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.     

The trapezius myocutaneous flap. Dependability and limitations

Many reports of the trapezius myocutaneous flap have centered on a single form of the flap. However, three distinct myocutaneous segments, the superior, the lateral island, and the extended island flaps, can be harvested from the trapezius muscle and its overlying skin. Fifty-five patients underwent reconstruction for head and neck defects using 56 trapezius myocutaneous flaps consisting of 28 superior, 24 lateral island, and four extended island flaps. The four vascular supplies of the trapezius muscle are discussed, with emphasis on the variable nature of the transverse cervical and dorsal scapular arteries. Major complications developed in two of 28 superior, five of 24 lateral island, and one of four extended island flaps. The superior flap, although the most dependable, has the most limited range of application. Both the lateral and extended island flaps have a broader range of clinical application, but their usefulness may be limited by previous neck surgery or occult neoplasm in the neck, as well as by the variable vascular supply. Due to the above limitations, 30% of our attempts to utilize the lateral island flap had to be aborted at the time of surgery and an alternate means of reconstruction used. The trapezius myocutaneous flaps are excellent reconstructive tools for selected defects.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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.     

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。     

Reconstruction of intermediate sized mucosal defects with the pectoralis major myofascial flap

An uncovered pectoralis major muscle flap (PMF) was utilized in 12 patients for reconstruction of mucosal defects of intermediate size. The PMF is nonhair-bearing and thinner and more flexible than the myocutaneous flap. Epithelialization of the PMF occurs slowly but results in a mucosal surface that is nonkeratinized and closely resembles normal. The paddle of the PMF contracts as much as 75% during healing. However, none of our patients developed deficits attributable to contracture of the flap, presumably because only modest-sized defects were repaired. The PMF is useful for reconstruction of intermediate-sized defects approximately 6 x 6 cm, defects that are too large to close with local flaps and tend to be too small to be closed conveniently with a bulky myocutaneous flap. Contracture of the PMF precludes its use for reconstruction of large defects.     

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.     

Microvascular tissue transplantation of the ear, nose and throat

Free tissue transfers are a versatile method of reconstruction in head and neck surgery. In the pharynx and oral cavity the functional result dictates the choice of flap. For these sites thin and pliant fasciocutaneous flaps are ideal tissue transfers, and we favour the radial forearm flap which is raised from the distal volar forearm. This flap is easy to dissect and the donor defect, which is grafted with split skin, does not inconvenience the patient. For reconstruction of thicker defects we prefer bulky myocutaneous flaps such as the latissimus dorsi, which has a reliable pedicle of adequate length. The rectus abdominis flap, if taken with peritoneum, is useful for reconstruction of large cheek defects involving all layers; the peritoneum replaces the oral mucosa. For hypopharyngeal reconstruction the free jejunal loop has advantages compared with local skin or myocutaneous flaps, since it is a one-stage procedure with a low rate of post-operative fistulae. In some cases of reconstruction of the oral cavity and oropharynx we have used a jejunal patch, but in general we prefer the radial forearm flap, since it is more resistant to mechanical trauma. The advantage of a free tissue transfer is its excellent blood supply, which makes it possible to apply these flaps in irradiated and infected tissue. It is important in microvascular tissue transfer to choose an appropriate flap for the size and depth of the resection. It is only necessary to be familiar with those transfers most commonly used in this region.     

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.     

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.     

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.     

Pulmonary Atelectasis After Reconstruction With a Latissimus Dorsi Myocutaneous Flap

Atelectasis is the most common postoperative complication encountered in head and neck surgery. Risk factors include preexisting pulmonary disease, type of surgery performed, and the length of anesthetic. It is controversial whether reconstruction of defects with regional myogenous flaps predisposes to atelectasis. The latissimus dorsi myocutaneous flap requires the patient to be placed on his side for a period of time. Whether it is the position or the surgery that contributes to the development of atelectasis has not been examined. Eighteen patients underwent latissimus dorsi myocutaneous flap reconstruction following major ablative procedures for head and neck cancer. The cutaneous area transferred ranged from 70 to 225 cm² (mean, 128 cm²). The flap size ranged from 7 × 10 to 15 × 15 cm. The majority of flaps were 10 × 15 cm or greater. These patients were compared to 18 patients who did not undergo pedicled myocutaneous chest flap reconstruction. Patients were matched for age, sex, length of operation, site of primary, and stage of disease. Postoperative atelectasis was radiographically detected in 89% of flap patients vs. 79% of controls. Major atelectasis was encountered in 16% of patients undergoing flap surgery vs. 11% of patients in the control group. Patients with large cutaneous paddles on their flaps (>120 cm²) had significantly more atelectasis than patients with smaller cutaneous paddles (P<.05, chi-squared). The incidence of radiographic postoperative atelectasis in patients having a latissimus dorsi myocutaneous flap is high. The size of the skin paddle harvested as well as the position change may contribute to this.     

舌骨下肌皮瓣静脉回流障碍的预防性处理

目的：针对部分甲状腺上静脉回流障碍的舌骨下肌皮瓣，采用切断静脉再吻合的舌骨下肌皮瓣和保留非常见型回流静脉的舌骨下肌皮瓣等方法提高该皮瓣的成活率。方法：采用同侧舌骨下肌皮瓣一期修复口腔肿瘤术后缺损38例，包括切断静脉再吻合的舌骨下肌皮瓣6例；带动静脉蒂舌骨下肌皮瓣32例，其中以颈外浅静脉和甲状腺上静脉2条静脉为回流静脉的5例，以面总静脉和甲状腺上静脉2条静脉为回流静脉的3例，以1条甲状腺上静脉为回流静脉的24例。结果本组37例肌皮瓣完全成活，肌皮瓣成活率97．4％。1例肌皮瓣远心端皮肤坏死约5％，剪除坏死组织后皮瓣成活。结论：保留颈外浅静脉或面总静脉等非常见型静脉为该肌皮瓣的回流静脉和采用切断静脉再吻合的舌骨下肌皮瓣的手术方法，是解决部分舌骨下肌皮瓣静脉回流障碍的有效措施。