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Operative Techniques in Otolaryngology (2005) 16, 270-274

RIGINAL CONTRIBUTIONS

he platysma myocutaneous flap

aniel Nitzan, DMD,a Lev Bedrin, MD,b Ran Yahalom, DMD,a Yoav P. Talmi, MD, FACSb

rom the aDepartment of Oral and Maxillofacial Surgery, Chaim Sheba Medical Center, Tel Hashomer, and the Tel Avivniversity Sackler School of Medicine, Tel Aviv, Israel; and the

Department of Otolaryngology–Head and Neck Surgery, Chaim Sheba Medical Center, Tel Hashomer, and the Tel Aviv

niversity Sackler School of Medicine, Tel Aviv, Israel.

Reconstruction of the primary defect is an integral part of the surgical treatment of head and neckcancer. Free flaps, particularly the radial forearm flap, provide excellent options for intraoral recon-struction of surgical defects. In cases in which the surgical defect is small and the options for free flapuse are limited, the platysma myocutaneous flap is a viable option. This flap is thin, pliable, andversatile. It is predictable and easy-to-harvest, and has minimal donor site morbidity. The indications,operative technique, and associated complications are discussed.© 2005 Elsevier Inc. All rights reserved.

KEYWORDSFlap;Platysma;Reconstruction;Myocutaneous

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The platysma myocutaneous flap dates back to 1887hen an Austrian surgeon, Robert Gersuny, described re-air of a cheek defect. Yet, it was only introduced to thenglish literature in 1978 by Futrell et al,1 and since then, itas become established as an attractive reconstructive alter-ative with several potential advantages. The diverse indi-ations described for the platysma myocutaneous flap con-ist of reconstruction of congenital abnormalities, traumaticnjuries, and, most commonly, malignancies of the head andeck.

ndications and advantages

he platysma flap should be considered for closure of skinr skin-and-muscle defects in the lower face, neck, and oralavity. Its versatility has been shown in the repair of benignypopharyngeal strictures,2 reconstruction of the chin andips,3,4 reimplantation of severed ears,5,6 and reconstructionf the trachea in patients with esophageal cancer.7 Thehinness and pliability of the muscle and skin paddle maket ideal for all sites in the oral cavity, where avoidance ofxcessive bulk is desirable. Functional impairment of de-lutition, speech, and denture fitting is minimal, the coloratch with facial skin is excellent, and the cosmetic ap-

Address reprint requests and correspondence: Daniel Nitzan, DMD,eller 26 Street, Rechovot, Israel.

nE-mail address: danielni@netvision.net.il.

043-1810/$ -see front matter © 2005 Elsevier Inc. All rights reserved.oi:10.1016/j.otot.2005.09.002

earance is optimized by primary closure of the neck inci-ion. The flap is harvested rapidly, and no new dissectionelds are entered. Tumor resection can be generous, and thelatysma flap obviates the need for special microsurgicalxpertise. The superiorly based design has a reliable arteriallood supply and, therefore, enjoys a high success rate.

ontraindications and disadvantages

year after Futrell et al1 reported their use of thelatysma myocutaneous flap, Ariyan8 introduced the pec-oralis major flap that quickly became the first choice forrimary reconstruction of oral cavity and oropharyngealefects. A reluctance to use the platysma flap has been aesult of the stated requirement of an intact facial arteryor flap survival.9 However, this has been refuted bothxperimentally10 and clinically.11-13

Other reported contraindications for use of thelatysma flap include prior neck dissection, facial arteryigation, preoperative irradiation, and ipsilateral facialerve paralysis. Previous surgery in the ipsilateral neckhat has violated the platysma muscle may result in arecarious blood supply and, therefore, should be con-idered a contraindication for using this flap. However,cGuirt et al11 reported that the key to success was the

lacement of the neck incision, and the patients in theireries who have undergone previous neck dissection had

o postoperative complications.

