Head and Neck Reconstruction Head and Neck Reconstruction with with MyocutaneousMyocutaneous and and FasciocutaneousFasciocutaneous FlapsFlaps

Amy K HsuAmy K HsuNYPH NYPH –– Weill Cornell Medical CenterWeill Cornell Medical Center

July 5, 2007July 5, 2007

BASIC FLAP THEORYBASIC FLAP THEORY

Flap ReconstructionFlap Reconstruction

ContouringContouringResurfacingResurfacingExposed surfaces (carotid, skin defect)Exposed surfaces (carotid, skin defect)Recreate Recreate resectedresected lumenlumenImproving function by providing tissue Improving function by providing tissue bulkbulkBring healthy tissue into defect site (nonBring healthy tissue into defect site (non--irradiated)irradiated)

Blood Supply To SkinBlood Supply To Skin

Segmental VesselsSegmental VesselsLarge vesselsLarge vesselsDeep to muscleDeep to muscleGives rise to perforatorsGives rise to perforatorsPerfusion pressure similar to aortaPerfusion pressure similar to aorta

Perforator VesselsPerforator VesselsPerfusesPerfuses musclemuscleCommunication between deeper segmental vessels and Communication between deeper segmental vessels and cutaneouscutaneousvessels (e.g., vessels (e.g., thoracoacromialthoracoacromial artery, artery, intercostalintercostal perforators)perforators)

CutaneousCutaneous VesselsVesselsMusculocutaneousMusculocutaneous: dominant supply to skin, perpendicular: dominant supply to skin, perpendicularDirect Direct CutaneousCutaneous: parallel, associated with vein, larger perfusion area: parallel, associated with vein, larger perfusion area

SubdermalSubdermal PlexusPlexusDermal PlexusDermal Plexus

Types of Types of CutaneousCutaneous FlapsFlaps

FasciocutaneousFasciocutaneousAxialAxial

Vessels (direct Vessels (direct cutaneouscutaneous) follow long axis of flap and supply ) follow long axis of flap and supply dermal / dermal / subdermalsubdermal plexusplexusViability related to length of vesselViability related to length of vessel

RandomRandomBlood supply from Blood supply from musculocutaneousmusculocutaneous arteries via dermal / arteries via dermal / subdermalsubdermal plexusplexusMaximum viable length related to Maximum viable length related to base:lengthbase:length ratioratio

MyocutaneousMyocutaneousBlood supply from perforators in underlying muscleBlood supply from perforators in underlying muscle

Optimizing Flap ViabilityOptimizing Flap Viability

Patient factorsPatient factorsGood nutritional statusGood nutritional statusDiabetic, SmokerDiabetic, SmokerAdequate hemoglobin levelAdequate hemoglobin level

Surgical techniqueSurgical techniqueAdvance flap planningAdvance flap planningMinimize tension, kinking, and pressureMinimize tension, kinking, and pressureAdequate Adequate hemostatishemostatis to avoid to avoid hematomahematomaAdequate dimensions of subcutaneous tunnel to prevent Adequate dimensions of subcutaneous tunnel to prevent pressure from overlying skin in tunneled flappressure from overlying skin in tunneled flap

Delay phenomenonDelay phenomenonArteriographyArteriography

Assessing Flap ViabilityAssessing Flap Viability

ColorColorPale/White: inadequate arterial flowPale/White: inadequate arterial flowDusky/Blue: inadequate venous drainageDusky/Blue: inadequate venous drainage

Dermal BleedingDermal BleedingAreas of dark bleedingAreas of dark bleedingNeedle prick testNeedle prick test

FluoresceinFluorescein DyeDyeIntact circulation fluoresces with UV lightIntact circulation fluoresces with UV lightAbscenseAbscense of fluorescence suggests poor capillary of fluorescence suggests poor capillary diffusion and possible future necrosisdiffusion and possible future necrosis

Enhancing Flap ViabilityEnhancing Flap Viability

Postoperative ManagementPostoperative ManagementEvacuation of Evacuation of hematomahematomaProperly functioning drainage tubes (separate drainage for Properly functioning drainage tubes (separate drainage for defect and donor site)defect and donor site)Antibiotic prophylaxisAntibiotic prophylaxis

