Same stage reconstruction of the tissue defects with island myocutaneous flap in head and neck surgery

      Same stage reconstruction of the tissue defects with island myocutaneous flap  in head and neck surgery  (pdf)

      Department of OtorhinolaryngologyHead and Neck Surgery,the Second Peoples Hospital of Guangdong,Guangzhou 510317,China

    ［Abstract］  Objective  In order to promote surviving quality and period,enlarge operative ranges of head and neck surgery,this paper was to summarize retrospectively the clinical experience of 104 cases reconstructed by island myocutaneous flap since 1985.Methods  To use four kinds of island myocutaneous flap,forehead,infrahyoid,trapezius and pectoralis major myocutaneous flap,repaired and reconstructed the large defects of ten anatomical regions in 104 cases of carcinoma of head and neck,at the same stage.Results  Of the 104 cases,myocutaneous island flaps fully survived in 91cases(87.6%),all necrosis in 4 cases（4/104，3.8%）,partial necrosis of skin island with that the muscular layer was still viable in 9 cases（9/104,8.6%）,haematoma in 7 cases(7/104，6.7%),infection in 11 cases(11/104，10.5%).Ⅰstage and Ⅱ stage surviving rates of the flaps were 87.6%(91/104)and 8.6%(9/104),respectively.100 cases of the these patients were radiated with 40~70 Gy after reconstructing operation and no one appeared the complications of myocutaneous flap necrosis and fission.Conclusion  It has excellent antiinfection and endurance of radiation.It is simple,convenient and has higher successful rate and satisfactory efficacy for using the four flaps.It is important to choice projects according tumor region and defect range.

    ［Key words］  island myocutaneous flap;tumor;head and neck;reconstruction

     The repairing and reconstructing are inevitable for leaving behind larger superficial defects and malformation in head and neck after the operation,which were completed in same stage with the radical operation to be better ways.It was satisfactory to use four kinds of island myocutaneous flap repaired and reconstructed the large defects of ten anatomical regions in 104 cases of carcinoma of head and neck at the same term from 1985 to 2003 years in our department,now reports as follows.

    1  Materials and methods

    1.1  General materials  There were 80 males and 24 females in this group,their ages ranged from 18 to 70 years,more in 45~60 years.All of these patients with malignant tumor in head and neck,in which,60 cases (60/104,57%)in cervical lymph node metastasis cancer;squamous cell cancer in 77 cases(77/104,74%);sarcoma in 10 cases(10/104,9.7%);adenocarcinoma in 6 cases(6/104,5.8%);adenoid cystic carcinoma in 5 cases(5/104,4.8%);malignant malanoma in 2 cases(2/104,1.9%);malignant pleomorphicadenoma 4 cases(4/104,3.8%).

    1.2  Treating methods  The defects of head and neck region with accounting in 104 flaps were reconstructed with 4 kinds of the myocutaneous island flaps,forehead,infrahyoid,trapezius and pectoralis major myocutaneous flap,largest diameter in 10 cm×7 cm and least in 3 cm×1.5 cm,respectively.All of these patients received radical therapy in 40~70 Gy after reconstructing operation except 4 cases to have to give up the therapy because of wholly layer necrosis or/and fission of the flaps.

    2  Results

    Of the 104 cases,myocutaneous island flaps fully survived in 91cases,wholly layer necrosis in 4 cases(4/104，3.8%;forehead in 2 cases and infrahyoid in 2 cases;),partial necrosis of skin island with that the muscular layer was still viable in 9 cases（9/104,8.6%;infrahyoid in 5 cases and pectoralis major myocutaneous flap in 4 cases）;and haematoma in 7 cases(7/104，6.7%),infection in 11 cases(11/104，10.5%)had healed up after clear wound,elicitation and exchanging drugs.No one appeared the complications of myocutaneous flap necrosis and fission within one hundred cases received radical therapy after reconstructing operation.Surviving rates of myocutaneous island flaps were that Ⅰstage and Ⅱ stage were 87.6%(91/104)and 8.6%(9/104),respectively,and total surviving rates were 96.2%(100/104).Followed up these patients over 1 year,better melioration was distributed to the function and shape of head and facial region,except longitudinal atrophy(Table 1). Table 1  Reconstructing region and myocutaneous flap style

    3  Discussions

    Anatomy relation was more complex and larger vessels were more superficial than other ones,and life maybe endangered as soon as myocutaneous flap necrosis and fission occurred［1］.It was very important that tissue defects,which might cause obviously decreasing to living quality due to postoperative complication occurred,were repaired as possible as your trying for getting back anatomy conformation and physiological function after the carcinoma resected. Going with orthopaedics technique developing and experience accumulating,as a result of increasing various approaches of autotranplant reconstruction,appeasement treatments might turn to more active to has became possible for afternoon cancer patient who had to be given up the operation because of repairing difficulty in past.The best approaches of repairing and reconstructing were simultaneously completed with radical operation.

