Application of neck anastomotic muscle flap embedded in 3-incision radical resection of oesophageal carcinoma: A protocol for systematic review and meta analysis

BACKGROUND

Oesophageal cancer is one of the most common malignant tumors and has been identified as one of the leading causes of cancer death worldwide. Surgery is considered to be the optimal treatment for patients with resectable oesophageal cancer. Oesophagectomy for oesophageal cancer can significantly extend the survival period of patients and provide a potential opportunity for a cure. However, there is still controversy regarding application of neck anastomotic muscle flap embedded. This systematic review and meta-analysis will be performed to determine whether the application of neck anastomotic muscle flap embedded would benefit patients more.

METHODS

We will search PubMed, Web of Science, Embase, Cancerlit, the Cochrane Central Register of Controlled Trials, and Google Scholar databases for relevant clinical trials published in any language before October 1, 2020. Randomized controlled trials (RCTs), quasi-RCTs, propensity score-matched comparative studies, and prospective cohort studies of interest, published or unpublished, that meet the inclusion criteria will be included. Subgroup analysis of the type of operation, tumor pathological stage, and ethnicity will be performed. INPLASY registration number: INPLASY202080059.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSION

As far as we know, this study will be the first meta-analysis to compare the efficacy of the application of neck anastomotic muscle flap embedded in 3-incision radical resection of oesophageal carcinoma. Due to the nature of the disease and intervention methods, RCTs may be inadequate, and we will carefully consider inclusion in high-quality, non-RCTs, but this may result in high heterogeneity and affect the reliability of the results.

Successful management of the supraclavicular artery island flap combined with a sternohyoid muscle flap for hypopharyngeal and laryngeal reconstruction

This retrospective study evaluated operative outcomes when using a supraclavicular artery island flap (SAIF) combined with a sternohyoid muscle flap (SHMF) to reconstruct defects after hypopharyngeal carcinoma resection. Reconstructive surgery for hypopharyngeal and laryngeal defects was performed with the SAIF + SHME combination in 6 patients during 2016 to 2018. Within 14 to 16 days after the surgery, all 6 patients could ingest food and block the tube (avoiding aspiration), with no pharyngeal fistulas. They then underwent irradiation up to a total of 60.5 Gy during the 4 weeks postoperatively. All 6 flaps survived, and there were no donor-site complications except minor dehiscence in 1 patient. Thus, the SAIF + SHMF combination can be used to reconstruct hypopharyngeal and laryngeal defects after hemi-laryngectomy in patients with hypopharyngeal carcinoma involving the unilateral larynx. This technique effectively preserved the swallowing function and phonation of the patients, thereby improving their quality of life.

A Randomized Controlled Trial Comparing Endoscopic-Assisted Versus Open Neck Tissue Expander Placement in Reconstruction of Post-Burn Facial Scar Deformities

BACKGROUND

Tissue expansion has evolved reconstruction surgery by providing a great source of additional tissue for large skin defects. Nevertheless, wide application of tissue expander reconstruction is challenging due to high complication rates and uncertainty about final outcomes. Recently, endoscopy has shown promise in reconstructive surgeries using tissue expander placement.

AIMS

This study aimed to compare outcomes between open and endoscopic-assisted neck tissue expander placement in reconstruction of post-burn facial scar deformities.

METHODS

Through a randomized clinical trial, 63 patients with facial burn scars were assigned to an open group or endoscopic group for placement of 81 tissue expanders. The complication rate, operative time, length of hospital stay, and time to full expansion were compared between the two groups.

RESULTS

Thirty-one patients were assigned to the open group and 32 patients to the endoscopic group. The average operative time was significantly reduced in the endoscopic group compared with the open group (42.2 ± 3.6, 56.5 ± 4.5 min, p < 0.05). The complication rate was significantly lower in the endoscopic group than the open group (6 vs. 16, p < 0.05). Hospital stay was also significantly diminished from 26.3 ± 7.7 h in open group to 7.4 ± 4.5 h in endoscopic group (p < 0.0001). There was a significant reduction in time to full expansion in the endoscopic group as compared with the open group (93.5 ± 10.2 vs. 112.1 ± 14.2 days, p = 0.002).

CONCLUSION

Endoscopic neck tissue expander placement significantly reduced operative time, the postoperative complication rate, length of hospital stay, and time to achieve full expansion and allowed early initiation of expansion and remote placement of the port in relation to the expander pocket.

LEVEL OF EVIDENCE I

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Videolaryngostroboscopy following Frontolateral Laryngectomy with Sternohyoid Flap

We conducted a retrospective study to analyze the videostroboscopic findings in a group of 21 patients who underwent vertical frontolateral laryngectomy with reconstruction by use of the sternohyoid muscle flap. They had T1b and T2 glottic tumors and a follow-up of more than 1 year. Three observers analyzed the recorded videostroboscopic data. The cases in which the stroboscopic evaluation of the vocal folds was incomplete were studied in regard to the clinical staging, the supraglottic hyperfunction, and the vibratory site; the Fisher exact test was applied. The glottic closure was complete in 15 individuals, and 6 had irregular vocal gaps. The site of vibration was glottic in 10 cases, supraglottic in 7, and mixed in 4. The amplitude was normal on 4 and slightly diminished on 9 preserved sides, whereas it was moderately or severely diminished on 16 and absent on 5 reconstructed sides. The mucosal wave vibratory pattern was always totally present on 15 preserved and 5 reconstructed sides: normal or slightly diminished in the preserved vocal folds, and moderately or severely diminished in the reconstructed ones. The reconstructed vocal folds had a nonvibrating portion in 5 cases. The movement extent of the preserved side was larger than that of the other side in 8 cases, and the sides were similar in 13 cases. The symmetry was regular in 18 cases. The periodicity was always or generally regular in 9 cases. There was supraglottic hyperadduction in 16 cases, with a lateral constriction predominance. The mucosal appearance was normal in 15 patients and wet in 6 patients. The epiglottis was straight in 14 cases and crescent in 7. Mucus formation was observed in 1 patient in the posterior vibratory portion. Videolaryngostroboscopy allowed thorough evaluation of the vibratory pattern of the vocal folds in 52.4% of the patients. The supraglottic hyperadduction component and the supraglottic vocal source presented difficulty for this evaluation. The site of vibration was glottic in 47.6%, supraglottic in 33.3%, and mixed in 19.1% of the cases. The vibratory pattern was diminished on both sides, but mainly on the reconstructed one.