Minimize Ischemic InsultsMinimize Ischemic InsultsHeparinHeparinSteroidsSteroidsASA and ASA and dypyridamoledypyridamole

Methods with potential applicationMethods with potential applicationVasodilators, hyperbaric oxygen, hypertensive perfusion, Vasodilators, hyperbaric oxygen, hypertensive perfusion, hypothermia, hypothermia, DextranDextran

Flap TypesFlap Types

PectoralisPectoralis MajorMajorDeltopectoralDeltopectoralLatissimusLatissimus DorsiDorsiTrapeziusTrapezius

PectoralisPectoralis Major FlapMajor Flap

Surgical AnatomySurgical Anatomy

Flap Type: Flap Type: MyocutaneousMyocutaneousBordersBorders

Superior: medial half of clavicleSuperior: medial half of clavicleInferior: cartilaginous portions of 6thInferior: cartilaginous portions of 6th--7th ribs7th ribsMedial: lateral border of sternumMedial: lateral border of sternumLateral: proximal Lateral: proximal sulcussulcus of of humerushumerus

Nerve SupplyNerve SupplyLateral pectoral nerve: travels medially on deep Lateral pectoral nerve: travels medially on deep surface of musclesurface of muscleMedial pectoral nerve: pierces Medial pectoral nerve: pierces pectoralispectoralis minor, 2minor, 2--3 3 branches to branches to pectoralispectoralis majormajor

Surgical AnatomySurgical Anatomy

Vascular SupplyVascular SupplyDominant supplyDominant supply

Pectoral branch of Pectoral branch of thoracoacromialthoracoacromial artery forms artery forms segmental blood supplysegmental blood supply

Adjunctive supplyAdjunctive supplyLateral thoracic arteryLateral thoracic arteryPectoral branches of Pectoral branches of intercostalintercostal arteriesarteries

IndicationsIndications

IntraoralIntraoral defects (tongue, FOM, defects (tongue, FOM, tonsillartonsillar fossafossa))External External cutaneouscutaneous defectsdefectsCombined Combined intraoralintraoral and and cutaneouscutaneous defectsdefectsCircumferential Circumferential pharyngopharyngo--esophageal defectsesophageal defectsLaryngopharyngectomyLaryngopharyngectomy with skin defectwith skin defectTemporal bone resectionTemporal bone resectionOrbital or facial defectsOrbital or facial defectsEsophageal stricture with esophageal reconstructionEsophageal stricture with esophageal reconstructionPyriformPyriform fossafossa defectdefectExposed carotid arteryExposed carotid artery

Types of Types of PectoralisPectoralis FlapsFlaps

MyocutaneousMyocutaneous “peninsula”: muscle and “peninsula”: muscle and skin raised togetherskin raised togetherMyocutaneousMyocutaneous “island”: muscle provides “island”: muscle provides pedicle, island of skin raised on lower part pedicle, island of skin raised on lower part of muscleof muscleNeurovascular island: vascular pedicle, Neurovascular island: vascular pedicle, distal portion with muscle and overlying distal portion with muscle and overlying skinskin

Surgical TechniqueSurgical Technique

After dissection down to the After dissection down to the pectoralispectoralis fascia, the fascia, the pectoralispectoralis muscle is muscle is incised and divided along muscle fiber bundlesincised and divided along muscle fiber bundlesPectoralisPectoralis major is elevated medially away from chest wall and underlying major is elevated medially away from chest wall and underlying pectoralispectoralis minor thus permitting identification of the neurovascular bundlminor thus permitting identification of the neurovascular bundle e on the undersurface of the on the undersurface of the pectoralispectoralis majormajorMuscle splitting incision is then extended Muscle splitting incision is then extended inferomediallyinferomedially and parallel to and parallel to nutrient vesselsnutrient vesselsIncision is made around the circumference of the distal Incision is made around the circumference of the distal parasternalparasternalcutaneouscutaneous flap (skin paddle) to prepare it to fit into surgical defect inflap (skin paddle) to prepare it to fit into surgical defect in the the head/neckhead/neckMuscle pedicle is dissected proximally up towards the clavicleMuscle pedicle is dissected proximally up towards the clavicleFlap positioned in the neck through a subcutaneous tunnel with tFlap positioned in the neck through a subcutaneous tunnel with the axis of he axis of rotation around the rotation around the midclaviclemidclavicleSkin paddle may be trimmed to the appropriate size/shape/thickneSkin paddle may be trimmed to the appropriate size/shape/thickness to fit ss to fit defectdefect