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271Nitzan et al The Platysma Myocutaneous Flap

Caution should be exercised when considering the platysmaap in the setting of prior irradiation to the neck, as a result ofotential postradiation arteritis and skin changes. Some inves-igators12,14,15 reported no morbidity to platysma flaps in pa-ients who have had radiation. It is noteworthy that prior neckurgery or irradiation is not only potentially detrimental to theap but also to the underlying structures. In cases in which theternocleidomastoid was removed or is to be excised, the flaps relatively contraindicated because the neck vessels are thenovered by skin only.

Verschuur et al16 reported a significant increase in com-lications in patients undergoing neoadjuvant chemother-py, although Ruark et al12 found no adverse effect withdministration of preoperative chemotherapy. A node-pos-tive neck is a contraindication for the use of the platysmaap. The platysma flap is relatively thin, and the need for

issue bulk is a relative contraindication to its use. Flaps asarge as 6 � 15 cm may be harvested17 in select individuals,ut if the defect size is larger, an alternative reconstructiveethod should be considered.

natomy

he platysma muscle is a remnant of the panniculus acariosisn the subcutaneous tissue of the neck. The muscle itself liesuperficial to the muscular fascial sheath. The submentalranch of the facial artery is the primary blood vessel to thelatysma muscle, and the superior thyroid artery, occipitalrtery, and posterior auricular artery are the secondary ves-els.18 The external jugular vein provides the primary venousrainage, followed by the submental vein. Rabson et al19 notedhat in contrast to the multi-axial arterial supply, there appearedo be a predominantly vertical orientation to venous drainagef the platysma muscle. They recommended that the externalugular and anterior communicating veins be included on thenferior surface when raising the platysma flap.

reoperative preparation

careful history and physical examination should be per-ormed to determine if the patient underwent prior neckurgery or radiation therapy. Because an attempt to raise thexternal jugular vein and anterior neck veins with the flapill be made, their presence and location should be noted.sking the patient to grimace and observing the neck, al-

hough even weak muscles can be successfully used, canstimate the size and development of the platysma.

perative procedure

he anticipated skin paddle should be outlined in the lowerateral neck. The male beard pattern can be considered in theap design. Parallel vertical incisions are outlined, startingt the chin medially and the mastoid process laterally, withxtension to slightly above the clavicle. A horizontal con-ecting incision at this level within 1-2 cm above the clav-

cle is carried through the platysma muscle, resulting in an r

pron configuration. These incisions can be modified ac-ording to the planned procedure, such as in cases in whichilateral neck dissections are performed. The skin paddle isutlined on the harvest side, and the muscular pedicle islevated in the subcutaneous tissue plane in that side. Thekin paddle is then created with an additional transversencision proximally to outline an island of the appropriateize (Figure 1A). This proximal transverse incision is madehrough the skin only, and the cervical skin superior to theutlined skin paddle is elevated in a supra-platysmal planeFigure 1B). Care is taken to leave small amounts of sub-utaneous tissue on both the platysma surface and the de-eloped skin flap, although that is not always technicallyeasible.

The method of flap elevation will vary depending on thendication for flap use. If an external skin defect is to beovered (Figure 1C), the skin over the platysma muscle be-ween the paddle and defect may be elevated to create a tunnel.lternatively, a skin incision is performed between the defect

nd the skin paddle, and the skin reflected back off of thelatysma on either side. Mobilizing the flap through a long skinunnel is difficult. If an intraoral defect is to be closed, a largelatysma skin flap may be raised, with the inferior margin ofhe skin paddle defining the most distal extent. The upper skinaddle incision is not made until after it is determined that theaddle will cover the defect.

An alternative and, in our mind, preferable method is toake the lower cut, including the transplatysmal incision

nd superiorly only the skin incision. After the neck proce-ure is completed or when the flap is to be placed, the skins elevated off the platysma that is already separated fromhe neck tissues. This procedure allows preservation of theuscle until the last minute and decreases associated mor-

idity. To minimize shearing of the skin island, circumfer-ntial tacking sutures are placed and can usually be left inlace (Figure 1D).

