3 18 J. Cranio-Max.-Fac. Surg. 17 (1989)

J. Cranio-Max.-Fac. Surg. 17 (1989) 318-322 © Georg Thieme Verlag Stuttgart • New York

The Platysma Myocutaneous Flap for Oral Reconstruction Experience with MacFee's Cervical Incision

Yujiro Handa 1, Tadashi Kitajima 2, Norio Takagi 3, Tadashi Yasuoka 3, Kouichi Naitoh 2, Norichika Tatematsu 3, Nobumitsu Oka 3

1 Dept. of Oral-Maxillofacial Surgery and Stomatology, 2 (Head: Dr. Y. Handa, D.M.D., D.M.Sc.), Shizuoka Saiseikai Hospital Dept. of Maxillofacial Surgery and Stomatology

3 (Head: Dr. T. Kitajima, D.M.D., D.D.Sc.), Shimada Municipal Hospital Department of Oral and Maxillofacial Surgery (Head: Prof. N. Oka, D.M.D., D.M.Sc.), Gifu University, School of Medicine, Japan

Submitted 24.7. 1988; accepted 22.11. 1988

Summary

The present study was performed to demonstrate and evaluate the effectiveness of the Platysma Myocutane- ous Flap in conjunction with MacFee's cervical inci- sion (MacFee, 1960) for reconstruction after oral can- cer excision. Ten squamous cell carcinoma cases were provided for postoperative evaluation of tongue movement and aesthetic problems of the cervical skin. It was found that the thickness of the skin island was adequate for covering the oral defects and was not a hindrance to proper postoperative function. MacFee's incision improved the condition of the scar caused by flap elevation. The procedure for preparing the muscle pedicle beneath the cervical skin tunnel was carried out without much difficulty by carefully preparing the surgical field.

Key words

Platysma myocutaneous flap - MacFee's cervical inci- sion - Oral reconstruction

Introduction

Transposition of cervical skin with its underlying platysma for reconstruction of the oral cavity first tried by Gersuny (1887) has been used for many years. In 1969, Farr et al. described the application of a "cervical island skin flap" to the oral cavity. They showed the procedure of preparing the flap by carrying out the epidermal removal below the beard line so that the vascularized pedicle, which is em- bedded under the defect, can be obtained. Later, Futrell et al. (1978) described the technique for elevating a platysma myocutaneous flap by reflecting the cervical skin, expos- ing the muscle and its distal skin paddle. The methods of Farr et al. (1969) and Futrell et al. (1978) have been applied since 1978 in our departments and over 50 cases have been operated on with some modifications (Takagi et al., 1981). Although the result of reconstruction was functionally favourable, the authors encountered postoperative cosmetic disturbances due to the vertical in- cision made for both flap elevation and radical neck dis- section. Coleman et al. showed, in 1982 and 1983, a case of buccal mucosal reconstruction whereby the axial pat- tern platysma myocutaneous flap was raised through the skin tunnel, using MacFee's cervical incision without un- dertaking radical neck dissection. In 1986, Manni and Bruaset also reported a method of raising this type of flap, preserving the facial artery, at the upper cervical horizon- tal incision designed for supra-omohyoid neck dissection. They summarized ten cases operated on and emphasized the technical ease and reliability of this flap. Since 1982, the authors have applied a random pattern platysma myo- cutaneous flap prepared via MacFee's incision for the oral reconstruction simultaneously with a radical neck dissec- tion. The purpose of this paper is to demonstrate our procedure and discuss the late results of ten cases operated on which were evaluated at one to five years after opera- tion.

Methods

Using MacFee's incision design, the size of the skin island of the flap is first outlined by reference to the extent of excision at the primary site (Fig. 1). The pedicle is prepared with care, to include the platysma muscle, as widely as possible because the vascularization of the flap is to be of a random pattern after performing radical neck dissection. A cervical skin tunnel is prepared in the fascia just on the platysma muscle (Figs. 2 a and b). In the preparation of the muscle pedicle, the entire flap is elevated upwards so as to preserve the nutrient connective tissue beneath the platys-

Fig.1 Design of the skin island and MacFee's cervical incision.

The Platysma Myocutaneous Flap for Oral Reconstruction J. Cranio-Max.-Fac. Surg. 17 (1989) 319

Fig.2a Cervical skin tunnel preparation. The entire platysma mus- cle was exposed by careful preparation,

ysma

/ Skin island

Fig.2b Schematic drawing of Fig, 2a

ma at the lower border of the mandible (Fig. 3). The flap is then rotated into the oral cavity passing through the sub- mandibular defect after radical neck dissection. With wa- ter-tight suturing the skin island is draped into the defect caused by the primary site excision (Figs. 4a and b). The defect at the donor site in the neck is closed by cranial ad- vancement of the supraclavicular skin.

