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Stepladder reconstructive options in post-ablative complex surgical defects in the head and neck
Abstract
Reconstruction of head and neck defects can pose many challenges to the reconstructive head and neck surgeon. Achieving the best cosmetic and functional results without compromising the safety of oncologic surgery are the primary reconstructive goals. Speech and articulation are particularly important in oral reconstructive procedures. In addition, preservation of the integrity and function of the donor sites should always be considered in all reconstructive procedures.
The aim of the study is to evaluate different reconstructive options in complex defects of the head and neck region after resection of malignant tumours. The feasibility of the reconstructive ladder starting from simple techniques such as local flaps and skin grafts up to free flaps will be assessed.
In this study we evaluated different reconstructive procedures used in 50 patients with complex head and neck defects undertaken at the department of surgery at the National Cancer Institute between July 2003 and December 2007.
The average age of patients was 52 years and the range was 26-67 years. Most of the tumours were either squamous cell carcinoma (74 %) or Basal cell carcinoma (20 %). Tumour sites included the nose (6 %), lip (10 %), cheek (12 %) scalp (6 %) as well as mucosal defects of the oral cavity (40 %) and the hypopharynx (20 %). We used local flaps and skin grafts in reconstruction in 36 % of cases and pedicled flaps in 32% while free flaps were used in 32 % of cases. Complications occurred in 32 % of patients of which total flaps loss constituted 6 % and partial flap loss 4 %. Minor complications such as oro-cutaneous fistulae, wound infection, seroma and haematoma were noticed in 22 % and all of them were treated conservatively. The final functional and aesthetic results were satisfactory in 60% of cases while poor results were encountered in patients who suffered some degree of flap loss. KEY WORDS: Head and neck reconstruction - Pedicled flaps - Free flaps.
Introduction:
Defects of the scalp arise from several aetiologies including trauma, burn, injury, infection, radiation and surgical excision of tumours. Multiple options for reconstruction of scalp defects exist that included primary closure, skin grafts, local flaps, regional and distal free flaps.
Patients and methods:
This was a prospective case-series study, which was carried out in the Department of Plastic Surgery of our Hospital. Step flap was used for small (2.5 cm × 2.5 cm) scalp skin defects reconstructions after skin tumour ablations. In this 2 years study, 15 patients (7 female , 8 male), ranging from 40 to 72 years (mean, 53 years), underwent an operation with local step flap for reconstruction of scalp defects caused by basal cell carcinoma or squamous cell carcinoma excision.
Results:
The patients who present with small scalp malignant tumours need complete resection and perfect reconstruction. This study showed that step flap with sufficient releasing was an effective method for reconstruction of small scalp defects due to skin malignancies. We had no case of flap complications such as ischaemia or necrosis.
Conclusion:
We recommend this local flap (z-flap) as a new approach for small scalp defect reconstruction in all areas of hair-bearing scalp.
Few published large series have described a surgical approach to maxillary skeletal reconstruction on the basis of the extent of maxillectomy.
We have reviewed a 10-year experience with 38 consecutive maxillary reconstructions with respect to maxillectomy defects, reconstructive procedures, reconstructed buttresses, and functional and aesthetic outcomes.
Maxillectomy defects were classified into three categories on the basis of the buttress concept. Buttress reconstruction was most frequently performed in category III maxillary defects (56%), followed by category I (50%) and category II (20%). The vascularized composite autograft included the rectus abdominis myocutaneous free flap combined with costal cartilage, and the latissimus dorsi myocutaneous free flap combined with the V-shaped scapula is an effective method for reliable reconstruction of both skeletal and soft tissues.
A critical assessment for skeletal defects and associated soft tissue defects is essential for an adequate approach to solve complex problems in maxillary reconstruction. On the basis of retrospective analysis of this series, a reconstructive algorithm for surgical management of maxillectomy defects is proposed. © 2004 Wiley Periodicals, Inc. Head Neck26: 247–256, 2004
Forty-five cases of head and neck reconstruction with pectoralis major myocutaneous flaps (PMMF) between 1985 and 1990 were analyzed retrospectively for complications. Thirty-two cases were done at the VA Medical Center and 13 at Albany Medical Center, a private university hospital. Total complication rate was 58%. In the VA population, complication rate was 59% as compared to 54% at the Albany Medical Center, which appears statistically not significant. It has been suggested that VA populations tend to have poorer health and socioeconomic status and are more likely to have higher complication rates. This conjecture is not borne out by this study. Complications are described and compared.