Frey's syndrome after superficial parotidectomy: role of the sternocleidomastoid muscle flap: a prospective nonrandomized controlled trial

BACKGROUND

The prevalence of Frey's syndrome (FS) after superficial parotidectomy in correlation to the sternocleidomastoid muscle flap (SCMMF) interposition is analyzed.

METHODS

A prospective nonrandomized controlled multicenter trial included 130 patients. During superficial parotidectomy, SCMMF was dissected, if excised specimens' volume exceeded 25 mL (SCMMF group). Follow-up examinations took place after 6, 12, and 24 months and included a Minor's test.

RESULTS

SCMMF was dissected in 30 (23.1%) patients. A total of 104, 80, and 68 patients completed the 1st, 2nd, and the 3rd follow-up, respectively. FS was detectable with nonvarying prevalence (46.3%, 45.6%, and 43.4%, respectively) during follow-up. The prevalence was higher in the SCMMF group (59.9%) than in the non-SCMMF group (41.8%; P = .92). The sweating area increased during follow-up (P = .12). Overall, 89.5% of patients characterized FS as not disturbing after 2 years.

CONCLUSIONS

FS occurred with a steady and high prevalence after superficial parotidectomy. In particular, SCMMF did not lower the risk of FS.

[BIPADDLED SPLIT PECTORALIS MAJOR MYOCUTANEOUS FLAPS FOR IMMEDIATE RECONSTRUCTION OF ORAL MUCOSAL DEFECTS AND NECK DEFECTS AFTER RESECTION OF RECURRENT ORAL CANCER]

OBJECTIVE

To investigate the feasibility of the bipaddled split pectoralis major myocutaneous flap for immediate reconstruction of oral mucosal defects and neck defects after resection of recurrent oral cancer.

METHODS

Six patients with oral mucosal defects combined with neck defects after recurrent oral cancer resection were treated with bipaddled split pectoralis major myocutaneous flap between September 2013 and September 2014. There were 5 males and 1 female with an average age of 54.7 years (range, 45-62 years), including 4 cases of recurrent tongue cancer, 1 case of recurrent mandibular gingival cancer, and 1 case of mouth floor carcinoma. All patients underwent local recurrence at 8 to 14 months after first operation, with no distant metastasis. The defects of the intraoral mucosa was 4.0 cm x 2.5 cm to 6.5 cm x 3.5 cm and the defect of the neck skin was 5.5 cm x 3.5 cm to 7.5 cm x 5.0 cm. The pectoralis major myocutaneous flaps (14.0 cm x 3.5 cm to 17.0 cm x 5.5 cm) were incised at the level of the 3rd to the 4th rib, and then split down along the muscle fiber till about 2 cm away from the thoracoacromial vessels, forming 2 independent skin paddles with 1-2 branch vessels to the pedicles of the distal ones. The distal skin paddles were used for oral reconstruction while the proximal paddles for repair of neck defects. The chest donor sites were sutured directly.

RESULTS

Cervical haematoma and infection happened in 1 patient respectively after operation, and were cured after symptomatic treatment. All 6 split pectoralis major myocutaneous flaps with 12 skin paddles completely survived. All patients were followed up 6 to 18 months (mean, 11 months). One patient died of pulmonary metastasis at 8 months after operation and the other 5 survived without relapse or metastasis during follow-up. The intraoral paddles showed good shape with satisfactory speech function and swallowing recovery. The paddles also healed perfectly on the neck with flat outlooks, and all patients obtained full appearance and free movement of the neck. No fistula formed on the submandibular region and neck.

CONCLUSION

The bipaddled split pectoralis major myocutaneous flap can complete simultaneous immediate reconstruction of oral mucosal defect and neck defect. It is very useful in the treatment of recurrent oral cancer.

The platysma myocutaneous flap

Reconstructing defects of the oral mucosa or skin of the lower one-third of the face can be accomplished by a variety of techniques. This article presents two versions of the platysma myocutaneous flap, which is a reliable, axial pattern, pedicled flap capable of providing excellent one-stage reconstruction of such defects. As discussed herein, the superiorly based and posteriorly based versions of the flap have wide application in the oral and facial region. Also provided is a review of other uses of this flap in head and neck surgery.

Use of a sternocleidomastoid myocutaneous flap based on the sternocleidomastoid branch of the superior thyroid artery to reconstruct extensive cheek defects

INTRODUCTION

Reconstruction of head and neck defects has always been challenging due to functional and cosmetic concerns. Although sternocleidomastoid (SCM) flaps have been used for many head and neck defects, use of an SCM flap to reconstruct a cheek defect based only on the superior thyroid artery has not been reported previously.

CASE REPORT

The case of a 40-year-old farmer with a large full-thickness cheek squamous cell carcinoma is reported. An SCM myocutaneous flap based on the SCM branch of the superior thyroid artery was used.