Results

In this paper, 10 patients were all diagnosed as Tz squa- mous cell carcinoma cases without mandibular bone and superficial cervical skin involvement. Table 1 shows the details of the cases. It was found that this technique was successful in three areas; the floor of the mouth, the man- dibular alveolus and the tongue margin. This is because the skin island of the flap is sufficiently pliable and thin for the reconstruction. Water-tight closure was obtainable without excessive bulk (Fig. 5). The postoperative tongue movement was not affected as the skin island of the flap provided enough coverage without causing much bulk, contraction or hindrance (Fig. 6). Using MacFee's incision and the platysma myocutaneous flap combination, the aesthetic appearance of the cervical skin was much im- proved (Figs. 7 a and b). Some complications were experienced after the skin island was transferred to the primary site. Although partial epi- dermal necrosis was observed in four cases, no additional surgery was required. Perforation of the skin island was also dete~ted in one case due to the looseness of the sutur- ing. It was repaired by additional sutures.

Discussion

The blood supply of the platysma muscle is supported by branches of the external carotid and subclavian arteries. The intermuscular and superficial fascia serve as scaffold- ing for vessels going to the skin (Hurwitz et al., 1983). In cases where these main artery branches are preserved, this flap can be considered as an axial pattern flap (Coleman et al., 1983). As described by Manni and Bruaset (1986), the platysma myocutaneous flap is applicable in an axial pat- tern with supra-omohyoid conservative neck dissection. It

Fig.3 The skin island and pedicle were elevated from the underly- ing tissue.

is impossible, however, to keep them intact when radical neck dissection is performed. Therefore, the platysma myocutaneous flap, described in this paper, is of a random pattern. Coleman et al. (1982) doubted whether there was sufficient vascularization of this flap when the facial ar- tery was ligated in a standard radical neck dissection. However, blood flow adjustment through the surviving submental artery and its anastomoses can be expected, as indicated in selective angiographic studies (Lasjaunias, 1981). Knowledge of the local anatomy must be taken into ac- count when designing a skin flap of safe dimensions (Grabb and Smith, 1979). The inter-fascial vascular net- work of the platysma is considered to vascularize the pedi- cle and the skin island in a random pattern platysma myo- cutaneous flap. The blood supply is thought to be more re- liable in the wider muscle pedicle of appropriate length.

320 J. Cranio-Max.-Fac. Surg. 17 (1989) Y. Handa et al.

Fig.4 a The skin island was transferred into the oral cavity through the submandibular region.

/ S k i n i s l a n d 1

c l e

Fig.4b Schematic drawing to demonstrate the location of the pedicle and skin island after suturing.

Fig.5 Skin island 6 months after operation. Note its mucosal ap- pearance and clear margin without excessive tension.

The area of the skin island is limited in size because of the antero-posterior distribution of the underlying platysma muscle. According to anatomical studies using Japanese cadavers (Shima, 1959), it is advisable to avoid including the lower anterior cervical region in the skin island be- cause of the existence of less-developed muscle fibres. In our series of cases, 12 × 7 cm in size was the largest skin island elevated for reconstruction. For the above reason, this flap was chiefly applied to T2 cases of oral cancer in our three departments. Other reconstruction methods have to be applied in more severe cases where segmental man- dibulectomy is required or where skin invasion is sus- pected. Some technical attempts were made in order not to inter- rupt the blood supply to the skin island in muscle pedicle preparation. Connective tissue layers were left attached on the inner and outer surfaces of the muscle pedicle, as de- scribed by Cannon et al. (1982), in order to keep the inter-

Table1 Patient information

Case Age* Primary site (TNM) Size of the M/F (yrs) skin island

(cm)

Complication in the skin Tongue Complaint of Follow-up island movement cervical scar period (yrs)

1 M 65 tongue margin (T2NoM0) 5.5 x 5 2 F 39 tongue margin (T2N1Mo) 6 x5 3 F 39 tongue margin (T2N1Mo) 5.5 x4 4 F 57 tongue margin(T2NoMo) 7 x5 5 M 54 tongue margin(T2N1Mo) 6 x5 6F 74 molargingiva(T2N~Mo) 6 x5 7 F 52 molargingiva(T2N~Mo) 6 x5 8 M 59 floor of the mouth (T2NoMo) 6.5 x 5.5 9 F 59 floor of the mouth(T2NoMo) 6 x5

10 M 45 tongue margin (T2NoMo) 12 x7 floor of the mouth

partial skin loss (10%) good none 4 none good none 5 skin perforation** fair none 3 none fair none 4 none good none 3 partial skin loss (35%) disturbed*** none 2 none fair none 4 partial skin loss (20%) good none 3 none good none 1 partial skin loss (5 %) good none 1

M/F male/female. * Age at first visit.

** Additional suture was performed for repair, *** Disturbed in lateral movement.

The Platysma Myocutaneous Flap for Oral Reconstruction J. Cranio-Max.-Fac. Surg. 17 (1989) 321

Fig.6a Fig.6b Fig.6c

Fig.6 Tongue function 1 year after operation. The patient can touch the upper lip (a), the right (b) and the left (c) commissure of the lips with his tongue tip.

