Head and neck reconstruction using the platysma myocutaneous flap

Head and Neck Reconstruction Using the Platysma Myocutaneous Flap

Deborah S. Ruark, MD, Willie C. McClairen, Jr., Mr), Uwe K. Schlehaider, MD, Raafat Z. Abdel-Misih, MD, Wilmington, Delaware

A retrospective analysis of our experience with 41 patients who received a platysma myoeutaneous flap for reconstruetion of intraoral and pharyngeal defects is presented. All patients had epidermoid carcinoma of the head and neck region, with tumor size ranging from T1 to T4. The primary sites of malignancy were the oral cavity (61%), the oropharynx (32%), and the hypopharynx (7%). Ei- ther radical or modified radical neck dissection re- quiring routine ligation of the facial artery was performed in all 41 patients. Adjuvant therapy in- eluded preoperative or postoperative radiotherapy (39%) and preoperative chemotherapy (73%). The mean hospital stay was 13 days. Flap-related complications occurred in eight patients (19%) only. These included partial flap necrosis involving the epithelium alone, skin necrosis of the neck suture line, and fistula formation. Most complications resolved with local care only. Minor surgical inter- vention was required in three patients. There were no perioperative deaths. These results indicate that the platysma myocutaneons flap is a viable alternative in head and neck reconstruction.

From the Department of Surgery, Medical Center of Delaware, Wil- mington, Delaware.

Presented at the 37th Annual Meeting of the Society of Head and Neck Surgeons, Maui, Hawaii, May 2, 1991.

Requests for reprints should be addressed to Deborah S. Ruark, MD, Department of Surgery, Monmouth Medical Center, 300 Second Avenue, Long Branch, New Jersey 07740.

Manuscript received March 20, 1992, and accepted in revised form September 17, 1992.

R econstruction of the primary defect is an essential component of the surgical treatment of head and

neck cancer. Many myocutaneous flaps for use in head and neck reconstruction have been described, including the pectoralis major, sternocleidomastoid, trapezius, and latissimus dorsi flaps [1]. Although various reports about the platysma myocutaneous flap have appeared in the literature during the past two decades [2-9], its use has met with some reluctance. In addition, few series have evaluated the clinical application of this flap in a significant number of patients. For this reason, we have ana- lyzed our experience with patients receiving a platysma myocutaneous flap for reconstruction of intraoral and pharyngeal defects. A comprehensive review of all reported series describing the platysma flap is also presented in order to examine indications, advantages, and complications.

PATIENTS AND METHODS From 1980 to 1990, 41 patients received a platysma

myocutaneous flap in a single-stage primary procedure at the Medical Center of Delaware. The patient population consisted of 27 men and 14 women, with a mean age of 57 years (range: 35 to 80 years). All patients had epidermoid carcinoma of the head and neck region, with tumor size ranging from T1 to T4 (TI: 12%, T2: 22%, T3: 39%, T4: 27%). The primary sites of malignancy were the oral cavity (61%), the oropharynx (32%), and the hypopharynx (7%). Areas of resection included the floor of the mouth, retromolar trigone, tonsillar fossa, tongue, soft palate, and lateral pharyngeal wall. Primary tumor resection was combined with either radical or modified radical neck dissection. Adjuvant therapy included preoperative radiotherapy in 2 patients (5%) and postoperative radiotherapy in 14 patients (34%). Preoperative chemotherapy varying from 2 to 4 courses was administered to 30 patients (73%).

Operative technique: Parallel vertical incisions are outlined starting at the chin medially and mastoid process laterally, with extension to slightly above the clavicle. A horizontal connecting incision at this level within 1 to 2 cm above the clavicle is carried through the platysma muscle, resulting in an "apron" configuration (Figure 1). The skin paddle is then created with an additional transverse incision proximally to outline an island of the appro- priate size (maximum dimensions: 6 X 10 cm). This proximal transverse incision is made through the skin only, and the cervical skin superior to the outlined skin paddle is elevated in a supraplatysmal plane (Figure 2). Care is taken to leave small amounts of subcutaneous tissue on both the platysma surface and the developed

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RUARK ET AL

Figure 1. Initial skin incisions (outlined by broken lines) are made FI I in an apron configuration, is

Figure 4, Radical neck dissection with-en bloc tumor resection is Figure 3. The myocutaneous flap is developed by elevation in a performed, followed by rotation of the flap 90 ~ to 180 ~ into the subplatysmal plane to the level of the mandible, resulting surgical defect.

skin flap. A lip-splitting extension of the apron incision may be used if required for the resection.

