction was performed. METHODS: Thirteen consecutive patients over a 34-month period underwent debridement and reconstruction of sternal wounds. Eleven patients (85%) were males, and two (15%) were females. Mean age was 61 years (range: 43-73 years). Acute purulent sternal infections occurred in seven patients, while chronic sternal osteomyelitis was seen in six patients. Use of the VAC device during the perioperative period was evaluated. RESULTS: Of the 13 patients, the VAC device was used prior to flap closure in six patients, and after flap closure in two patients. Sternal debridement with bilateral pectoralis muscle flaps was used to reconstruct 12 patients, and one patient underwent debridement only with VAC placement. All 13 patients (100%) had complete closure of their complex wounds at an average of follow-up of 14 months. CONCLUSIONS: The VAC device is useful in the treatment of sternal osteomyelitis in three contexts: (1) as a temporary wound care technique preoperatively that minimizes dressing changes and prevents shear stresses of an open sternum, (2) as the sole method of wound closure in specific cases, and (3) as a technique to facilitate healing in postoperative flap reconstruction cases complicated by reinfection.     

Reconstruction of the face and neck scar contractures using staged transfer of expanded "Super-thin flaps"

BACKGROUND: The authors introduced the "Super-thin flap" concept, which is sometimes called the subdermal vascular network (SVN) flap, in 1994. Since 1994, we have reconstructed face and neck scar contractures using various types of "Super-thin flaps." In this report, we introduce expanded "Super-thin flaps" for reconstruction of the face and neck for the first time in a patient. METHODS: Since 2000 we have used 21 expanded flaps to reconstruct 21 face or neck scar cases in nine males and 12 females. In the first operation, an expander was inserted on the fascia of the pectoralis major muscle, and then about 1,000 cc of saline was injected during a 2-month period. In the second operation, the flap was thinned primarily and applied to the recipient site. Three weeks after the second operation, the pedicle of the flap was cut down and sutured. RESULTS: Flap size ranged from 4 cm x 14 cm to 10 cm x 22 cm. Expanded volume ranged from 800 cc to 1,200 cc. All flaps survived completely and scar tissues were replaced with normal skin. Flaps did not shrink after the operations, and contractures did not recur. CONCLUSION: Advantages of the expanded flaps are presented: (1) Large flaps can be harvested because of the expander; (2) Extremely thin flaps can be safely employed; (3) Texture and color match are good; (4) Donor site can be closed primarily; and (5) Microsurgery is not required. However, the disadvantage of the method is the requirement for two or three operations.     

颈部放射性溃疡的治疗

目的:探讨颈部放射性溃疡的手术方法。方法:彻底或姑息性切除颈部放射性溃疡组织后,根据颈部组织损伤程度的不同,分别用同侧胸三角皮瓣或胸大肌肌皮瓣进行颈部缺损的修复,供区使用全厚皮片修复。结果:11例胸三角皮瓣、3例胸大肌肌皮瓣全部成活,愈合良好,术后患者生活质量明显改善。结论:胸三角皮瓣与胸大肌肌皮瓣血运可靠,是修复颈部放射性溃疡的有效、简单和安全的方法。     

火器性四肢组织缺损的显微外科修复

目的 对四肢组织缺损进行修复与功能重建。方法 自１９７９年以来,采用显微外科,修复与重建外多种新术式,对８００例四肢战伤性皮肤,肌肉,骨骼,血管及神经损伤进行修复与功能重建。结果 对３０例战作骨缺损,采用吻合血管的骨移植,全部获得成功,对１５０例周围神经火器伤,采用神经束间缝合及束间移植术,其总优良率传统方法为优;对５００例周围血管火器伤,早期进行血管吻合和血管移植术,血管通畅率为９１％,对１２０