Split Flap in Head and Neck Reconstruction

Thomas J. Krizek, MD, New Haven, Connecticut Martin C. Robson, MD, New Haven, Connecticut

An intact skin bridge remains an inviolate compo- nent of descriptions of well designed pedicle flaps. Despite an overwhelming amount of experimental data and clinical experience to the contrary, the skin is commonly accepted as a major contributor to the blood supply of pedicle flaps. Flap recon- struction of head and neck surgical defects is often limited by the constraints of the size, shape, and surface characteristics of the donor pedicle flap tissue. Most pedicle flaps require secondary proce- dures to divide the intact skin, attempt contour- ing, and complete the closure.

In a series of experiments, Milton [I] made the incisive observation that the length to width ratio of a flap was irrelevant as long as the chosen width of the flap contained a sufficiently large vessel. Secondly, he concluded that if such a seg- mental vessel were present, the skin of the pedi- Cle itself could be dispensed with altogether. The deltopectoral flap of Bakamjian [2] is clearly such a pedicle flap. Based on the known segmental vas- culature of the perforating vessels of the internal mammary system, the flow is axial toward the shoulder. McGregor and Jackson [3] attribute the safety of the deltopectoral flap to a self-contained, virtually closed, arteriovenous system within the area of the flap. This being true, the deltopectoral flap should functionally be an "island" pedicle. Although the necessity for transferring the flap as a true island has not yet presented itself, the prin- ciples of island flap transfer have been applied to the deltopectoral flap.

From the Department of Surgery, Section of Plastic and Reconstruc- tive Surgery, Yale University School of Medicine, New Haven, Con- necticut.

Reprint requests should be addressed to Dr Krizek, Yale University School of Medicine, 333 Cedar Street, New Haven, Connecticut 06510.

Presented at the First Join! Meeting of the Society of Head and Neck Surgeons and the American Society for Head and Neck Sur- gery, Hot Springs. Virginia, April 30 to May 2, .1973.

Vertical Split Flap

The deltopectoral flap may be raised as a unit and then divided vertically into two tongues of tissue. (Figure l.) These separate tongues may be fashioned to fit into irregular or multiple defects. They may be also folded on themselves to provide both lining and external surfacing to close orocu- taneous fistulas. The advantage of the split flap is the opportunity to provide lining without having to either introduce a second pedicle flap or line the flap itself with a skin graft at a preliminary procedure. The intact skin bridges, however, re- quire a second procedure t6 achieve closure.

Tangential Split F.lap

'The deltopectoral flap may also be "split" tan- gentially by de-epithelization of portions of the flap. (Figure 2.) Removal of the cutaneous bridge enables the entire "carrying" portion of the flap to be buried permanently beneath the skin of the neck. (Figure :3.) The distal portion of the flap may be used for resurfacing skin defects or for in- traoral lining. No secondary procedure is neces- sary for dividing the flap or for complete closure.

The distal aspect of the flap is carefully fitted to the defect to be closed. The skin is carefully in- cised down to the immediate subdermal level. All proximal skin is meticulously excised by free hand dissection, hopefully preserving the subdermal vascular plexus. Epidermal remnants in the form of the base of hair follicles or eccrine glands may indeed be left on the flap but have presented no clinical problem [4]. The tangential excision has been employed in hirsute persons to remove most follicles [5]. When covered with skin grafts, the flap can he used to line or to reconstruct totally the cervical esophagus without the problem of hair growth.

488 The American Journal of Surgery

Split Flap in Reconstruction

Combined Split Flap

The advantages of both the vertical and the tangential split may be combined in the deltopec- total flap. (Figure 4.) The opportunity of splitting the flap vertically provides tissue for internal Hn- ing as well as external resurfacing in oral and hy- popharyngeal fistulas. Meticulous de-epitheliza- tion will convert the split lining segment into a functional island of tissue. Circumferential closure of the defect may then be accomplished; the fistu- la is completely closed and no secondary revision- al procedure is necessary. (Figure 5.)

Comments

The concept of island flap transfer is not new. After Dunham's [6] two stage creation of an island in 1893, Monks [7] reconstructed an eyelid with a temporal island flap in 1898. A well defined isolat- ed vasculature formed the basis of Esser's [8] early island flaps for reconstruction of facial injuries during World War I. More recently, island flaps Figure 1. The vertically sprit deltopectoral flap.

Figure 2. A, de-epithelization of the proximal, buried portion of the flap; B, conversion of the flap into an is land, making closure com- plete and a secondary stage un- necessary. ® [] 0, E,ith0,,iiz,d ,

Figure 3. A, large preauricular de- fect, with deltopectoral f lap de- epithelized proximal ly; B, flap in- serted beneath neck skin, and closure completed in one stage.

Volume 126, October 1973 489

Krizek and Robson

© i

~ Oe-[pithetialized A~ea

Figure 4. Deltopectoral flap split vertically. Proximal de.eplthelization converts portion of flap into island uselul for lining.

based on the superficial temporal [4] and supraor- bital vessels [9] have been employed to advantage, The neurovascular island pedicle flap of Littler [I0] is part of every hand surgeon's armamentari- urn. Corso [11] has carefully reviewed the vascula- ture of the face, documenting the many possible flaps which can be designed.