CONCLUSION

An SCM myocutaneous flap is a valuable option for head and neck reconstructions with reasonable aesthetic results. For properly selected cases, this flap obviates the need to use the pectoralis major or other more distant flaps.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Vertical trapezius myocutaneous flap for repairing soft tissue defect after head and neck tumor resection]

OBJECTIVE

To introduce the experience of the clinical application of vertical trapezius myocutaneous flap in repairing soft tissue defects after head and neck tumor resection.

METHODS

Between June 2008 and February 2010, 12 cases of soft tissue defect caused by head and neck tumor resection were repaired with vertical trapezius myocutaneous flap. There were 9 males and 3 females with an age range from 32 to 76 years (median, 54 years). Twelve cases including 2 cases of basal cell carcinoma of orbital skin, 2 cases of squamous cell carcinoma of the parotid gland, 2 cases of submandibular gland malignant mixed tumor, 2 cases of metastatic lymph nodes of nasopharyngea carcinoma after radiotherapy, 1 case of squamous cell carcinoma of tongue, and 3 cases of squamous cell carcinoma of occipital skin, and all were classified as TNM stages T3 or T4. The area of soft tissue defect ranged from 13 cm x 6 cm to 25 cm x 13 cm. The vertical trapezius myocutaneous flap ranged from 14 cm x 7 cm to 26 cm x 14 cm and was transferred to repair defect tissue in the homolateral wounds after tumor resection and neck dissection homochronously. The donor sites were sutured directly.

RESULTS

All incisions healed primarily without infection. Eleven flaps survived except 1 flap with edge necrosis, which was cured after dressing change. Subcutaneous hematocele and effusion occurred in 2 cases on the back after tube was removed at 7 days postoperatively, and they were cured by sucked and pressured dressing. Eleven patients were followed/up 1-3 years (mean, 2 years). Nine cases had no tumor recurrence and the flaps had satisfactory appearance; the abduction function of shoulder joint were normal. One case of orbit basal cell carcinoma occurred 3 months after operation and 1 case of nasopharyngeal carcinoma died of brain metastasis 12 months after operation.

CONCLUSION

It is an easy and simple therapy to repair head and neck soft tissue defect using the vertical trapezius myocutaneous flap, which can meet the needs of repairing tissue defect of head and neck.

[The platysma myocutaneous flap (PMF) for reconstruction of defects after extended parotidectomy]

In order to reestablish the facial symmetry after the tumor removal, we can use sternocleidomastoid muscle transposition, dermis-fat graft, superficial musculoaponeurotic system (SMAS) plication, temporoparietal fascia flaps, microvascular free flaps and the platysma muscle flap. The technic depends on the size of the defect.

MATERIAL AND METHODS

In this study we present our results of using a superiorly based platysma myocutaneous flap for reconstruction of defects after extended parotidectomy. The patients were treated for malign tumor of parotid gland which invaded the skin.

RESULTS

All flaps were readily harvested at the time of tumor resection. Only two patients presented venous congestion. No flap was lost. There was no morbidity of donor site. The cosmetic outcome was satisfactory.

DISCUSSION

The platysma myocutaneous flap is an alternative to more complex reconstructive technics, such as free flap transfer, and gives a satisfactory cosmetic result.

CONCLUSIONS

The platysma myocutaneous flap is easy to harvest and has low donor site morbidity. The main disadvantage is represented by the vascularity problems.

[The clinical application of parotid fascia-SMAS-platysma flap in the lifting of lower face and neck]

OBJECTIVE

To investigate the technique of lower face and neck lifting with parotid fascia-SMAS-platysma flap.

METHODS

To improve the lifting strength of SMAS and the cosmetic result, the traditional SMAS-platysma flap was modified as parotid fascia-SMAS-platysma flap. The modified flap was folded and suspended step by step to lift the lower face and neck.

RESULTS

From Oct. 2004 to Oct. 2008, 78 patients were treated with this method. The patients' age ranged from 40 to 65 years old. There were 2 cases of male and 76 cases of female. All the patients were followed up for 6 months to 4 year with satisfactory results.

CONCLUSIONS

Folding and suspension of the parotid fascia-SMAS-platysma flap step by step can effectively lift the saggy tissue of lower face and neck.

[Lower trapezius myocutaneous flap for repairing defects in head and neck region]

OBJECTIVE

To evaluate the anatomy basis and clinical effects of the lower trapezius myocutaneous flap to reconstruct defects in the head and neck.

METHODS

From Jan. 2000 to Jan. 2004, lower trapezius myocutaneous flaps which were used to reconstruct the defects in the head and neck after radical tumors resection in twenty four cases in Center of Craniomaxillofacial Surgery of the Second Affiliated Hospital of Sun Yat-sen University were analyzed retrospectively. Male was 14,female was 10. Ages ranged from 35 to 76 (median = 54). The causes of the defects were malignant neoplasm of the tongue (n = 10), buccal (n =4), oral floor (n = 2), parotid (n = 1 ), oropharynx (n = 2), gingiva (n = 3), maxillary sinus (n = 1), zygomatic and frontal part (n = 1). Fifteen patients were primary, nine patients were recurrent. The flaps ranged from 8 cm x 7 cm to 12 cm x 10 cm.

RESULTS

Twenty one flaps survived fully and the other three had partial necrosis at the distal portion. Twenty two donor sites were closed primarily. Follow up 6 to 24 months, all flaps were good, the texture and color of the flaps were satisfying.

CONCLUSIONS

Lower trapezius myocutaneous flap is a thin, pliable and simple myocutaneous with a long pediculi and wide arc of rotation, and it is preferred for reconstructing huge soft-tissues defects in the head and neck regions simultaneously.