    3.1  Common characteristics to myocutaneous island flaps  Four kinds of island myocutaneous flap were wholly axis used in our group,which carried arteries,vein wellknown and enriching supply blood,feeding muscle and skin through vasculature branches;large circumrotating angle;excellent antiinfection and endurance of radiation;high surviving rate;having better tenacity,elasticity,physiological harmony;skin color of flaps verging on ones of head and neck region.It was better approach to that same stage reconstruction of head and neck defects resulted in the operation,deferring of flaps was unnecessary because of the skin of flap pedicel removed.The suitable and survival flap might remarkably improve the physiological function and facial appearance,promote survival rate and life quality,opening operative range and terminal patients might be actively cured.

    3.2  Applying principle of island myocutaneous flap  Four kinds of island myocutaneous flap had obviously common characteristics,but also had each peculiarities,and the operative approaches were decided basing on  peculiarities of each patient,location and range of defects,which were not wholly replaced each other.According with applying principles of myocutaneous flap,it was necessary for the comparative beauty and fine function,which should avoid complex methods and make myocutaneous flap from fardistance,and could apply with transplant of flap with pedicel,no dissociation and could hook in stitching,no transplanting skin in supplying area［2］,and adequately considered contradictions of the surgical treatment in same region both pedicel and metastasis neck lymph glands.Common contracting rate of flaps was 10%,correlating ages and fatness or lankness.It must be known to act according to actual circumstances,avoid folding and contorting,and the infection not was main causes of flap necrosis,the key points were how protecting every parts of supplying blood communicating with vessel pedicel between skin and muscles of skinisland［3］.Clinical practice indication:The skinisland should occur the partial or all necrosis while being any factors of blocking spplying blood and overtaking enduring of myocutaneous flap.Of the 104 myocutaneous flap,whole layer necrosis in 4 cases,partial necrosis of skinisland in 9 cases due to the pedicle of myocutaneous flap over shortness,larger tension,folding angle and local press.Author consider:when myocutaneous flap was made,rather the pedicle slightly long than over shortness,rather skinisland slightly large than over small,avoiding muscle pedicle pressed,no excess 180°in torsion,prohibit bend as a sharp angle in pedicle and wild operation.We should sew in a few between muscle and hypoderma temporarily,protect vessel branches to skinisland when myocutaneous flap was taken out.Taking first time to sufficient eduction never appeasement as soon as amassing blood,fluid and infection occurred.Fifteen cases with these complications in our group,who were cured,no kickback appeared,through active treatment in time.

    3.3  Applying key points of four myocutaneous flaps

    3.3.1  Main two systems of supplying blood to forehead flap;trochlea,supraorbital arteries and superficial temporal arteries.No matter which pedicle was used,the axis flap might be formed.Island forehead flap in our group was adopt to the system of superficial temporal arteries and the accompanying veins,which located at subskin and cling a layer compact fiber tissue under vessel; foreside range is extending part of aponeurosis epicranialis and subaponeurosis is loose connective tissue,which bleeding fewness and convenience to dissection;interior lateral is the temporal muscle membrane

    ［4］.Forehead flap tissue capacity fewness with thin,which adapt to reconstructing range in enlarging local resection and the area of dispensing with a large number of tissue as such repairing region of cheek,posteriormolar and zygomapicface as we had done it in our group.The pedicle of myocutaneous flap was passed into receiving area with the shortest approach and two tunnels;subskin tunnels of interior lateral of zygomapicarch and exterior lateral of zygomapicarch,which repairing defect areas better to the former in softhard palate and posteriormolar region,the latter in cheek and zygomapicface region.The punching defect of cheek might be repaired with the front extremity of forehead flap to be folded as a tile shape,which front extremity was formed as liner,middle and posterior extremity as exterior layer skin,it was completed at one time that the root part of the folding,whose surfaceskin was removed,sewed with front edge of punching defect,as such 3 cases with satisfaction in our group as we had done it.Author suggest:It was important signification for keeping fine supplying blood that removed partial infrazygomapicarch and the coracoid for the preventing pedicle pressed when the mandible branch remained.Resulting in large skin defect because of maxillary sinus carcinoma invaded zygomapicface skin region in 2 cases who were reconstructed with the forehead flaps,it was a pity,to had full layer necrosis,that main reason maybe binding up so tightening that supplying blood was obstructed.The largest shortness of the forehead flap was remaining obvious secondary malformation on forehead region,more and more unwilling accepted by patients in nowadays.It was according with surgical principle,as pectoralis major flap as it located at no carcinoma region,that pedicel of forehead flap did not cumber the radical treatment of carcinoma.In addition,because its specialties was not replaced wholly by other flaps,it was contributed to reconstructing range in enlarging local resection and the area of dispensing with a large number of tissue for repairing,applying of forehead flap was still considered when better flaps was not discovered and it was necessary being cautious to balance both benefit and malpractice.