The defect resulting from partial or complete maxillectomy can often be reconstructed with a skin graft and a prosthesis. In situations where this simple maneuver is unsatisfactory, a more complex reconstructive modality, providing the restoration of composite tissue, is required. The scapular microvascular-free flap was used in this series of 11 patients, as a cutaneous flap in 3 and as an osteocutaneous flap in 8, to meet the specific reconstructive needs of each patient. Excellent to satisfactory restoration of facial contour and palatal function was achieved in 10 patients. There was 1 flap failure. There were no donor site complications. Selected case histories are presented to demonstrate a spectrum of reconstructive problems. There are clear limitations to its applicability, such as the odd scapular bone contour, the thickness of the cutaneous paddle, the position change required for flap harvesting, and the risk of flap failure. The scapular flap has proven to be useful in restoring bony and soft tissue contour of the face, rigid support for the velum, oronasal separation, support for the orbit, and obliteration of the maxillary sinus. We found the scapular-free flap to be a useful tool for reconstructing complex and variable maxillectomy defects.
Twenty-six patients with head and neck tumors were submitted to 27 microvascular reconstructive procedures. In 15, the mandible was reconstructed using the rib (4), iliac crest (7), and scapula (4). Nine patients underwent craniofacial reconstructions with the latissimus dorsi (5), rectus abdominis (2), greater omentum (2), and scapular (1) flaps. Two patients received a jejunum (1) and a stomach plus greater omentum (1) flaps for pharyngoesophageal reconstruction. Three illustrative cases, one from each group, are presented in detail. Good results were obtained in 22 patients (85%), with both functional and morphological rehabilitation. There were five flap losses (two in the same patient) due to thrombosis of the microvascular anastomoses. There was no operative mortality, and the average operative time was 11 hours. The good results observed in these very advanced cases show that there is a place for these complex procedures in the treatment of selected cases of head and neck tumors.
• This article reviews our experience with 86 patients undergoing 95 pectoralis major myocutaneous flap reconstructions. Complications and their incidence were very similar to those reported in previous series. Three cases of hidden recurrences appear to be previously unreported complications. The problem of delayed detection of recurrence in at-risk patients is an important one and may be unique to myocutaneous flaps. With the exception of the problem of hidden recurrence, the pectoralis major myocutaneous flap compares favorably with other methods of reconstruction of head and neck defects. Its size, viability, and versatility make it a valuable tool for extending the limits of resectability and reconstruction.
(Arch Otolaryngol 1983;109:812-814)
Although the pectoralis major myocutaneous flap (PMMF) has proved to be a reliable method of reconstruction for the head and neck surgeon, the current emphasis in tissue replacement has shifted to microvascular free-tissue transfer. This has prompted us to review retrospectively all PMMFs performed for reconstruction following head and neck cancer resection at the University of Connecticut Health Center over a recent four-year period. A total of 24 flaps were utilized consecutively in 23 patients, following a variety of ablative procedures. Postoperative complications occurred in 14 of the 24 flaps (59%), and 11 of the 14 patients who experienced postoperative complications had received previous radiation therapy. Seven of the complications were felt to be major because they prolonged hospital stay, or they required secondary reconstructive procedures (four of seven cases). There were no instances of total flap failure. In our experience, the PMMF has proved to be reliable and useful in a variety of head and neck reconstructive procedures. We conclude that the PMMF remains an excellent option for repair of defects resulting from head and neck cancer resection.
A wide range of pedicled and free tissue transfer flaps have been described in the reconstruction of the complex maxillofacial defect, but no preferred reconstructive technique has so far emerged. The previous methods described may effectively close the oronasal fistula but reliable support for the cheek and orbit while providing a basis for an implant retained prosthesis is less likely to be achieved.
The methods of using the flap in low, high, and central maxillectomy defects as well as cases requiring orbital exenteration are described.