[Treatment of scar contracture abnormality on the neck of the children with huge trapezius muscle flap expanded]

OBJECTIVE

To seek a kind of safe and effective method to treat scar contracture abnormality on the neck of the children.

METHODS

We take the trunk line of transverse cervical artery as the vessel pedicle, and shift huge trapezius muscle flap expanded to the neck in order to treat scar contracture abnormality on the neck of the children.

RESULTS

Clinically, we applied this method to treat ten children who suffered from contracture abnormality on the neck, and not only provide enough skin soft tissue (the length may be beyond the midline) to treat the abnormality, but also make the flap alive, obtain the satisfying postoperative effect.

CONCLUSIONS

Based on the warranty of the flap blood supply, this flap is very suitable to treat scar contracture abnormality on the neck of the children.

[Myocutaneous platysma flap containing external jugular vein for the oral reconstruction after cancer excision]

OBJECTIVE

To improve the blood circulation of myocutaneous platysma flap and its survival rate.

METHODS

There were seventeen oral cancer patients in this group. After the tumor excision, the oral defect was reconstructed with myocutaneous platysma flap which had submandibular pedicle and contained external jugular vein.

RESULTS

There was no any circulation compromise in this group. The survival rate of the flap was 100% . Two cases encountered oral-facial fistula but were cured by dressing change.

CONCLUSIONS

Preserving and containing the external jugular vein in the flap is helpful for improving the blood circulation of the myocutaneous platysma flap and making its survival rate higher.

The Superiorly Based Platysma Flap for Oral Reconstruction in Conjunction With Neck Dissection: A Case Series

PURPOSE

The purpose of this study was to access the reliability and use of the superiorly based platysma flap for reconstruction of small and medium oral defects.

PATIENTS AND METHODS

This case series consists of 5 patients who were reconstructed with a superiorly based platysma flap for defects of the following oral region: buccal mucosa, floor of the mouth, and lateral gingiva. The flaps were monitored for complications, including skin loss and ischemia in the postoperative period.

RESULTS

Three patients (60%) had some skin sloughing in the recipient site. None of the patients had complications in the donor site.

CONCLUSION

The superiorly based platysma flap can survive after the facial artery has been ligated, which is the normal procedure during neck dissection. If skin sloughing occurs, it is usually inconsequential for intraoral reconstruction because the underlying muscle remains viable and undergoes epithelialization.

The ansa cervicalis revisited

Recurrent laryngeal nerve paralysis represents a major complication in oesophageal cancer surgery. Nerve-muscle transplantation to the paraglottic space after resection of the recurrent laryngeal nerve with the ansa cervicalis (AC) has recently become the procedure of choice. The aim of this study was to investigate the anatomical variations of AC in order to avoid iatrogenic injuries and facilitate surgical procedures. We examined 100 adult human formalin-fixed cadavers. The ansa cervicalis showed a great degree of variation regarding origin and distribution. The origin of the superior root of AC was found to be superior to the digastric muscle in 92% of the cases. Its vertical descent was found to be superficial to the external carotid artery in 72% and superficial to the internal carotid artery in 28% of the specimens. The inferior root of AC was derived from the primary rami of C2 and C3 in 38%, from C2, C3 and C4 in 10%, from C3 in 40% and from C2 in 12% of the cases. The inferior root passed posterolaterally to the internal jugular vein in 74% and anteromedially in 26% of the cases. The roots of AC were long (70%) or short (30%), and the union between the two roots was situated inferior or superior to the omohyoid. Not only is knowledge of the anatomy of the ansa cervicalis important for nerve grafting procedures, but surgeons should be aware of AC and its relationships to the great vessels of the neck in order to avoid inadvertent injury during surgical procedures of the neck.

Repairing Esophageal Perforations With a Transverse Cervical Musculofascial Flap

OBJECTIVES/HYPOTHESIS

Although rare, perforations of the esophagus following spinal surgery via an anterior approach are serious life-threatening problems. Complications include abscess formation, mediastinitis, sepsis, and fistula that can carry a mortality rate of 20%-50%. Early diagnosis and treatment are imperative. A common method of repair is isolation and primary repair of the defect in the esophagus, with interpositional muscle coverage. A transverse cervical myofascial artery flap is described here as a potential reconstructive option.

STUDY DESIGN/METHODS

Retrospective review was performed on 3 patients who had repair of esophageal perforations following spinal surgery with an anterior approach.

RESULTS

In all 3 cases, hardware was found to be eroding through the esophagus. The hardware was removed at the time of repair and flap coverage in 2 patients, and each went on to an oral diet within 10 days without complication, with follow-up exceeding 6 months. A third patient with recurrent erosions could not have the hardware removed and subsequently suffered with another erosion through the muscle flap. A secondary surgery with pectoralis flap coverage was successful but required revision surgeries for flap debulking. No patients had limitation of shoulder movement after flap reconstruction, and all went on to a normal diet without dysphagia.

CONCLUSIONS

The transverse cervical artery musculofascial flap can be an ideal method for repair of small cervical esophageal perforations, although spinal hardware should be removed if felt to be the etiology of the perforation.

[Clinical analysis about survival condition of different types of platysma myocutaneous flaps]

OBJECTIVE

To compare the postoperative outcome among different types of platysma myocutaneous flaps by reviewing 54 cases.

METHODS

From 1984 to 2004, 54 patients with oral cancer underwent immediate reconstruction of intraoral defects using the platysma myocutaneous flaps. In 54 cases, 12 cases were transversal platysma myocutaneous flaps and the other 42 cases were vertical platysma myocutaneous flaps. In these 42 cases, 26 cases preserved facial artery and vein yet 16 cases didn't preserve them. The survival condition of these flaps were compared.