AdvantagesAdvantages

Single stage reconstructive procedureSingle stage reconstructive procedureCan be done with patient supine (no repositioning Can be done with patient supine (no repositioning necessary)necessary)Minimal donor site morbidity, easy to harvestMinimal donor site morbidity, easy to harvestRobust flap with strong axial blood supplyRobust flap with strong axial blood supplyLarge Large cutaneouscutaneous surface availablesurface availableMaximal arc of rotation and maximal reach (up to lateral Maximal arc of rotation and maximal reach (up to lateral canthuscanthus))Restores Restores resectedresected tissue bulktissue bulkExcellent protection for exposed carotid arteryExcellent protection for exposed carotid arteryCosmetically acceptableCosmetically acceptableSubsequent use of other regional flaps is possibleSubsequent use of other regional flaps is possible

DisadvantagesDisadvantages

CutaneousCutaneous portion of flap may have hairportion of flap may have hairColor match to facial skin not idealColor match to facial skin not idealPostPost--op scarring and deformity of chest, breast op scarring and deformity of chest, breast deformity in womendeformity in womenTransfer of excessive tissue bulk (usually Transfer of excessive tissue bulk (usually cosmetic but may be functional as well)cosmetic but may be functional as well)Lengthens surgical procedureLengthens surgical procedureLoss of Loss of pectoralispectoralis function (especially if function (especially if concurrent injury to CN XI)concurrent injury to CN XI)

DeltoDelto--Pectoral FlapsPectoral Flaps

Surgical AnatomySurgical Anatomy

Flap Type: Flap Type: FasciocutaneousFasciocutaneousBorders:Borders:

Superior: length of clavicleSuperior: length of clavicleInferior: middle portion of Inferior: middle portion of pectoralispectoralis muscle (depends on width muscle (depends on width of flap taken)of flap taken)Medial: lateral aspect of sternumMedial: lateral aspect of sternumLateral: deltoid muscle to posterior Lateral: deltoid muscle to posterior axillaryaxillary line (depends on line (depends on length of flap taken)length of flap taken)

Vascular SupplyVascular SupplyPerforating branches of 2ndPerforating branches of 2nd--4th 4th intercostalintercostal artery (from internal artery (from internal mammary artery)mammary artery)Deltoid perforator in midDeltoid perforator in mid--lateral position of shoulderlateral position of shoulderAxial flap medial to Axial flap medial to deltopectoraldeltopectoral groove, random flap laterallygroove, random flap laterally

Surgical TechniqueSurgical Technique

IntercostalIntercostal perforators become the pedicleperforators become the pedicleFascia must be included in flap (Fascia must be included in flap (anastamosinganastamosing vessels lie vessels lie just superficial to the deep fascia covering the just superficial to the deep fascia covering the pectoralispectoralismajor and deltoid muscles)major and deltoid muscles)To fill longer defects, this flap can be extended To fill longer defects, this flap can be extended posteriorlyposteriorly or down arm (delayed/twoor down arm (delayed/two--staged procedure)staged procedure)If there is doubt to viability of flap, especially in the If there is doubt to viability of flap, especially in the elderly, it can be delayed for 10 days prior to placementelderly, it can be delayed for 10 days prior to placementClosure of donor site with skin graftClosure of donor site with skin graft

ConsiderationsConsiderations

IndicationsIndicationsInternal and external defects of oral cavity, Internal and external defects of oral cavity, oropharynxoropharynx, , hypopharynxhypopharynxFacial reconstruction with large Facial reconstruction with large cutaneouscutaneous defectsdefectsCarotid coverage after Carotid coverage after pharyngocutaneouspharyngocutaneous fistula formationfistula formationHypopharyngealHypopharyngeal reconstruction reconstruction