The myocutaneous flap is then developed starting at the lower incision by elevating the skin paddle with the attached muscle in a subplatysmal plane to the level of the mandible (Figure 3). The external jugular vein is elevated with the flap on its inferior surface, and the marginal mandibular nerve is preserved during the superior dissec. tion. En bloc resection of the tumor is then performed along with radical or modified radical neck dissection,

including marginal or segmental mandibulectomy if necessary. It is important to note that, during our formal neck dissection, the facial artery is always ligated. The platysma myocutaneous flap is then rotated 90 ~ to 180 ~ depending on the location of the surgical defect (Figure 4) and is sutured into position with a single layer of interrupted, absorbable sutures (Figure 5). The neck incision is dosed primarily over closed-suction drains. The completed platysma myocutaneous flap in a patient is shown in Figure 6, with the neck closure shown in Figure 7.

714 THE AMERICAN JOURNAL OF SURGERY VOLUME 165 JUNE 1993

PLATYSMA MYOCUTANEOUSFLAP

RESULTS Patients were evaluated for both immediate and de-

layed postoperative complications, with follow-up ranging from 17 months to 11 years. Flap-related complications occurred in eight patients (19%). Three patients experienced partial flap necrosis (25% to 40%) involving the epithelium alone. There was no loss of muscle, and, with local care consisting of bedside d6bridement, these flaps healed by secondary intention. Skin sloughing of the neck donor site developed in three patients, one of whom had only minor dehiscence of the suture line. Interesting- ly, one patient did not develop donor-site skin necrosis until 2 months postoperatively, when the patient was near completion of postoperative radiotherapy. Surgical inter- vention of skin grafting to the donor site in the neck was required in two of these patients.

The remaining two patients with complications developed fistulas: one orocutaneous fistula and one pharyngo- cutaneous fistula combined with partial epithelial flap necrosis. The first patient required reoperation for mandibular plate removal to facilitate fistula healing; in the second patient, the fistula closed spontaneously with con- servative management. There were no perioperative deaths. The mean hospital stay for the entire group was

Figure 5. The platysma myocutaneous flap is sutured into position with a single layer of interrupted, absorbable sutures.

Figure 6. Platysma myocutaneous flap sutured into final position Figure 7. Platysma myocutaneous flap with primary closure of intraorally, wrapped around mandibular plate. Arrow indicates chin. neck incision.


RUARK ET AL

13 days. In the subgroup of patients who developed complications, the mean hospital stay was 17 days.

COMMENTS Review of the literature revealed 9 reports of experi-

ence with the platysma myocutaneous flap, for a total of 124 patients (Table I), excluding our series of 41 patients. Prior to these series, a number of methods using cervical tissue had been described for reconstruction of facial and intraoral defects. The lateral cervical island skin flap with platysma described by Farr et al [10] and the "apron" skin flap without platysma reported by Edgerton [11] demonstrated some usefulness. Both techniques had limi- tations, however, and did not gain long-lasting popularity.

Historically, the origin of the platysma flap can be traced back to 1887, when Robert Gersuny, an Austrian surgeon, described his repair of a full-thickness cheek defect [12]. It was not until 1978, however, that the platysma flap, as described by FutreU et al [6], became established as an attractive reconstructive alternative with several potential advantages. The results of our study re-emphasize this conclusion.

The various indications described for the platysma myocutaneous flap consist of reconstruction for congeni- tal abnormalities, traumatic injuries, and, most common- ly, malignancies of the head and neck. Its uses range from external skin coverage in facial reconstruction to functional restoration with internal lining in the upper aerodi- gestive tract.

The potential versatility of the platysma myocutaneous flap has been confirmed by reports showing its role in repair of benign hypopharyngeal strictures [13], reconstruction of the chin and lower lip [14,15], replantation of a totally amputated ear [16], and reconstruction of the trachea in patients with esophageal cancer [17].

The majority of series (67%), however, including our own, describe the primary use of the platysma myocutaneous flap to be soft-tissue replacement and lining for intraoral and pharyngeal defects after tumor resection. Analysis of our results reveals numerous advantages that make the platysma myocutaneous flap our most frequently used flap in head and neck reconstruction. The thinness and pliability of the muscle and skin paddle make it ideal for all positions in the oral cavity, where avoidance of excessive bulk is desirable, particularly in the floor of the mouth and gum regions. There is negligi- ble functional impairment of deglutition, speech, and denture fitting. When this flap is used, minimal time of less than 30 minutes is added to the operative procedure, no new dissection fields are entered, and the cosmetic appearance is optimized by primary closure of the neck incision. With regard to cancer principles, the tumor resection can be generous without concern for the size of the resulting defect, and follow-up procedures for recurrence are easily allowed. In addition, the platysma myocutaneous flap obviates the need for special microsurgical ex- pertise.