The deep circumflex iliac artery (DCIA) flap with internal oblique provides a reliable reconstruction for the maxillectomy as the fistula is closed with muscle which becomes epithelialized with minimal bulk. The large volume of bone available from the iliac crest can restore the facial contour, support the orbital contents, reconstruct the orbital rim, and provide sufficient bulk of bone for the placement of implants.
Operative treatment of head and neck cancer requires radical resection of the tumor with not only severe impairment of important functions like swallowing speech, and respiration but also aesthetic mutilation because of the exposed character of the head and neck region. Therefore the rehabilitation from a functional and cosmetic standpoint is an essential goal of treatment in addition to control of the malignant disease. Fortunately regional plastic surgery offers a variety of options for reconstruction of the defects to receive a solution tailored to each individual patient.
Between the years 1986 and 1996, 107 patients with advanced head and neck cancer were treated surgically by radical resection of the tumor and plastic reconstruction. In this study we made a retrospective analysis of the functional and aesthetic outcome of the techniques of reconstructive surgery we used for rehabilitation. The sex ratio was 79 males to 28 females. Average age was 59.4 years (ranging from 39 to 78 years). Most of the patients suffered from squamous cell carcinoma of the upper digestive tract (97 cases). The others included an adenocarcinoma of the paranasal sinuses (three cases), adenoid cystic cancer of the palate (two cases), squamous cell carcinoma of the temporal bone (two cases), two deep infiltrating basaliomas in the area of the nose and forehead and one chondrosarcoma of the neck. Our oncological concept includes a radical resection of the tumor and a onestep reconstruction of the defect, if the patient's general condition enables this approach. The surgical techniques we used include the approved pedicled myocutaneous flaps like the pectoralis major flap, latissimus dorsi flap (which can be also applied as a free microvascular tissue graft), temporalis muscle flap, and the free radial forearm flap.
In previous years, the pedicled myocutaneous pectoralis-major- and latissimus-dorsi-flaps were used for reconstruction (n = 67), but the arc of rotation and the huge bulk of the graft are limiting factors for the indication of these techniques. The free forearm flap has increasingly been used to provide an excellent closure of large pharyngeal defects (n = 16), whereas the temporalis flap is useful for restoration after limited resection of the palate (n = 18). Beside these rather invasive procedures, aesthetic rehabilitation may be achieved with bone-anchored epithesis especially after exenteration of the orbit and ablation of the external ear in case of elderly patients with multiple morbidities (n = 5). In most cases, sufficient rehabilitation from the anatomical and functional point of view was possible even after large tumor resections. A main problem can be longstanding aspiration after resection of large areas of the pharyngeal mucosa (n = 8). Complications included eight cases of necrosis of the flaps and seven patients who developed significant seromas at the donor site.
The potential of modern regional reconstructive surgery enables the surgeon to achieve anatomically and functionally rehabilitation in a one-step procedure in most cases, even after extended resection for head and neck cancer. One should be aware of the fact that these techniques do not offer a significant improvement of prognosis. As such, the aggressiveness of surgical therapy should remain in reasonable relation to the prognosis of the malignant disease.
Reconstruction of the complex pharyngeal wound after radiotherapy presents a surgical challenge.
Evaluation of the gastro-omental flap in the reconstruction of the pharynx and overlying soft tissue after local flap failure.
A 70-year-old patient underwent a total laryngectomy and radical neck dissection after 70 Gy of external beam radiotherapy for an advanced squamous cell carcinoma of the pyriform sinus. Postoperatively, a large pharyngocutaneous fistula developed. Attempted closure with a pectoralis major flap was unsuccessful. A tubed gastro-omental free flap based on the right gastroepiploic vessels was used to reconstruct the pharynx. The accompanying greater omentum was skin grafted after filling the large soft tissue defect in the neck. The wounds healed primarily, and oral alimentation was resumed on the seventh postoperative day.
The gastro-omental flap is a versatile composite flap which can provide mucosal lining as well as abundant soft tissue. It should be considered a secondary option in irradiated, complex pharyngeal wounds when local flaps are not available to be used in conjunction with free jujunal transfer.