AdvantagesAdvantagesBest color match and texture for facial reconstructionBest color match and texture for facial reconstructionFlap can reach as high as the Flap can reach as high as the zygomaticzygomatic archarchThinner than Thinner than pectoralispectoralis ((reconstrutionreconstrution of skin, mucosal surfaces)of skin, mucosal surfaces)

DisadvantagesDisadvantagesLeaves unsightly donor siteLeaves unsightly donor siteMay require a delayed/twoMay require a delayed/two--staged procedurestaged procedureContraindicated if prior cardiac surgery (use of internal mammarContraindicated if prior cardiac surgery (use of internal mammary y artery)artery)

LatissimusLatissimus DorsiDorsi FlapsFlaps

Surgical AnatomySurgical Anatomy

Flap Type: Flap Type: MyocutaneousMyocutaneousBordersBorders

Medial: posterior spineMedial: posterior spineLateral: posterior Lateral: posterior axillaryaxillary foldfold

Vascular SupplyVascular SupplyPredominantly from the Predominantly from the thoracodorsalthoracodorsal artery arising artery arising from the from the subscapularsubscapular artery (enters the artery (enters the latissimuslatissimusmuscle 12 cm below the muscle 12 cm below the axillaaxilla along the posterior along the posterior axillaryaxillary fold)fold)Adjunctive supply from perforating branches of Adjunctive supply from perforating branches of intercostalintercostal arteriesarteries

Surgical TechniqueSurgical Technique

Incise anterior border of Incise anterior border of latissimuslatissimus muscle flap and skin muscle flap and skin island, and raise the muscle off the chest wallisland, and raise the muscle off the chest wallIdentify pedicle as it enters the muscle and dissect it as Identify pedicle as it enters the muscle and dissect it as far as the far as the axillaryaxillary vesselsvesselsWhen the vascular pedicle has been separated from the When the vascular pedicle has been separated from the rest of the muscle, the muscle itself can be divided just rest of the muscle, the muscle itself can be divided just proximal to the insertion of the pedicle, allowing for proximal to the insertion of the pedicle, allowing for great mobilitygreat mobilityMuscle flap and skin island is passed deep to the Muscle flap and skin island is passed deep to the pectoral head of the pectoral head of the pectoralispectoralis major, brought through major, brought through the muscle below the clavicle, and passed beneath the the muscle below the clavicle, and passed beneath the skin of the neck to resurface either face or skullskin of the neck to resurface either face or skull

AdvantagesAdvantages

Indications: similar to those of Indications: similar to those of pectoralispectoralis major flap (less major flap (less common), also used for breast reconstructioncommon), also used for breast reconstructionOut of irradiated fieldOut of irradiated fieldResidual donor defect of less than 10 cm in width can be Residual donor defect of less than 10 cm in width can be closed by undermining and advancement of wound edgesclosed by undermining and advancement of wound edgesVersatile flap with large amount of skin and soft tissue, Versatile flap with large amount of skin and soft tissue, latissimuslatissimus dorsidorsi covers most of back, and portions of it may covers most of back, and portions of it may be used at a timebe used at a timeExtended arc of rotation (to vertex of scalp)Extended arc of rotation (to vertex of scalp)Muscle is supplied by multiple vascular pedicle perforators on Muscle is supplied by multiple vascular pedicle perforators on the whole of its deep surfacethe whole of its deep surfaceLess hair transferLess hair transferPotential for Potential for bilobedbilobed skin islandsskin islands

DisadvantagesDisadvantages

Color match to facial skin is poorColor match to facial skin is poorFlap may be bulky in large patientsFlap may be bulky in large patientsRequires repositioning to lateral Requires repositioning to lateral decubitusdecubitusPropensity for Propensity for seromaseroma formation at donor siteformation at donor siteRequires extended tunneling between Requires extended tunneling between pectoralispectoralismajor/minormajor/minorFunctional defect in patients with radical neck Functional defect in patients with radical neck dissection and sacrifice of CN XIdissection and sacrifice of CN XI