RESULTS

In the 12 cases of transversal platysma myocutaneous flaps, 10 cases survived totally and 2 cases had partial necrosis. In the 26 cases of vertical platysma myocutaneous flaps preserved facial artery and vein, 23 cases survived completely and 3 cases had partial necrosis. However, in the 16 cases of vertical platysma myocutaneous flaps in that facial artery and veins were not preserved, 10 cases survived completely, whereas 4 cases had partial necrosis and 2 cases had complete necrosis.

CONCLUSIONS

The survival rates of platysma myocutaneous flaps that didn't preserve facial artery and vein were low. Its clinical use should be prudent.

[Application of platysma flap in face lifting]

OBJECTIVE

To introduce a safe and simple method to improve the effect of face lifting.

METHODS

During face lifting three anatomic dissection was applied. All the cases were performed with transferring the SMAS flap from the anterior ear to the posterior and fixing platysma flap with deep fascia of mastoid region, then removed fixed and sutured skin flap.

RESULTS

12 cases with satisfying effect were followed up for 6 - 12 months. No complications were found such as facial nerve injuring.

CONCLUSION

The application of pedicle SMAS flap and platysma flap in face lifting is simple and safe.

Anatomy of the platysma muscle and the evaluation of it for the reconstruction of facial defects

Reconstruction of the defects with various flaps is the main issue in plastic and reconstructive surgery. Tissues used for the repair of the defects of the face should be convenient for this most important aesthetic unit. Color, elasticity, and volume of the transferred tissues have the utmost importance for successful results. Platysma muscle flap appears to be a good alternative method for the reconstruction of the facial defects. Anatomic dissections on five fresh cadavers for the evaluation of the vascular structures and 11 clinical cases of reconstruction of the defects of the face and the neck with platysma muscle and musculocutaneous flaps are performed in this study to evaluate the efficacy and reliability of platysma flaps. Cadaveric dissections were performed on the face and the neck regions on both sides. Eleven patients with various defects on the face and the upper neck regions were surgically treated: three transverse cervical artery-based transverse musculocutaneous platysma flaps, seven facial artery-based vertical musculocutaneous platysma flaps, and one superior thyroidal artery-based platysma muscle flap were used for the repairs. The patients ranged in age from 42 to 74 years. The defects measured 2x3 cm to 6x9 cm and the flaps 3x3 cm to 7x10 cm. The follow-up periods were 2 to 21 months. Postoperative venous congestion between the 5th and 9th days was observed in seven patients. One patient had infection of the donor site, and another had infection of the recipient site; both recovered with systemic and topical antibiotherapy. Partial flap loss occurred in one patient. Our study concluded that platysma flaps showed sufficient tissue match with successful results for the reconstructive procedures of facial defects.

Laryngeal reconstruction by platysma myofascial flap after vertical partial laryngectomy

BACKGROUND

Many methods of glottic reconstruction have been described for patients undergoing vertical partial laryngectomy to reestablish the glottic integrity.

METHODS

Fifteen patients with T2 squamous cell carcinoma of the glottis were included in this prospective clinical trial. All patients were treated by vertical partial laryngectomy with laryngeal reconstruction by platysma myofascial flap. The surgical procedure and flap design were described. Vocal function was assessed by videolaryngostroboscopy and subjective and objective voice analysis before and after surgery.

RESULTS

Complete neoglottic closure and acceptable voice quality were obtained by platysma myofascial flap in all cases. No statistically significant difference was found between the preoperative and postoperative acoustic parameters.

CONCLUSIONS

Platysma myofascial flap provides the basic requirements for laryngeal reconstruction with its own favorable characteristics and also allows complete glottic closure without interfering with respiration and deglutition. This technique may be an effective alternative achieving an acceptable quality of voice.

Two designs of platysma myocutaneous flap for reconstruction of oral and facial defects following cancer surgery

This study evaluates the effects of two different designs of platysma myocutaneous flap, vertical and transverse, used in the reconstruction of defects following the excision of oral and facial tumors. Modified radical neck dissection or selected neck dissection was also performed. Out of the 48 patients, vertical and transverse platysma myocutaneous flaps were used for 41 and 7, respectively. The postoperative outcome for the vertical flaps was 37 cases surviving, two cases of complete necrosis, and two cases of partial necrosis. With the transverse flaps, six survived and there was one case of complete necrosis. The success rate was 90.2% and 85.7% for the vertical and the transverse flap, respectively. The form and function of recipient sites were well recovered. In conclusion, the platysma myocutaneous flap has clinical value in selected patients needing reconstruction of small and medium-sized intraoral or facial defects. It is recommended that the vertical design be used for reconstruction of buccal mucosa defects, and the transverse design for mouth-floor and facial defects.

[The restoration of chronic facial paralysis with a modified technique of sternocleidomastoid muscle transposition]

OBJECTIVE

To evaluate a modified technique of sternocleidomastoid muscle transposition for the dynamic reanimation of the chronic facial paralysis.

METHODS

Both of the sternal and cleidus extremities of the sternocleidomastoid muscle were elevated from their bony attachment. The mastoid extremity was left in the place as a pedicle for the blood supply. The muscle stripes were then transposed into the face through the tunnel under the skin and the ends were sutured to the opposite orbicularis oris muscle of the upper and lower lips to correct the deformity of the mouth and nose.

RESULTS

Forty-four patients with the chronic facial paralysis had successfully been treated by using the above-mentioned technique. The static asymmetry of mouth corner and the independent oral activity of the paralyzed side were corrected without any failure. With the follow-ups up to 3 years, the results were satisfied.