In modern multi-disciplinary cancer treatment, rehabilitation and functional results represent utmost intent in reconstructive surgery of the oral cavity. Even in cases where the stage of disease is advanced) and the perspective of survival is limited, it is possible to achieve an acceptable quality of life. The authors report, in this study, the morpho-functional results and the morbidity observed in glossectomies in which the reconstruction was performed using three different methods. In a total of 264 reconstructive flaps of the head and neck regions, the authors considered three groups of 15 patients that had had reconstruction after the demolitive procedure. Respectively these groups were divided by the followed methods: free forearm flap, pectoralis major myocutaneous flap and nasolabial flap. The morbidity showed an extremely low rate of flap loss in all the groups, but "minor" complications, such as fistulas and leakages, were significantly more frequent in the myocutaneous flaps group. Functional evaluation for speech and deglutition showed good results in most patients. Extremely severe postoperative conditions as a permanent NG tube or incomprehensible speech had been observed in less than 15% of the cases. Particularly, the pectoralis major flap, showed its best functional performances in the total or subtotal glossectomies with a sacrifice of the muscles of the oral floor. The free forearm flap is reliable and safe with its low thickness and pliability, especially for partial glossectomies. The nasolabial flap was confirmed to be the first reconstructive choice for selected limited resections of the tongue and of the antero-lateral floor. With this experience it is possible, even in more complex free flaps, to reduce the time consumption and the complication rate. Free flaps do not substitute routinely myocutaneous and conventional flaps, but they represent the "ideal" reconstructive alternatives for specific and selected indications.
The present article describes a method that preserves circulation during the preparation of the pectoralis major myocutaneous flap used in head and neck reconstruction. The major disadvantage of this flap is its poor circulation and consequent partial necrosis. To solve this problem, we analyzed the circulation and hemodynamics of the pectoralis major myocutaneous flap (the perforator of the anterior intercostal branch located about 1 to 2 cm medial to the areola in the fourth intercostal space is important), evaluated the safe donor sites in the chest wall for a skin island (the perforator is included on the skin island's central axis), improved the surgical procedure for elevating flaps (for preventing perforator injuries), and devised a means to transfer flaps, thereby increasing the range of the flaps (the transfer route is under the clavicle). Using this technique, head and neck reconstruction was performed on 62 patients. The diagnosis included oral cancer (21), oropharyngeal carcinoma (10), parotid carcinoma (10), hypopharyngeal carcinoma (9), and other head and neck malignant tumors (12). Of these, partial or marginal necrosis of the flap caused by circulatory problems was detected in three patients (5 percent). Using our method, the problems associated with inadequate circulation in the pectoralis major myocutaneous flap were greatly alleviated, thus reconfirming the usefulness of this flap in head and neck reconstruction.
Ablation of large intraoral cancers can create extensive through-and-through defects of the lateral face, resulting in loss of external facial skin, the lateral and anterior mandible, and the lateral mouth. Repair requires reconstruction of the lips, mandible, and full-thickness cheek defects. Ideal reconstruction with vascularized composite free flaps requires adequate bone and sufficiently large, yet versatile, skin flaps capable of resurfacing extensive intraoral and external defects.
A series of 12 patients with large lateral facial-mandibular defects is reviewed. All patients were treated for squamous cell carcinoma except for 1 patient with osteoblastic sarcoma of the mandible. All patients underwent primary reconstruction with various free flap techniques, including 6 scapular free flaps, 2 iliac crest free flaps, 3 free fibula flaps, and 1 radial forearm flap. Attainment of reconstructive goals, free flap survival, and complication rates were assessed.
All defects were successfully reconstructed in the primary setting. No flap failures occurred. One venous occlusion was successfully salvaged. No orocutaneous fistulas or postoperative hematomas were noted.
The reconstructive options for extensive defects of the lateral face and jaw are reviewed with attention to the complex three-dimensional soft tissue requirements. The superiority of the scapular composite flap is emphasized because this single free flap provides two independent and versatile skin paddles of optimal thickness in addition to adequate bone stock.