Although the majority of primary tumor sites were located in the oral cavity, a high percentage (32%) in our series originated more posteriorly and superiorly in the

oropharynx. In fact, seven patients underwent partial soft palate resection in conjunction with the en bloc tumor ablation. Reconstruction was successfully completed by approximation of the platysma myocutaneous flap to the soft palate mucosal margin, without tension in all cases. Placement of the skin paddle during creation of the platysma myocutaneous flap in soft palate reconstruction did not differ from that in the other 34 patients, as described and illustrated earlier. Segmental mandibular resection with plate reconstruction was necessary in our patients with T4 lesions (27%). The platysma flap provided the advantage of complete muscle wrapping of the plate, thereby decreasing the possibility of plate exposure postoperatively.

Previous reports have stated that one of the major disadvantages of the platysma myocutaneous flap is its dependence on the facial artery to assure flap survival. Conley et al [3] stated that the vascular supply provided by the facial artery cannot be violated without placing the flap at significant risk, and, when this occurs, all or part of the flap is lost in about 40% of patients. Furthermore, Coleman et al [9,18] emphasized that the platysma myocutaneous flap cannot be used in the standard radical neck dissection because the facial artery is divided, which devascularizes the flap. Other authors have incorporated this theory into their reports as fact [4,13-15].

However, Hurwitz et al [7] performed a detailed study of the blood supply of the platysma muscle and found that an intact facial artery is not crucial to the survival of the platysma myocutaneous flap. This conclusion was recently supported in 1991, when McGuirt et al [19] reported their experience with 19 patients receiving a platysma myocutaneous flap with anterior facial artery sacrifice. Excellent results were obtained, with a lower complication rate than those reported in other series that cited sacrifice of the facial artery as a contraindication (Table I). In our series, the facial artery was ligated proximal to the submental artery within the submandibu- lar region routinely in all patients, without significant morbidity. A radical or modified radical neck dissection was performed after harvesting of the platysma flap, without particular attention to preserving a "dominant" vascular pedicle. The platysma muscle and overlying skin are supplied by a multi-axial network of direct cutaneous arteries, and, when the muscle pedicle base is superior (Figure 3), the blood supply from the cheek and lower face is left undisturbed.

Our complication rate of 19% is acceptable. In fact, this incidence of flap-related complications was signifi- cantly lower than those of most of the series reported in the literature (see Table I) and than the average complication rate of 37% when all reported platysma flap series are combined. With regard to other types of reconstructive procedures that may have been used for our group of patients, the pectoralis major myocutaneous flap most closely fits the criteria for selection. Flap-related complication rates with the "workhorse" pectoralis flap vary widely in the literature, but a recent detailed analysis by Shah et al [20] reveals that the incidence may be as high as 63%. We reserve the use of the pectoralis major myo-


PLATYSMA MYOCUTANEOUS FLAP

TABLE I Reported Series of Plastysma Myocutaneous Flaps

No. of No. of Patients Patients With Routine Facial

Year Reference Primary Site of Flap or Flaps Complications (%) Artery Ligation

1978 [6] Intraoral 14 2 (14) Unclear, but implied 1982 [8] Oral cavity 22 12 (55) Unclear, but implied 1983 [9] Face, oral, cavity, oropharynx, neck 24 10 (42) Seldom 1983 [7] Facial (external) reconstruction 8 t (13) Seldom 1983 [5] Intraoral 6 2 (33) Implied 1983 [4] Posterior wall of pharynx 6 3 (50) No 1986 [2.1 Oral cavity 10 4 (40) No 1986 [3] Oropharynx, hypopharynx, supraglottic larynx 14 7 (50) Frequently 1991 [19] Oral cavity, oropharynx, hypopharynx 20 5 (25) Yes 1993 Present series Oral cavity, oropharynx, hypopharynx 41 8 (19) Yes

cutaneous flap for those cases in which excessive bulk is desirable (for example, total glossectomy), for local recurrence necessitating another flap, or when there is a contraindication to the use of a platysma flap.

Reported contraindications to the use of the platysma myocutaneous flap have included prior neck dissection, preoperative irradiation, ipsilateral facial nerve paralysis, and ligation of the facial artery [3,5,8]. We have already proved this last contraindication to be invalid. None of the 41 patients in our series had facial nerve paralysis, so we cannot comment on that factor as a contraindication. However, we do not routinely determine the state of platysma function and development before surgery by hav- ing the patient grimace, as suggested by Cannon et al [8]. The probability of encountering facial nerve palsy is ex- ceedingly low, and, therefore, this caveat is likely to be based on opinion rather than experience.