CONCLUSIONS

The chronic facial paralysis with the deformity of the mouth and nose could be corrected with the sternocleidomastoid muscle transposition technique. A part expression of the mouth could also be achieved.

[Application the sternocleidomastoid muscle-great auricular nerve flap in radical parotidectomy]

OBJECTIVE

To study a new method for repair of facial depression and facial nerve defect after parotid carcinoma resection.

METHODS

12 patients with parotid carcinoma and peripheral bone invasion were treated using facial nerve canal dissection and radical resection of the tumor, the parotid gland and the involved facial nerve and bone, including the mastoid, stylomastoid foramen, styloid process and the rear part of the mandible. A sternocleidomastoid muscle flap was elevated and transferred to repair the facial depression. The great annular nerve in the flap was anastomosed with the severed end of the facial nerve in the canal.

RESULTS

The depressed deformity of the parotid area was well corrected in 9 patients. The aesthetic results were compromised in 2 patients because of tumor recurrence and reoperation. The depressed deformity was not corrected in 1 patient because of infection. Postoperatively, the function of the facial nerve recovered to a normal level. The recovery time ranged from 12 to 20 weeks ,with an average of 16.3 weeks. The local control rate of tumor was improved.

CONCLUSIONS

Immediate transplantation of the sternocleidomastoid muscle-great auricular nerve flap and facial nerve canal dissection in radical parotidectomy can repair the depressed deformity of the parotid area, restore facial nerve function,and decrease tumor recurrence. The method is an ideal operation with functional recovery.

Sternocleidomastoid myocutaneous flap for intraoral reconstruction after resection of oral squamous cell carcinoma

PURPOSE

The sternocleidomastoid (SCM) myocutaneous flap remains an important tool in head and neck reconstruction. This article retrospectively reviews 40 consecutive SCM myocutaneous flaps used for the reconstruction after resection of oral squamous cell carcinoma with respect to reliability and complications.

PATIENTS

From 1987 to 1997, 40 patients underwent SCM myocutaneous flap reconstruction of the oral cavity. The age and gender of the patients, site of primary tumor TNM stage, type of associated operation, and clinical course were analyzed.

RESULTS

In 8 cases, partial epithelial loss over the skin paddle occurred with survival of the muscle and at least some of the dermis. Unilateral supraomohyoid neck dissection (SND) was performed in 11 cases, and unilateral functional neck dissection, which preserves SCM and/or internal jugular vein and/or accessory nerve, in 16 cases. Pathologically positive nodes were recognized in 14 of these 27 neck dissection cases; in 11 of these 14 cases, the neck lesion was controlled.

CONCLUSION

The SCM myocutaneous flap appears to be simple to use and useful for reconstruction of the defect after resection of oral carcinoma, and the indications for this flap will be extended in accordance with the recent increases in the number of supraomohyoid and functional neck dissection cases.

The posteriorly based platysma flap in oral and facial reconstruction: A case series

PURPOSE

The purpose of this study was to assess the reliability and use of the posteriorly based platysma flap for oral and facial reconstruction.

PATIENTS AND METHODS

This case series consists of 7 patients who were reconstructed with a posteriorly based platysma flap for various tumor resection defects of the oral and facial region. The flaps were monitored for complications, including skin loss and ischemia in the postoperative period.

RESULTS

Three of the patients (43%) in this study had no complications. Three patients (43%) had some skin sloughing, but the underlying muscle remained viable and mucosalized normally. One patient (14%) had 40% flap loss of the distal end, possibly due to vascular compromise that occurred during a concomitant neck dissection.

CONCLUSION

The posteriorly based platysma flap is a reliable reconstruction option for defects in the facial and oral region. If skin sloughing occurs, it is usually inconsequential for intraoral reconstruction as the underlying muscle remains viable and undergoes epithelialization.

Anterior belly of digastric muscle transfer: a useful technique in head and neck surgery

BACKGROUND

Permanent loss of the marginal mandibular branch of the facial nerve (MMBFN) may result from an inadvertent injury or an intentional sacrifice during tumor resection. This may occur in isolation or as a part of total facial nerve palsy. The loss of the MMBFN results in paralysis of the depressors of the ipsilateral lower lip with troublesome cosmetic and functional deficits.

METHOD

A series of 14 patients with permanent loss of the MMBFN during resection of head and neck tumors were treated with the anterior belly of digastric muscle transfer (ABDMT). The loss of the MMBFN occurred in isolation in five patients and formed a part of total facial nerve palsy in nine. Immediate reconstruction was performed on nine patients, and it was done as a secondary procedure in the remainder. Two patients in the latter group had prior facial reanimation, although the paralyzed lower lip was not reconstructed.

RESULTS

The average follow-up period was 23.2 (range, 3-48) months. Satisfactory results were achieved in all of the patients, although revision of the ABDMT was required in one patient.

CONCLUSIONS

ABDMT is a simple and reliable reconstructive technique for restoring the depressor function of the lower lip resulting from MMBFN palsy. It is the treatment of choice during primary extirpative surgery for head and neck tumors when the MMBFN requires sacrifice for tumor clearance or is inadvertently injured. The reconstructive options for MMBFN palsy, particularly in the absence of the anterior belly of digastric muscle, are discussed.

Surgical closures of oropharyngocutaneous fistulas

Of the 146 patients undergoing surgery for oropharyngeal cancer in our institution, 12 (8.2 percent) developed fistulas. As a first line of therapy, conservative measures were used, which consisted of debridement, Xeroform gauze packing, and nasogastric feeding. Seven fistulas closed after conservative treatment. Of the five patients who required surgery for fistula closure, three had large (more than 20 mm) and two had mid-size (5- to 20-mm) fistulas. In all cases, internal flaps were prepared from the healthy viable tissues surrounding the fistula, and sternocleidomastoid-trapezius-platysma myocutaneous flaps were used for external closure. None of the closures failed, and we obtained good functional and aesthetic results.