Fig.7a Fig.7b

Fig.7 The cervical skin of Case 4 (a) and Case 7 (b) 4 years after operation. There is no ugly scar in the central part of the neck.

Fig.8 An example of unfavourable scar of the neck caused by vertical cervical incision for flap elevation and radical neck dissec- tion.

fascial vascular network as intact as possible. The antero- posterior range of the pedicle was designed as wide as pos- sible. At the lower margin of the mandible, preparation was carried out with care to preserve nutrient connective tissue between the platysma and the mandible. Some stay sutures in the caudal end of the skin island are recom- mended to avoid accidental separation of skin and under- lying muscle. In the oral site procedure, tension adjustment of the sutured skin island is the most important for its sta- bility and survival. For this purpose, the skin island has to be designed with sufficient area and furthermore, in the defect margin, preparation of an adequate margin for sut- uring is also recommended. In cases where the floor of the mouth is involved, the alveolar structures sometimes have to be partially removed to avoid excessive tension. In this situation, the buccal mucoperiosteal flap is provided as a suturing edge for the island margin. It is always important to consider the postoperative aes- thetic situation in patients receiving oral cancer treatment. A cervical scar, especially that in a vertical direction, occa- sionally becomes problematic (Fig. 8). In the series of cases

presented, the cervical scar was effectively restricted by combined usage of MacFee's cervical incision with a pla- tysma myocutaneous flap.

Conclusions

As the result of this study, it was revealed that the platys- ma myocutaneous flap, prepared in a random pattern, was effective in T2 cases for reconstruction of the floor of the mouth, the mandibular alveolus and the tongue margin. Use of this flap combined with MacFee's cervical incision contributed much to the better postoperative aesthetic ap- pearance of the cervical skin.

References

Cannon, C. tL, M.E. Johns, J.P. Atkins, M. Keane, R.W. Cantrell: Reconstruction of the oral cavity using the platysma myocuta- neous flap. Arch. Otolaryngol. 108 (1982) 491

Coleman, J.J., F. Nahai, S.J. Mathes- Platysma musculocutaneous flap: Clinical and anatomic considerations in head and neck re- construct ion. Am J. Surg. 144 (1982) 477

322 J. Cranio-Max.-Fac. Surg. 17 (1989) Y. Handa et al.: The Hatysma Myocutaneous Flap for Oral Reconstruction

Coleman, J. J., M. J. Jurkiewicz, F. Nahai, S. J. Mathes: The platysma musculocutaneous flap: Experience with 24 cases. Plast. Reconstr, Surg. 72 (1983) 315

Farr, H.W., B. Jean-Gilles, A. Die: Cervical island skin flap repair of oral and pharyngeal defects in composite operation for cancer. Am. J. Surg. 118 (1969) 759

Futrell, J. W., M. E. Johns, M. T. Edgerton, R. W. Cantrell, G. S. Fitz- Hugh: Platysma myocutaneous flap for intraoral reconstruction. Am. J. Surg. 136 (1978) 504

Gersuny, R.: Plastischer Ersatz der Wangenschleimhaut. Zentralblatt fiir Chirurgie 14 (1887) 706

Grabb, W. C, J.W. Smith: Plastic Surgery. 3rd Ed. Little Brown, Bos- ton (1979) 36-37

Hurwitz, D.J., J.A. Rabson, J.W. Futrell: The anatomic bases for the platysma skin flap. Plast. Reconstr. Surg. 72 (1983) 302

Lasjaunias, P.L.: Craniofacial and Upper Cervical Arteries: Func- tional, clinical and angiographic aspects, Williams & Wilkins, Bal- timore-London (1981) 169-174

MacFee, W.F.: Transverse incisions for neck dissection. Ann. Surg. 151 (1960) 279

Manni, J.J., L Bruaset: Reconstruction of the anterior oral cavity using the platysma rnyocntaneous island flap. Laryngoscope 96 (1986) 564

Shima, H.: Anatomical study on the cervical muscles of Japanese; Part 1: The platysma. Koku Kaibo Kenkyu 11 (1959) 171 (in Jap- anese)

Takagi, N., R. Yamada, T. Miyagishima, F. Tominaga, N. Hanamu- ra, N. Tatematsu, N. Oka: A modification of Farr's cervical island skin flap for reconstruction of oral defect after cancer resection. Jpn. J. Oral Surg. 27 (1981) 1082 (in Japanese)

Dr. Y. Handa, D.M.D., D.M.Sc. Dept. of Oral-Maxillofacial Surgery and Stomatology Shizuoka Saiseikai Hospital Oshika 1-1-1, 422 Shizuoka Japan

Dr. T. Kitajima, D.M.D., D.D.Sc. Dept. of Maxillofacial Surgery and Stomatology Shimada Municipal Hospital Noda 1200-5, 427 Shimada (Sbizuoka) Japan