Even lacking the well defined anatomic docu- mentat ion of vasculature, others have tangentially split flaps by de-epithelizing their cutaneous bridges. By this maneuver, they have functionally converted the flaps into islands sustained on the subdermal ple'.~us. DesPrez and Kiehn [12] turned neck skin into the oral cavity for lining and de.. scribed de-epithelizing all intervening buried tis- sue, Champion [13] described a similar maneuver, folding a portion of a forehead flap into the mouth for lining buccal mucosa and using the remainder for cheek resurfacing. To convert the fistula clo- sure to a single stage procedure, he de-epithelized the bridge of tissue comprising the fold. Geor- glade, Mladick, and Thorne [14] de-epithelized a

Figure 5. A, orocutaneous defect; B, flap with island outlined; C , island created by vertical split and proximal de-epithelization; D, island being inserted for lining, re- mainder of flap being used for ex- ternal cover.

490 Thl American dourna| of Surgery

Split Flap in Reconstruction

portion of a nasolabial flap to facilitate recon- struction of the upper lip. These recommendations are referred to almost incidentally in the course of their descriptions.

The rationale, for the maneuver, however, is be- coming bet ter documented. Milton [I] confirmed that the skin bridge was not necessary. Salyer, Nickell, and Hammerick [15] and Daniel and Wil- liams [16] suggest that not only is this skin bridge unnecessary, but it may also be detr imental t o the vasculature of a flap. They demonstrated that the planning of flaps about a known arterial blood supply is of greater importance than the integrity of a skin bridge.

The deltopectoral flap is based on such a known vasculature. Therefore, splitting the flap either vertically or tangentially is theoretically sound. Vertical splitt ing of the Abbe flap, similarly based on a demonstrable artery, has been reported by Cannon [I7]. Other well known flaps which would lend themselves to vertical and/or tangential splitting would be the forehead flap [18] based on the superficial temporal and posterior auricular vessels, the groin flap [19] based on the superficial circumflex lilac vessels, and the hypogastric flap [20] based on the superficial inferior epigastric vessels.

Summary and Conclusions

The deltopectoral flap with its self-contained vasculature is functionally an island flap. It may be split vertically to provide two distal tongue~ of tissue. It may be split tangentially such that the distal tissue will survive as an island and may be completely implanted in one stage. Finally, a combination of a vertical incision and de-epitheli- zation of a distal island of skin makes it possible to insert intraluminal lining and complete exter- nal coverage in one stage.

References

1. Milton SH: The tubed pedicle flap. Br J Plast Surg 22: 53, 1969.

2. Bakamjian VK: Total reconstruction of pharynx with a medial ly based deltopectoral skin flap. NY State J Med 68: 2771, 1968.

3. McGregor IA, Jackson IT: The extended role of the deltopectoral flap. Br J Plast Surg 23:173, 1970.

4. Kernahan, DA, Litt lewood AHM: Experience in the use of arterial flaps about the face. Plast Reconstr Surg 28: 207, 1961.

5. Krizek TJ, Robson MC: The deltepectorat flap for recon- struction of irradiated head and neck cancer patients. Surg Gynecol Obstet 135: 787, 1972.

6. Dunham T: A method for obtaining a skin-flap from the scalp and a permanent buried vascular pedicle for covering defects of the face. Ant1 Surg 17: 677, 1893.

7. Monks GH: The restoration of the lower eyelid by a new method. Boston Med Surg J 139" 385, 1898.

8. Esser J FS: Island flaps. N Y Med J 106: 264, 1917. 9. Converse JM, Wood-Smith D: Experiences with the fore-

head island flap with a subcutaneous pedicle. Plast Reconstr Surg 31 : 522, 1963.

10. Littler JW: The neurovascular pedicle~method of digital transposition for reconstruction of the thumb. Plast Reconstr Surg 12: 303, 1953.

11. Corso PR: Variations of the arterial, venous, and capil- lary circulation of the soft tissues of the head by dec- ades as demonstrated by the methyl methacralate in- jection technique, and their application to the con- struction of flaps and pedicles. Plast Reconstr Surg 27: 160, 1961.

12. DesPrez JD, Kiehn CL: Methods of reconstructioq of an- terior oral cavity and mandible for malignancy. Plast Reconstr Surg 24: 238, 1959.

13. Champion R: Closure of full-thickness cheek loss by forehead flap. Br J Plast Surg 13: 76, 1960.

14. Georgiade NG, Mladick RA, Thorne FL: Nasolabial tun- nel flap. Plast Reconstr Surg 43: 463, 1969.

15. Satyer KE, Nickell WB, Hammerick JM: Survival of vas- cular pedicle island flaps. Surg Forum 22: 505, 1972.

16. Daniel RK, Williams HB: Experimental arterial flaps. Surg Forum 22: 507, 1972.

17. Cannon 8: The split vermil ion flap. Surg Gynecol Obstet 73: 95, 1941.

18. Hoopes JE, Edgerton MT: Immediate forehead flap re- pair in resection for oropharyngeal cancer. Am J Surg 112: 527, 1966.

19. McGregor IA, Jackson IT: The groin flap. Br J Plast Surg 25: 3, 1972.

20. Shaw DT, Payne RL: One staged tubed abdominal flaps. Surg Gynecol Obstet 83: 205, 1946.

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