[Pharyngeal closure after pharyngolaryngectomy]

Pharyngolaryngectomy was performed in 53 patients. In 36 patients pharynx defect was less than 50% of pharynx circumference and it was closed without reconstruction. Larger pharynx defects were closed using platysma myocutaneous flap (13 cases), pectoralis mayor flap (3 cases) and free forearm flap with microvascular anastomosis (1 case). Healing results are presented in each group of patients.

The platysma myocutaneous visor flap for intraoral reconstruction. A case report

The use of a modified myocutaneous platysma flap is presented for a patient with a large ameloblastoma of the mandible. The possible advantages and limitations of the technique are discussed.

Use of a platysma myocutaneous flap for the reimplantation of a severed ear: experience with five cases

CONTEXT

The traumatic loss of an ear greatly affects the patient because of the severe aesthetic deformity it entails. The characteristic format of the ear, with a fine skin covering a thin and elastic cartilage, is not found anywhere else in the human body. Thus, to reconstruct an ear, the surgeon may try to imitate it by sculpting cartilage and covering it with skin.

OBJECTIVE

To use a platysma myocutaneous flap for the reimplantation of a severed ear in humans.

DESIGN

Case report.

SETTING

Emergency unit of the university hospital, Faculty of Medicine, Ribeirão Preto - USP.

CASE REPORT

Five cases are reported, with whole ear reimplantation in 3 of them and only segments in 2 cases. The surgical technique used was original and was based on the principle of auricular cartilage revascularization using the platysma muscle. We implanted traumatically severed auricular cartilage into the platysma muscle. The prefabricated ear was later transferred to its original site in the form of a myocutaneous-cartilaginous flap. Of the 5 cases treated using this technique, 4 were successful. In these 4 cases the reimplanted ears showed no short- or long-term problems, with an aesthetic result quite close to natural appearance. In one case there was necrosis of the entire flap, with total loss of the ear. The surgical technique described is simple and utilizes the severed ear of the patient. Its application is excellent for skin losses in the auricular region or for the ear itself, thus obviating the need for microsurgery or the use of protheses or grafts.

Platysma myocutaneous flap for intraoral reconstruction: an option in the compromised patient

The platysma myocutaneous flap is an infrequently used flap in head and neck reconstruction. This flap should be considered for reconstruction of small and medium-sized defects of the oral cavity. We present two cases demonstrating the utility of this local flap in reconstruction. Advantages, contraindications and limitations of the platysma myocutaneous flap are discussed.

Selective role of partial XI-VII anastomosis in facial reanimation

OBJECTIVES

Review techniques available for transposition of an alternative motor neuron if end-to-end anastomosis or interposition nerve grafting cannot be accomplished when there has been a complete facial nerve loss. Describe the selective use of a partial spinal accessory-facial nerve anastomosis and highlight cases when this may be a useful alternative. Describe the modifications of decompression of the facial nerve for tension-free anastomosis and the use of the muscle pedicle for repair of cerebrospinal fluid leakage.

STUDY DESIGN

Report of three cases and a review of the literature.

METHODS

Charts were reviewed and indications for the procedure were analyzed. The degree of facial movement was recorded as well as the resolution of any cerebrospinal fluid leak.

RESULTS

The results varied between Class III and Class IV on the House-Brackmann scale following initial complete paralysis. In the two cases in which spinal fluid leakage had occurred before surgery the leakage was resolved. No donor site morbidity was noted.

CONCLUSIONS

The potential of low morbidity associated with the use of the sternocleidomastoid branch, along with the potential for delivering a vascularized muscle pedicle to the temporal bone region, makes selective use of this procedure a valuable addition to the multiple reconstruction options for the paralyzed face.

Strap muscle neurovascular supply

OBJECTIVES/HYPOTHESIS

Knowledge and preservation of the neurovascular supply to strap muscles, such as the sternohyoid (SH) muscle, used in laryngotracheal reconstruction are important in preventing loss of tissue and bulk from ischemia and/or denervation.

STUDY DESIGN

Arteriovenous and neural supply variations to the strap muscles were examined in cadaver specimens.

METHODS

Strap muscle neurovascular supply was studied in 16 cadavers, including one transparent corrosion cast specimen with injected vessels.

RESULTS

For the upper SH and upper belly of the omohyoid (OMO), the arterial supply consistently arose from a branch of the superior thyroid artery (STA) most commonly terminating at the cricothyroid membrane. The inferior SH was supplied by the inferior thyroid artery. The ansa cervicalis innervated the SH inferiorly with a branch below the loop. Each arterial branch to the muscles had an accompanying venous tributary. The corrosion cast specimen demonstrated that the arterial lumen diameters were almost threefold larger in branches entering the upper SH, compared with the lower SH or OMO. Small intramuscular arteries without axial supply were found within the middle third of the upper SH, the lower SH, and the upper OMO.

CONCLUSIONS

It is possible to preserve neurovascular integrity in an inferiorly based SH flap. The superior and medial borders are released, with dissection of vascular supply laterally and deep to the muscle, and preservation of the inferior terminal ansa branch.