Wide defects resulting after resection of malignant tumors of the head and neck need an adeguate closure. In the last 16 years, 85 pectoralis major myocutaneous island flap procedures were carried out for the immediate reconstruction of surgical defects following extirpation of malignant tumors at various sites of the upper aerodigestive tract. The final functional and cosmetic results were satisfactory. Partial necrosis was observed in four cases. We did not have any cases of total flap necrosis. Post-operative fistulas were encountered in 14 cases (surgical closure was not necessary). The application and complications of the pectoralis major myocutaneous flap placed at cervical level are reviewed. The aspects of postoperative swallowing function of such surgery are discussed. Reconstruction with the pectoralis major myocutaneous flap is a safe and versatile procedure, yielding good clinical and functional results in patients with advanced head and neck tumors.
Wide resection of tumors of the middle third of the face often results in complex three-dimensional defects and facial paralysis either due to removal of the facial nerve within the tumoral tissue or to extensive resection of the facial muscles.
We report the cases of three patients who underwent wide excision of tumors of the cheek region, operations that resulted in tissue defects and facial palsy. Defect reconstruction and facial reanimation was accomplished in one stage through functional muscle transplantation.
Follow-up of more than 1 year showed good symmetry at rest and reanimation of the corner of the mouth in all cases, but one patient, in which the ipsilateral facial main trunk was used as motor nerve supply to the transplanted muscle, developed significant muscle contracture and binding of the cheek skin.
Every effort should be made to optimize the functional and cosmetic outcomes of neurovascular muscle transfers through precise planning and careful execution of the intricate details of the surgical technique for muscle transplantation.
The pectoralis major myocutaneous pedicled flap (PMMPF) has been considered to be the "workhorse" of pedicled flaps for head and neck reconstruction, and several series of PMMPF procedures have been reported in the literature. Between 1983 and 1997, 244 reconstruction procedures using the PMMPF were carried out on 229 patients by the Otolaryngology-Head and Neck Surgery Department at the Toronto General Hospital. Pectoralis major myocutaneous pedicled flap reconstructions were completed after ablation of cancer in the following sites: oral cavity, 113; oropharynx/hypopharynx, 50; larynx, 59; and other, 21. The locations of reconstruction were oral cavity, 121; pharynx, 74; and neck or face, 50. Of the 244 cases, 202 were carried out as primary reconstructive procedures, whereas 42 flaps were "salvage" procedures (reconstruction after fistula, flap failure, osteoradionecrosis, and internal jugular vein rupture). Eighty-five cases (35%) were affected by complications such as dehiscence, infection, hematoma, seroma, partial flap failure, total flap failure, fistula, and donor site complications. The duration of admission for cases with complications was longer, and higher complication rates were associated with salvage procedures, number of comorbidities, number of pack-years of cigarettes smoked, and oral cavity reconstructions. This series of consecutive PMMPF procedures is the largest reported to date.
Hypopharyngeal cancer often presents at an advanced stage. Radical surgery has played an important role in the treatment of these cases; however, it always results in a large, or even a circumferential, defect of the pharyngoesophageal segment (PES) that causes some difficulties during reconstruction.
Twelve patients with advanced hypopharyngeal cancer and cervical esophageal invasion received surgery resulting in a circumferential defect of PES, which was reconstructed with the contralateral unaffected laryngotracheal flap and a patch-on pectoralis major myocutaneous flap (PMMCF).
The operation time of this method was shorter compared with free flap reconstruction. Only two minor complications and no pharyngocutaneous fistulas were found postoperatively. Nine patients can resume a regular diet. During the follow-up period (median, 38 months), there were no local recurrences and only one contralateral neck recurrence.
The preliminary result shows this technique is a simple and effective method with low morbidity and satisfactory oncologic and functional results.
Radical surgery followed by radiotherapy plays an important role in the treatment of patients with hypopharyngeal cancer. However, there is no general consensus as to which is the best method of reconstruction after surgical resection.
We retrospectively reviewed the records of 91 patients who underwent radical surgery and reconstruction. Postoperative complications and oncologic results of the different reconstructive methods were compared.