TrapeziusTrapezius FlapsFlaps

Surgical ConsiderationsSurgical Considerations

Superiorly Based (Upper) Superiorly Based (Upper) TrapeziusTrapezius FlapFlap::Blood supply: occipital artery, Blood supply: occipital artery, paraspinalparaspinal perforatorsperforatorsReliable flap, limited arc of rotations, may require skin graftReliable flap, limited arc of rotations, may require skin graft

Lateral Island Lateral Island TrapeziusTrapezius FlapFlapBlood supply: superficial branches of transverse cervical Blood supply: superficial branches of transverse cervical arteryarteryUses: defects of Uses: defects of oropharynxoropharynx, posterior oral cavity, , posterior oral cavity, hypopharynxhypopharynx

Inferior (Lower) Inferior (Lower) TrapeziusTrapezius Island FlapIsland FlapBlood supply: descending branches of transverse cervical artery,Blood supply: descending branches of transverse cervical artery,dorsal scapular arterydorsal scapular arteryLong pedicle, most commonly used Long pedicle, most commonly used trapeziustrapezius flapflap

ConsiderationsConsiderations

Indications: Indications: oropharyngealoropharyngeal and and hypopharyngealhypopharyngeal defects, defects, lateral neck, posterior facelateral neck, posterior faceAdvantages:Advantages:

Three forms allow for versatilityThree forms allow for versatilityRelatively flat and thinRelatively flat and thinSingle stage procedureSingle stage procedure

Disadvantages:Disadvantages:Relatively limited arc of rotationRelatively limited arc of rotationSignificant donor site morbidity (upper extremity weakness)Significant donor site morbidity (upper extremity weakness)May require skin graft closureMay require skin graft closureWeaker blood supplyWeaker blood supplyAwkward positioningAwkward positioning

Summary of Vascular SupplySummary of Vascular Supply

PectoralisPectoralisPectoral branch of Pectoral branch of thoracoacromialthoracoacromial arteryartery

DeltopectoralDeltopectoralIntercostalIntercostal perforators from internal mammary arteryperforators from internal mammary artery

LatissimusLatissimus DorsiDorsiThoracodorsalThoracodorsal artery (from artery (from subscapularsubscapular artery)artery)

TrapeziusTrapeziusOccipital artery, transverse cervical arteryOccipital artery, transverse cervical artery

THANK YOUTHANK YOU

Dr. Dr. ReisacherReisacherKathyKathy

ReferencesReferences

1.1. Ward, P.H., Berman, W.E.: “Plastic and Reconstructive Ward, P.H., Berman, W.E.: “Plastic and Reconstructive Surgery of the Head and Neck”. Mosby Company (1984) : Surgery of the Head and Neck”. Mosby Company (1984) : Vol. 2, pgs. 860Vol. 2, pgs. 860--979.979.

2.2. Rowe, N.L., Williams, J.L. : “Maxillofacial Injuries”. Rowe, N.L., Williams, J.L. : “Maxillofacial Injuries”. ChurchhillChurchhill Livingstone (1985): pgs. 609Livingstone (1985): pgs. 609--617.617.

3.3. Milton, S.H.: Pedicle skin flaps: the fallacy of the length, Milton, S.H.: Pedicle skin flaps: the fallacy of the length, width, and ratio, Br. J. width, and ratio, Br. J. SurgSurg. 57: 502, 1970.. 57: 502, 1970.

4.4. ReinischReinisch, J.F.: The , J.F.: The pathophysiologypathophysiology of skin flap circulationof skin flap circulation--the delay phenomenon, the delay phenomenon, PlastPlast. . ReconstrReconstr. . SurgSurg. 54: 585, . 54: 585, 1974.1974.

5.5. BaekBaek, S., Lawson, W., , S., Lawson, W., BillerBiller, H.F.: An analysis of 133 , H.F.: An analysis of 133 pectoralispectoralis major major myocutaneousmyocutaneous flaps, flaps, PlastPlast. . ReconstrReconstr. . SurgSurg. . 36: 173, 1965.36: 173, 1965.