Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 510e513

Head and neck reconstruction using a combinedsternomastoid musculocutaneous external jugularveno-accompanying-artery adipofascial flap

Kazuo Kishi a,*, Hideo Nakajima a, Nobuaki Imanishi b, Tatsuo Nakajima a

a Department of Plastic and Reconstructive Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku,Tokyo 160-8582, Japanb Department of Anatomy, Keio University School of Medicine, 35 Shinanomachi, Shinjukuku, Tokyo 160-8582, Japan

Received 6 March 2007; accepted 30 November 2007

KEYWORDSSternomastoid;Veno-accompanying-artery;Flap;Head and neck

* Corresponding author. Tel.: þ81 (03352 1054.

E-mail address: kkishi@sc.itc.keio.

1748-6815/$-seefrontmatterª2007Bridoi:10.1016/j.bjps.2007.11.048

Summary We combined a sternomastoid musculocutaneous (SMC) flap and an external jug-ular veno-accompanying-artery adipofascial (EJ VAF) flap, for head and neck defect recon-struction. The SMC flap provides a rich arterial flow and the EJ VAF flap good venousdrainage, making a reliable flap easy-to-raise combination. The flap took well in two patientsrequiring head and neck reconstruction.ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

The convenient, easy-to-raise veno-accompanying-arteryadipofascial flap (VAF flap) is useful for covering skindefects while minimising donor sites loss.1e3 The flap’sblood supply from the arterial network within 1 cm alongthe cutaneous vein, although having excellent venousdrainage, may be insufficient for large flaps. An externaljugular (EJ) VAF flap may be used to cover small skin ormucosal defects of the head and neck but large flaps cannotbe raised using the EJ VAF flap pedicle alone.

The sternomastoid musclocutaneous (SMC) flap is alsoused for small defects of the head and neck region. Thesternomastoid muscle blood supply is type II based on

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ac.jp (K. Kishi).

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Mathes and Nahai’s classification, so the SMC flap itselfprovides an unreliable blood supply if the flap raised isbased on the occipital artery alone and may engender flapcongestion and necrosis.

Based on an anatomical study, we combined EJ VAF andSMC flaps for covering defects of the head and neck.

Materials and methods

Anatomy

Using 10 cadavers systemically injected with a lead oxide-gelatin mixture as described elsewhere,1 we dissected theneck beneath the sternomastoid muscle and separatedout the sternomastoid muscle, X-raying samples to observethe arterial neck anatomy of each layer. After dissection,

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Head and neck reconstruction 511

we injected the external jugular vein with lead oxide toclarify its location.

Surgical procedure

Before design, external jugular veins are marked with a feltpen and desired skin is marked on the cranial side of theclavicle to include the EJ vein with its accompanying arteryand the sternomastoid muscle. Under general anaesthesia,diluted epinephrine is injected intradermally and the skinincised caudally to reach the plane beneath the sterno-mastoid muscle. The flap is dissected from the loose layerbeneath this muscle. Branches from the thyrocervical trunkand superior thyroid artery are dissected while raising theflap but keeping the branch from the occipital arteryintact. The flap must include the adipofascial tissuebeneath the platysma. The donor site is closed leavinga drain beneath sutured skin.

Results

The sternomastoid muscle is nourished by the thyrocervicaltrunk, superior thyroid artery, and an occipital arterybranch. Using the uppermost occipital artery as the pedicleof the SMC flap may destabilise the lowermost thyrocervicaltrunk blood supply. Angiographic examination showed thearterial network to be extensive within the sternomastoidmuscle and in tissues surrounding the sternomastoid muscle(Figure 1). The accompanying arterial network accom-panies the external jugular vein. We designed the combinedEJ VAF flap based on these anatomical studies (Figure 2).The occipital artery and external jugular vein are close

Figure 1 Arterial anatomy of the neck region (a) with and (b) wirocervical trunk (solid yellow arrows), superior thyroid artery (openheads). The sternomastoid muscle interior and surrounding tissuesvein (in blue with red arrows).

together in the occipital region, giving the SMC EJ VAFflap a relatively free rotation arc.

Case reports

Case 1

A 40-year-old woman who was suffering from an atypicalleft temporal to occipital meningioma required additionalresection after tumour regrowth (Figure 3) leavinga 5� 8 cm dural defect and partial temporal bone loss.We designed the combined SMC EJ VAF flap on the neckon the same side de-epithelialising a 6� 9 cm skin portionwith a scalpel to remove hair bulbs and sebaceous glandscompletely. We then inverted the flap to cover the duraldefect, filling dead space made after partial re-sectioningof the temporal bone with the flap pedicle of the flap.The flap set well in the defect. One year postoperatively,magnetic resonance imaging (MRI) showed the flap tohave taken well.