Reconstruction with gastric pull-up had the lowest pharyngocutaneous (PC) fistula (0%) and pharyngoesophageal (PE) stenosis rates (0%). However, the overall postoperative complication rate was high (64%). Laryngotracheal flap (LTF) reconstruction had relatively lower rates of PC fistula (3%), PE stenosis (10%), and overall complications (22%). The introduction of the LTF technique significantly decreased postoperative complications from 71% to 30% (p = .0001), with similar tumor control and survival.
Hypopharyngeal reconstruction with an LTF is a simple and effective method. The chance of using a complex flap is decreased. The postoperative complications are reduced, and the oncologic results are satisfactory.
Compound cervicofacial and cervicothoracic rotation flaps are highly versatile flaps that may be applied to a variety of defects of the cheek, orbit, periauricular region, and neck. These rotation advancement flaps should be a staple of the head and neck surgeon's reconstructive armamentarium.
This is a retrospective review of medical records at a university-based head and neck cancer center.
Thirty-three patients were identified, with a mean age of 66 years. Primary or recurrent skin neoplasms made up the most common indication for surgery, followed by primary parotid tumors and cervical lymphatic metastases from upper aerodigestive tract malignancies. Defects of the cheek, orbit, periauricular region, and neck were reconstructed with cervicofacial or cervicothoracic flaps, with larger wounds requiring variable extension of the incision onto the chest wall. Other reconstructive modalities were used in 18 cases to increase tissue bulk or provide internal lining. Minor wound complications occurred in 13 patients. There was no statistically significant association between wound complications and smoking or previous radiation therapy.
Compound cervicofacial and cervicothoracic rotation flaps provide a straightforward, reliable, and efficient means to reconstruct complex defects of the face, lateral skull base, and neck, with the potential for excellent cosmetic results.
The reconstruction of columellar defects is still a challenging procedure because of limited local and regional flap options and the characteristics of the anatomy of this site. Although a number of methods are available to repair nasal columella defects, no treatment of choice ensuring an excellent texture- and color-matched tissue in one stage has been determined to date.
In this case, we used a reverse-flow submental island flap prefabricated with the costal cartilage for the reconstruction of a complex columellar defect.
The flap survived completely with reversible venous congestion. The cosmetic result and nasal respiratory function were acceptable during the follow-up time of 6 months.
We propose that the prefabricated reverse submental flap may be an alternative among the surgical options for columellar defects. This flap may also be considered in the reconstructive repertoire of other composite defects of the head and neck region.
To evaluate the factors related to surgical complications, rate of gastrostomy tube (G-tube) dependence, and hospitalization in patients undergoing reconstruction with a pectoralis myocutaneous flap vs a soft-tissue revascularized flap.
Quasi-experimental case series with a historic control group.
A total of 179 patients (138 men and 41 women) with a mean (SD) age of 58 (14) years treated between January 1, 1986, and December 31, 1995, with a pectoralis flap (108 patients) or a revascularized free flap (71 patients).
Inclusion criteria were first or second extirpation, reconstruction with soft-tissue flap, or defect including the upper aerodigestive tract. Exclusion criteria were secondary reconstruction, or reconstruction for salvage of a complication.
Although the major complication rate was not significantly different according to reconstructive approach, hypopharyngeal defects had a significantly higher major complication rate of 30% (6/20) compared with 8% (13/159) for other defect sites (P<.003). The minor complication rate was higher in the pectoralis group, at 57% (62/108), than in the revascularized flap group, at 21% (15/71) (P<.001). G-tube dependence was higher in the pectoralis group at 42% (40/96), in contrast to the revascularized flap group at 16% (10/63) (P<.001). G-tube dependence was 25% higher in patients who underwent salvage surgery after radiation (42% [30/72]) than in patients treated with postoperative radiation (17% [12/69]) (P<.004). Revascularized flaps helped ameliorate the effects of radiation before surgery; 56% (23/41) of the patients who received pectoralis flaps were G-tube dependent, while the rate of G-tube dependence in the revascularized flap group was 23% (7/31) (P<.004). Hospitalization was longer in the pectoralis group (14 days) than the revascularized flap group (12 days) (P<.006).
Patients who undergo reconstruction with a pectoralis flap have significantly higher minor complication rates, a higher rate of G-tube dependence, and longer hospitalization than patients who undergo reconstruction with a soft-tissue revascularized flap.
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