Infrahyoid myocutaneous flap in reconstructive maxillofacial cancer and trauma surgery

We report the use of an island infrahyoid myocutaneous flap, pedicled on the superior thyroid vessels, in a group of 21 patients. This flap allows reconstruction of intraoral defects or defects of the lower portion of the face, as large as 10 x 4 cm. We used it in 15 cases to repair parts of the oral cavity, after tumour resection, in 2 patients with mandibular osteoradionecrosis and in 4 patients with gunshot injuries. Among the 21 flaps, no muscular necrosis was observed; however, 4 total necrosis and 4 partial necrosis (< or = 25% of the skin area) of the skin paddle were recorded. Loss of the skin paddle was primarily attributable to the anatomical variations of the veins draining this flap.

The longus colli muscle flap for reconstruction of the lateral pharyngeal wall

BACKGROUND

Full-thickness lateral pharyngeal wall (LPW) defects are difficult to reconstruct, whether the larynx is preserved or removed (extended total laryngectomy). A simple, reliable reconstructive method using local tissue which optimizes wound healing and functional results would allow partial laryngectomy more often, without incurring the cost, donor site morbidity, and increased operative length of regional or free flaps. My objective was to propose use of the longus colli muscle as a reconstructive flap for defects of the LPW.

METHODS

Results of using the longus colli muscle flap (LCMF) in a series of 16 patients with primary tumors of the pharyngeal wall or pyriform sinus are presented. The majority had surgery and planned postoperative radiotherapy.

RESULTS

There were no wound infections or fistulas. One of 2 previously radiated patients had a transient wound-healing problem. Although 88% of the patients were stage III and IV and 50% had T3-4 primary tumors, there were only 2 local failures, for a local control rate of 88%. Corresponding cancer-free survival was 69% (median follow-up of 22 months). Two thirds of the patients took all or some food by mouth, and of the 12 with larynx preserved, 58% were decannulated, and 11 had a good to normal voice.

CONCLUSIONS

The reliability of wound healing and absence of negative impact on oncologic and functional results validate use of the LCMF as a reconstructive option for defects in the LPW at both the oropharynx and hypopharynx levels.

Vocal function following vertical hemilaryngectomy: comparison of four reconstruction techniques in the canine

The goals of laryngeal reconstruction have been prevention of aspiration, production of a functional voice, and maintenance of an adequate airway for decannulation. A number of procedures for partial laryngeal reconstruction have accomplished these objectives. However, few studies have attempted to compare patients' vocal characteristics following different reconstruction procedures. In this study, an in vivo canine model was used to compare acoustic and aerodynamic measures of vocal function for the following vertical hemilaryngectomy reconstruction techniques: 1) a superiorly based sternohyoid muscle flap, 2) a modified epiglottic laryngoplasty, 3) a new procedure using a layered vascularized buccal mucosal flap and a transversely oriented sternohyoid muscle flap, and 4) hemilaryngeal transplantation combined with arytenoid adduction. Hemitransplantation provided the most efficient phonation of the four techniques. The vascularized buccal mucosa flap produced the best phonation of the autologous tissue techniques examined. Both vascularized buccal mucosa flap and hemilaryngeal transplantation subjects demonstrated a mucosal wave on stroboscopy. The results indicate that vocal function will improve as the layered structure of the vocal fold is more accurately replicated in a reconstructed hemilarynx. Endoscopic findings and whole organ sections are presented.

Use of muscle flap to cover infections of the carotid artery after carotid endarterectomy

Wound infection after carotid endarterectomy is an extremely uncommon complication. This complication occurred in two of our patients in a series of 170 consecutive carotid endarterectomies over the last 3 years. There has been an increased use of prosthetic patch grafts to close carotid endarterectomy sites. However, the presence of infection in the setting of prosthetic graft material poses difficulties in management and may lead to life-threatening complications. Recent strategies for the management of wound infections (in cases where the artery/graft interface is intact) include the use of appropriate antibiotics, repeated wound debridement, and covering the tissue defect or the perigraft area with well-vascularized muscle flap. In this case report the use of sternocleidomastoid muscle flap as a coverage for the infected area is described. The use of sternocleidomastoid muscle flap helped control the infective process and secured the viability of the patched carotid arteries.

Platysma Myocutaneous Flap: Use for Intraoral Reconstruction

Twenty patients were treated for intraoral epidermoid carcinoma with a single-stage reconstructive technique using a myocutaneous flap based on the platysma muscle. This flap carries on its distal tip a portion of isolated cervical skin to be used for intraoral replacement of the resected tissue. The superior vascular pedicle, the submental branch of the facial artery, was used. The platysma skin flap will survive if the blood supply from at least one region is preserved. In addition, it may be beneficial to include the external jugular and/or the communicating veins in the flap. Only three minor complications were seen and healed spontaneously. The flap has proved to be highly reliable and has significant benefits over many other techniques commonly used for head and neck reconstruction. (Otolaryngol Head Neck Surg 1997;116:493–6.)

Midface soft tissue reconstruction with the facio-cervico-pectoral flap

The reconstruction of large soft tissue defects in the orbital and maxillomalar region is a difficult task. A good functional and aesthetic result has to be achieved. The cervicopectoral rotation flap has many advantages; it is easy, rapid and safe to harvest, compatible with cervical dissection and radiotherapy. It is an anatomical unit, with skin properties similar to the rest of the facial skin. This is our pedicle flap of choice for large soft tissue defects in the midface, specially in elderly patients. We use it in association with the temporalis myofascial flap in cases of orbital exenteration. In large defects, the alternatives to these flaps are microsurgical free flaps or other pedicled flaps. These flaps require more complex techniques, are time consuming surgically, have greater morbidity and equal or worse functional and aesthetic results. In this paper we present our experience. Twenty-two patients with large soft tissue defects in the maxillomalar and orbital regions have had reconstructions with these flaps (facio-cervico-pectoral rotation flap and temporalis myofascial flap) in the last 8 years.