The muscle and skin paddle are mobilized toward theefect by elevation of the platysma in an inferior-to-superiorirection. The plane of elevation should include the fascia ofhe sternocleidomastoid, as well as the anterior and externalugular veins if feasible. Inclusion of these veins that are leftntact superiorly adds to the venous drainage of the flap. Bylevating the fascia of the sternocleidomastoid from lateralo medial, the superior thyroid contribution should be leftntact. This procedure will create a rotation point for the flaphat is relatively low, and additional length can be obtainedy bringing the fascia overlying the strap muscles up withhe anterior jugular veins.

The muscle may be detached along its posterior andosterosuperior margins. Care should be taken not to injurehe mandibular branch or external jugular vein when this iserformed. Mobilization of the flap may require division ofhe superior thyroid contribution. In any case, every efforthould be made to keep the base of the flap as wide asossible.

We have used the platysma flap in 7 cases, 6 with a skinaddle. There were 6 flaps used for oral or pharyngealeconstruction and 1 for facial skin reconstruction. In 2ases, the flap was used to cover buccal defects, and was

otated on its axis and inserted lateral to the mandible. This

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272 Operative Techniques in Otolaryngology, Vol 16, No 4, December 2005

lacement implies some compression of the flap. None ofhe flaps failed, and no other complications were encoun-ered. It is noteworthy that during skin closure, because ofemoval of a usually oval skin paddle, the scar seems rect-

igure 1 (A) Surgical defect with incision and skin flap correspoC) Skin paddle sutured to the underlying muscle and raised. (D)

ngular in shape (Figure 1E), but this is unavoidable be- p

ause the additional removal of skin to allow better contours usually not possible. The neck skin is routinely closed.

obilization of the upper chest skin may facilitate closuref the skin paddle donor site. One to 2 suction drains are

o defect size outlined. (B) Skin flap elevated without the platysma.utured in place. (E) Postoperative result.

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273Nitzan et al The Platysma Myocutaneous Flap

omplications

lthough no complications were encountered in our patientroup, the reported rate of complications is between 14%1

nd 55%.14 These complications include partial or completeap necrosis, pharyngocutaneous and orocutaneous fistu-

a,15 and wound dehiscence. A rare reported complication isnjury to the mandibular branch of the facial nerve.

ostoperative care

rains are removed when the output is �30 mL per day.ension on the flap is minimized if the patient’s head is

urned toward the donor side, which can be accomplishedith head support.

iscussion

he platysma myocutaneous flap is a reliable reconstructiveethod, with survival rates of 80% to 95%.20-22 It is tech-

ically easy to harvest, is enclosed in the operative field, andan provide up to 90 cm2 of skin for resurfacing. Its mainimitation is also its forte (ie, lack of bulk). Limited skinvailability and the lack of sensation are other factors toonsider. Therefore, its use is limited when restoration ofulk is thought to be important, particularly in reconstruc-ion of large tongue defects. In conclusion, although not arst-line reconstructive technique, the platysma flap is an-ther myocutaneous flap in our armamentarium, useful forapid closure of small to midsize defects of the lower face,

Figure 1

ral cavity, hypopharynx, and oropharynx.

eferences

1. Futrell JW, Johns ME, Edgerton MT, et al: Platysma myocutaneousflap for intraoral reconstruction. Am J Surg 136:504-507, 1978

2. Friedman M, Schild JA, Venkatesan TK: Platysma myocutaneous flapfor repair of hypopharyngeal strictures. Ann Otol Rhinol Laryngol99:945-950, 1990

3. Yeo JF, Egyedi P: Reconstruction of soft tissues of the chin and lowerlip region following excision of a basal cell carcinoma. J Craniomax-illofac Surg 16:337-339, 1988

4. Moschella F, Cordova A: Platysma muscle cutaneous flap for largedefects of the lower lip and mental region. Plast Reconstr Surg 101:1803-1809, 1998

5. Ariyan S, