British Journal ofP/mfic Surgery (1995). 48, 569-571 0 1995 The Bntlsh Assocdon of Plastic Surgeons

BRITISH JOURNAL OF PLASTIC SURGERY

Cheek reconstruction with an expanded prefabricated musculocutaneous free flap : case report

H. H. Igawa, H. M. Minakawa, T. Sugihara and K. Homma*

Department of Plastic and Reconstructive Surgery, Hokkaido University School of Medicine and *Division of Plastic and Reconstructive Surgery, Sapporo General Hospital, Sapporo, Japan

SUMMARY. We present a case of reconstruction of the left cheek with a prefabricated musculocutaneous flap. A pedicled serratus anterior muscle flap was transferred to the left chest, deep to skin. The muscle flap and overlying skin were expanded. The expanded, prefabricated musculocutaneous flap was then transferred as a free flap to the left cheek defect.

Many types of flaps are now available in reconstructive surgery. However, the flap may not match the sur- rounding skin’s colour or texture and so give the impression that it is a patch. In addition, the flap may be too thick and so require revision. Having regard to the colour, texture and volume of a flap needed for a deep cheek defect, we prefabricated a musculo- cutaneous flap and transferred it as a free flap.

Case report A 65year-old male presented with a left cheek soft tissue defect 6 x 7 cm, involving the skin, muscles of facial ex- pression and the masseter muscle (Fig. 1). He had had wide local excision of a primary adenoid cystic carcinoma of the skin and repair with split thickness skin graft approximately 14 months before. There were no signs of local recurrence or distant metastases of the tumour.

Reconstruction with a prefabricated flap was planned. A 6 cm wide section of the left serratus anterior muscle, with a volume a little more than that of the excised muscles of the left cheek (Fig. 2, left), was transferred with its vascular pedicle intact to beneath the left upper anterior chest skin, where the colour and texture were well matched to those of the cheek skin. A rectangular tissue expander (640 cc, Dow Corning) was then inserted beneath the transferred serratus anterior muscle (Fig. 2, right). For 3 months after surgery, physiological saline was gradually injected into the expander.

At a second operation, the fully expanded, 7 x 8 cm area of anterior chest skin and serratus anterior muscle over the expander were raised as a prefabricated musculocutaneous flap, with muscle under the whole skin paddle (Fig. 3, left). The prefabricated musculocutaneous flap was transferred to the cheek defect as a free flap, with anastomosis of the flap pedicle thoracodorsal artery and vein to the transverse cervical artery and the external jugular vein. The flap donor site could be closed primarily, using the remaining expanded skin of the chest (Fig. 3, right). The prefabricated musculo- cutaneous flap survived completely and its colour and texture were well matched to those of the surrounding cheek skin. The prefabricated musculocutaneous flap was not too thick, so that secondary surgery on the flap, for example debulking, was not necessary. There has been no recurrence of the tumour over the following 3 years and the patient is very satisfied with the reconstructed cheek (Fig. 4).

Discussion

In reconstructive surgery, the colour, texture and volume of a flap must be taken into consideration to achieve a high quality result. With this in mind, we report our case of a prefabricated flap.

Washiol was the first to attempt to prefabricate a flap; an intestinal segment stripped of its mucosa with a pedicle of mesenteric vessels was used to sustain a segment of overlying abdominal skin in dogs. Erol and Spira’ used omentum to make island flaps in pigs; omentum with a pedicle of gastroepiploic vessels was used to vascularise skin grafts, skin, muscle and bone. Erol and colleagues prefabricated island graft flaps in dogs and humans;3’4 a free skin graft was placed over an artery and vein and later transferred as a secondary vascularised pedicled flap based on the vessels. Yao made prefabricated flaps by vascular pedicle implan- tation into tubed skin flaps in rabbits and also reported clinical applications of similar flaps for ear recon- struction.5 Shintomi and Ohura reported clinical cases using free or pedicled prefabricated flaps.6 They used a vascular bundle with a small amount of muscle on its distal end to prefabricate a skin flap and called their prefabricated flaps “ muscle vascularised pedicle ” flaps. Their clinical cases required surgical delay of the flap several times to get a large flap because most of a “ muscle vascularised pedicle flap ” is basically random-pattern except in the region where the pedicle and its small amount of muscle is attached. Pribaz et al.’ showed that the repeated use of a vascular pedicle to prefabricate flaps in rabbits was possible. They also reported a clinical case using a repeated transfer.

It is possible to elevate a prefabricated flap from any region of the body where the colour and texture match those of the skin surrounding the defect which requires repair. Any prefabricated flap with a volume nearly equal to that of the tissue defect can be made. Taking all this into consideration, we used a prefabricated musculocutaneous flap instead of a conventional musculocutaneous flap to reconstruct the cheek in our case. The prefabricated musculocutaneous flap was

569

British Journal of Plastic Surgery

Fig. 1

Fig. 3 Fig. 4

Figure I--65year-old male with left cheek defect which involves the skin, the underlying muscles of facial expression and part of the masseter. Figure 2--(Left) Left serratus anterior muscle elevated. (Right) Muscle transferred to left chest and tissue expander placed deep to it. Figure 3-(Left) Prefabricated musculocutaneous flap elevated. (Right) Flap inset into cheek and donor site closed. Figure &Postoperative result.

composed of anterior chest skin and part of the serratus anterior muscle. The anterior chest skin was chosen because its colour and texture most resembled those of the cheek skin. In contrast, the back skin was extremely different in colour from the cheek skin and was thick and hard. The serratus anterior muscle was chosen because it is not thick and could have almost the same volume as the excised cheek muscles after tissue expansion. In addition, the concave deformity of the muscle donor site is not obvious and the functional defect after elevation of the muscle is minimal compared with the latissimus dorsi or pectoralis major muscles. We also thought that the latissimus dorsi or pectoralis major muscle might be too thick to be transferred as a substitute for the

excised cheek muscles, even if the best use was made of a tissue expander in this patient. For these reasons we did not use a conventional musculocutaneous flap such as a free latissimus dorsi or pectoralis major musculocutaneous flap. The prefabricated musculo- cutaneous flap was successfully transferred without any surgical delay, which is required for “muscle vascularised pedicle” flaps.6 The transfer of the exact volume of the prefabricated musculocutaneous flap made secondary surgery, such as flap debulking, unnecessary. In addition, the use of the tissue expander made it possible to close the flap donor site primarily. We believe that prefabricated flaps will be used more often to achieve excellent colour, texture and volume of flaps.

Prefabricated musculocutaneous free flap 571

Acknowledgements We were very grateful to Dr T. Ohura and Dr T. Yoshida for their suggestions and help.

References

1. Washio H. An intestinal conduit for free transplantation of other tissues. Plast Reconstr Surg 1971; 48: 48-51.

2. Erol 00, Spira, M. Development and utilization of a composite island flap employing omentum: experimental investigation. Plast Reconstr Surg 1980; 65: 405518.

3. Ero 00. The transformation of a free skin graft into a vascularized pedicled flap. Plast Reconstr Surg 1976; 58: 470-7.

4. Eroll 60, Parsa FD, Spira M. The use of the secondary island graft-flap in reconstruction of the burned ear. Br J Plast Surg 1981; 34: 417-21.

5. Yao ST. Vascular implantation into skin hap: experimental study and clinical application: a preliminary report. Plast Reconstr Surg 1981; 68: 4049.

6. Shintomi Y, Ohura T. The use of muscle vascularized pedicle flaps. Plast Reconstr Surg 1982; 70: 725-34.

7. Pribaz JJ, Maitz PKM, Fine NA. Flap prefabrication using the “vascular crane” principle: an experimental study and clinical application. Br J Plast Surg 1994; 47: 25G-6.

The Authors

Hiroharu H. Igawa, MD Hidehiko Minakawa, MD Tsuneki Sugihara, MD

Department of Plastic and Reconstructive Surgery, Hokkaido University School of Medicine, Kita-14, Nishi-5, Kita-ku, Sapporo, 060 Japan.

Ken-ichi Homma, MD Division of Plastic and Reconstructive Surgery, Sapporo General Hospital, Kita- 1, Nishi-9, Chuo-ku, Sapporo, 060 Japan.

Correspondence to Dr. H. H. Igawa.

Paper received 4 January 1995. Accepted 6 July 1995, after revision.