Previous irradiation to the neck appears to be a rela- tive contraindication to using the platysma flap, although conclusive evidence is lacking. In our series, only two patients (5%) had preoperative radiation; neither developed postoperative complications. In the series reported by Cannon et al [8], five patients received doses of 4,300 rads or more prior to flap reconstruction, and all did well, with no major complications. Despite this information, we suggest caution when considering using the platysma flap in the setting of prior irradiation to the neck, due to potential postradiation arteritis and skin changes.

Previous surgery in the ipsilateral neck that has violated the platysma muscle may result in a precarious blood supply and, therefore, should be considered a contraindication to using this flap. However, McGuirt et al [19] found this concern to be debatable, particularly in patients with prior radical neck dissection. They believed that the key to success was the placement of the neck incision, and the two patients in their series who had undergone previous neck dissection had no postoperative complications. Although this contraindieation remains debatable, we prefer to use other reconstructive methods when this situation exists.

A common concern involving the viability of any reconstructive flap, either myocutaneous or microvascular, is the maintenance of venous drainage. Little emphasis

has been placed on the knowledge and preservation of the venous outflow of the platysma flap, in stark contrast to the arterial supply. Rabson et al [21] noted that, in contrast to the multi-axial arterial supply, there appeared to be a predominantly vertical orientation to venous drainage of the platysma muscle. This observation was made during neck dissections of 17 adult cadavers after great vessel perfusion. In an earlier report by the same group, it was recommended that the external jugular and anterior communicating veins be included on the inferior surface when raising the platysma flap [7]. These investigators found that although the valves of these veins are reversed, these vessels do not usually distend during flap elevation, which suggests a contribution to venous outflow. We con- cur with this finding and consider this an important technical point that ultimately may be essential to flap viability.

Analysis of our results reveals several observations that deserve attention, as they have not been cited in previous reports. A large proportion of our patient population (73%) received induction chemotherapy, which dif- fers from other series. No adverse effect could be demonstrated by administration of preoperative chemotherapy, as evidenced by our low complication rate of 19%. Four- teen patients (34%) received adjuvant postoperative radiotherapy, which did not appear to affect immediate or long-term results of the reconstruction. As mentioned previously, a lip-splitting extension of the apron incision can be used if required for tumor resection without jeop- ardizing the vascularity of the flap. Lastly, large tumor size or invasion of adjacent structures was not a contraindication to the use of the platysma myocutaneous flap, as demonstrated by the fact that two thirds of our patient population had T3 or T4 malignancies.

CONCLUSIONS The platysma myocutaneous flap was used in 41 pa-

tients for reconstruction in the head and neck area, the largest series reported to date. Our results confirm the reliability and versatility of the platysma myocutaneous flap and indicate that the flap can be used without significant morbidity. Contrary to previous reports, routine ligation of the facial artery was not found to have an adverse effect on flap viability. Because of the stated


RUARK ET AL

benefits and results, we advocate the use of the platysma myocutaneous flap in head and neck reconstruction after ablative cancer surgery.

R E F E R E N C E S 1. Ariyan S, Cuono B. Myocutaneous flap for head and neck reconstruction. Head Neck Surg 1980; 2: 321-45. 2. Manni J J, Bruaset I. Reconstruction of the anterior oral cavity using the platysma myocutaneous island flap. Laryngoscope 1986; 96: 564-7. 3. Conley J J, Lanier DM, Tinsley P Jr. Platysma myocutaneous flap revisited. Arch Otolaryngol Head Neck Surg 1986; 112: 711-3. 4. Nieto CS, Gallego LL, Cortes JCG. Reconstruction of the posterior wall of the pharynx using a myocutaneous platysma flap. Br J Hast Surg 1983; 36: 36-9. 5. Persky MS, Kaufman D, Cohen NL. Platysma myocutaneous flap for intraoral defects. Arch Otolaryngol 1983; 109: 463-4. 6. Futrell JW, Johns ME, Edgerton MT, Cantrell RW, Fitz-Hugh GS. Platysma myocutaneous flap for intraoral reconstruction. Am J Surg 1978; 136: 504-7. 7. Hurwitz D J, Rabson JA, Futrell JW. The anatomic basis for the platysma skin flap. Plast Reconstr Surg 1983; 72: 302-14. 8. Cannon CR, Johns ME, Atkins JP Jr, Keane WM, Cantrell RW. Reconstruction of the oral cavity using the platysma myocutaneous flap. Arch Otolaryngol 1982; 108: 491-4. 9. Coleman JJ III, Jurkiewicz M J, Nahai F, Mathes SJ. The platysma musculocutaneous flap: experience with 24 cases. Plast Reconstr Surg 1983; 72: 315-23. 10. Farr HW, Jean-Gilles B, Die A. Cervical island skin flap repair of oral and pharyngeal defects in the composite operation for can-