Case 2

A 55-year-old woman undergoing surgical reconstruction ofa deformity following tongue carcinoma resection 20 yearsearlier (Figure 4) had received a latissmus dorsi musculocu-taneous flap combined with a vascularised rib. Partial necro-sis of the flap had occurred, resulting in a fistula from oralbase to chin. Although the fistula at the chin was 2 cm indiameter, a sufficient volume to occupy the dead spacewas required. A sternomastoid musculocutaneous, external

thout the sternomastoid muscle which is nourished by the thy-yellow arrows), and an occipital artery branch (yellow arrow-

have an extensive arterial network as does the external jugular

Figure 3 (a) Atypical left temporal to occipital meningiomawhose resection resulted in a 5� 8 cm dural defect and partialtemporal bone loss. Dotted line indicates the anticipated duraldefect and temporal bone position. (b) SMC EJ VAF combinedflap. (c) The skin was de-epithelialised and (d) turned up tocover the dural defect and dead space. Note the absence offlap congestion. (e) After the operation. (f) Computerised to-mography 1 week postoperatively (g) MRI 1 year postopera-tively. Open arrowheads indicate the transposed flap.

Figure 2 SMC EJ VAF combined flap. Adipofascial tissuesbeneath the platysma are included.

512 K. Kishi et al.

jugular VAF combined flap was designed, and transposed tothe dead space. The flap took well without necrosis, and thefistula was closed completely.

Discussion

VAF flaps, first reported in 19981e3 and designed consistentwith venous blood flow, possess excellent venous drainage,enabling large flaps to be raised without congestion.

Those designed against the venous flow are restricted insize but reverse venous flow may be made via a veinaccompanying large cutaneous veins,4 giving reverse VAFflaps much better drainage capacity than flaps withoutcutaneous veins. Reverse EJ VAF flaps have been used forthe head and neck, although large flaps are not reliable.VAF flaps could be enlarged, however, by combining themwith other flaps, especially those raised small due to insuf-ficient venous drainage. The SMC flap is often used for smalldefects in head and neck reconstruction.5,6 The sternomas-toid muscle is supplied by blood from the occipital artery,superior thyroid artery, and thyrocervical trunk. Raisinga flap based on one of these vessels alone may not be suc-cessful, however, because the blood supply to the muscle isseparate.

Given this background, we combined SMC and EJ VAFflaps to stabilise blood circulation and raised larger flaps inthe head and neck region. The external jugular vein and thesternomastoid muscle are close together cranially, makingthe flap easy to design based on the cranial pedicle. Whenthe combined SMC and EJ VAF flaps were raised, nocongestive colour was seen and fresh blood was observedfrom the flap margin proving the complementary nature ofthe two flaps.

Figure 4 (a) Fistula from oral base to chin after reconstruction with a latissmus dorsi musculocutaneous flap combined with a vas-cularised rib. (b) Fistula. (c) SMC EJ VAF design. (d, e) Flap elevation. (f) Two years postoperatively, fistula free.

Head and neck reconstruction 513

Among MC flaps other than those of the sternomastoidmuscle, the platysma MC flap is sometimes used for smallhead and neck defects, but does not contain a rich arterialnetwork and the blood supply of the platysma muscle itselfis unreliable. The arterial network providing for platysmaMC flap survival in adipofascial tissue beneath the platysmais the same as that of the EJ VAF flap.7

Incorporating the sternomastoid muscle in a flap makesit bulky, restricting flap use to cases requiring a dead spaceto be occupied by tissue with a rich blood flow.

References

1. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying arteriesof the cutaneous veins and cutaneous nerves in the extremities:anatomical study and a concept of the venoadipofascial and/orneuroadipofascial pedicled fasciocutaneous flap. Plast ReconstrSurg 1998;102:779e91.

2. Nakajima H, Imanishi N, Fukuzumi S, et al. Accompanying ar-teries of the lesser saphenous vein and sural nerve: anatomicstudy and its clinical applications. Plast Reconstr Surg 1999;103:104e20.

3. Nakajima H, Imanishi N, Fukuzumi S. Vaginal reconstructionwith the femoral veno-neuroaccompanying artery fasciocutane-ous flap. Br J Plast Surg 1999;52:547e53.

4. Imanishi N, Nakajima H, Fukuzumi S, et al. Venous drainage ofthe distally based lesser saphenous-sural veno-neuroadipofas-cial pedicled fasciocutaneous flap: a radiographic perfusionstudy. Plast Reconstr Surg 1999;103:494e8.

5. Parkash S, Ramakrishnan K, Ananthakrishnan N. Sternomastoidbased island flap for lining after resection of oral carcinomas.Br J Plast Surg 1980;33:115e8.

6. Ariyan S. One-stage reconstruction for defects of the mouth us-ing a sternomastoid myocutaneous flap. Plast Reconstr Surg1979;63:618e25.

7. Imanishi N, Nakajima H, Kishi K, et al. Is the platysma flapmusculocutaneous? Angiographic study of the platysma. PlastReconstr Surg 2005 Apr;115:1018e24.