    3.3.2  Supplying blood of infrahyoid flap came from branches of thyroid superior artery mainly,a fewer from branches of cricothyoid,sternocleidomastoid,superior laryngeal and tongue arteries and veins from thyroid superior vein［5］.Its tissue capacity was the same with midding defect region in size and could hook in stitching,no transplanting skin in supplying area,reconstructing mainly in region of inframandible,mouthfloor,special in foreside of tonguemouth floor in this group.The flap always revealed large tension while the flap was turn to posterior of tonguemouth floor for repairing due to the superior thyroid artery and vein were so short that it was pulled to receiving area to be more difficulty,occasionally.Literature reports［6］:We should remain the exteriorcervical vein as possible as making the flap,it could inosculate with the circumfluence vein of the flap to insure the supplying blood of the flap when necessary.Infrahyoid flaps had full necrosis in 2 cases,partial necrosis in 4 cases because of the obstruction of vein circumfluence.Author suggest:It was important that anterior and posterior branches of superior thyroid artery did not dissect so many and might be attached to the pedicle with partial thyroid,and it was better to protect the good supplying blood of the myocutaneous flap.Two of the myocutanous flaps reached receiving area very difficulty in the length because of the superior thyroid vein were shorter,but which it became possible due to increase pedicle extending when the superior thyroid vein were inosculated with exterior cervical superficial vein.Because the vasculature pedicle of the myocutaneous flap located at superior neck,as supplying blood system had to be protected,making flap may affected to the radical neck lymph node dissection in every inch.Two cases of these patients had recurrented to neck node metastasis at postoperative 10,12 mon,respectively,maybe restricted to radical neck lymph node dissection,due to take up with making flap.This flap did not suitable to choice when occurred at same region both the vasculature pedicle of the myocutaneous flap and neck node metastasis.

    3.3.3  The main supplying blood of trapezius flap comes from horizonal cervical artery and the veins going with it,which horizonal cervical artery was derived from the thyrocervical trunk artery in 58.33% and subclavian artery in 40% separately［7］,and the flap was applied to larger defects of mandible,mouth floor,tongue,laryngopharynx and parotid region in our group. According to the condition of various patients,anatomy area and range of tumor,and occasionally,we take the foreside of the flap serving as the pedicle of the flap when necessary,so the flap could be pulled to receiving region due to the vasculature pedicle of the trapezius flap was shorter and tissue capacity was more with thick.Goodwin WJ Jr(1982)reported:Because horizonal cervical vein was main circumfluence vein of the trapezius flap,which the its variance was larger than other ones,therefore,the flap necrosis that resulted to the obstruction of main circumfluence vein,was more than the ones of artery obstruction.Author think:we should prepare two schemes for the reconstruction while trapezius flap was used,in virtue of that horizonal cervical artery in a few peoples went under or inside arm plexus nerves,in addition,the flap should be give up while lower neck lymph nodes metastasis was suspected.

    3.3.4  The main supplying blood of pectoralis major myocutaneous flap comes from chest muscle branch of thoracoacromial artery and the veins accompanying it,and broad blood stream communicated with rectus abdominis and serratus anterior membrane［8］,which it might carry an island myocutaneous flap that might extend to the xiphoid process and rectus abdominis sheath.Ariyan(1979)reported:He had taken a pectoralis major myocutaneous flap overstepped pectoralis over 6 cm,which greatly prolonged vasculature pedicle,even get to the skull base and tissue capacity enrichment adopting to the larger postoperative defects in head and neck.The pectoralis major myocutaneous flap provided fine function,which might cover on carotid sheath for protecting and rectified shape malformation resulted from resect sternocleidomastoid muscle in radical neck lymph node dissection.It was very important for the neck region to receipt radical therapy at preoperation or/and postoperation［6］.The flap was mainly provided to repairing larger defects of mandible,mouth floor,tongue,laryngopharynx and parotid region in our group.We had to master moderation in size and avoided high tension to the pectoralis major myocutaneous flap while repaired the defects of the intramouth remained mandible,which intramouth overstaffing revealed while the flap overbig,could not sew up or burst open while oversmall.Three cases of these flaps revealed partial necrosis resulted from shorter pedicel and high tension.Author consider:we should remove 3 cm clavicle segment what the pedicle went over its front,which greatly prolonged the pedicle to 2~3cm,neither high tension nor functional interfering of upper limbs.  Because vasculature pedicle was easy reversed to an acute angle resulting in blood stream obstruction while ascending movement,and receiving a hard restricting of clavicle,we claimed that did not take the pedicle from subclavicle tunnel passing while clavical segment was not removed.  The tissue capacity of pectoralis major myocutaneous flap was larger than others,what it was important that we always stitched repairing region with three layer for strengthening stability of anastomosing region and preventing postoperative fistula occurred.It was propitious to radical neck lymph node dissection in every inch that the flap was the replant organ of notumor region,and more aspects were superior to other flaps in the repairing operative defects of head and neck.The shortcomings of pectoralis major myocutaneous flap were the overstaffing and difficultsculpting due to the thick chest muscle and fatness,breast shift and malformation for female,unsuitability for male with more hair chest.

    Reference

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    (编辑：侯克俭)