cer. Am J Surg 1969; 118: 759-63. 11. Edgerton MT Jr. Replacement of lining to oral cavity following surgery. Cancer 1951; 4: 110-9. 12. Gersuny R. Plastischer Ersatz de Wangenscheimhaut. Zen- tralbl Chir 1887; 14: 706. 13. Friedman M, Schild JA, Venkatesan TK. Platysma myocutaneous flap for repair of hypopharyngeal strictures. Ann Otol Rhinol Laryngol 1990; 99: 945-50. 14. Yeo JF, Egyedi P. Reconstruction of soft tissues of the chin and lower lip region following excision of a basal cell carcinoma. J Craniomaxillofac Surg 1988; 16: 337-9. 15. Posnick JC, MeCraw JB. Reconstruction of the chin-lower cheek complex with a platysma myocutaneous flap. J Oral Maxillo- fae Surg 1988; 46: 152-5. 16. Ariyan S, Chicarilli ZN. Replantation of a totally amputated ear by means of a platysma musculocutaneous "sandwich" flap. Plast Reeonstr Surg 1986; 78: 385-9. 17. Sodeyama H, Matsuo K, Ishizaka K, et al. Platysma musculocutaneous flap for reconstruction of trachea in esophageal cancer. Ann Thorac Surg 1990; 50: 485-7. 18. Coleman JJ III, Nahai F, Mathes SJ. Platysma musculocutaneous flap: clinical and anatomic considerations in head and neck reconstruction. Am J Surg 1982; 144: 477-81. 19. McGuirt WF, Matthews BL, Brody JA, May JS. Platysma myocutaneous flap: caveats reexamined. Laryngoscope 1991; 101: 1238-44. 20. Shah JP, Haribhakti V, Loree TR, Sutaria P. Complications of the pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1990; 160: 352-5. 21. Rabson JA, Hurwitz DJ, Futrell JW. The cutaneous blood supply of the neck: relevance to incision planning and surgical reconstruction. Br J Plast Surg 1985; 38: 208-19.

EDITORIAL COMMENT

Erie E. Peacock, Jr., MD, Chapel Hill, North Carolina

Many years ago, there was a familiar saying in plastic surgery, "Maturity can be evaluated by how often a reconstructive surgeon thinks of using a flap to reconstruct a defect and then finds a way to make a free graft suffice." The adage arose because a generation of young plastic surgeons trained in military hospitals, where time and expense were not factors and where most patients were young and could be immobilized in extreme positions for relatively long periods, entered civilian practice with a fond- ness for flap restorations. Although the cost of hospitalization was not the factor in the 1950s that it is now, the advisability of using free grafts in older patients was a lesson that had to be learned in the post-war decade.

History repeats itselfl Another

From the Department of Plastic Surgery, Uni- versity of Virginia, Charlottesville, Virginia.

generation of young plastic surgeons, highly trained to use expensive equipment, often in university research- oriented centers, have entered practice in the last days of fee-for-service practice. My observations are that many of these surgeons consider a restorative problem primarily as an opportunity to utilize their extraordi- nary technical skill and the hospital's extraordinarily expensive equipment to reconstruct defects utilizing free flap transfer by microvascular anastomosis of tiny blood vessels. Al- though the chapter on the history of the development of free flap restorations is one of the most exciting and productive in the annals of our spe- cialty, all of the results have not been good. Two problems have become painfully evident. The first problem, of course, is expense. The relatively enormous cost of transplanting tissue on a microvascular anastomosis has

been obvious since its inception. An example is a complicated soft tissue defect involving exposure of bone and joints in the lower extremity. Ex- pense is not a factor in these problems; we simply were not able to solve them satisfactorily before free flap transfers became available. Other problems, however, including head and neck and upper extremity defects, often can be solved without re- sorting to free flap transfers, and, when this is the case, expense may be a major factor.

The second factor is the diminu- tion of standards for donor site ac- ceptability and final restorative appearance. Many upper extremity restorations by free flap transfer simply would not be acceptable following a free graft or pedicle flap reconstruction. The placement of incision lines, the bulk and quality of coverage, and donor site appearance seem


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Head and neck reconstruction using the platysma myocutaneous flap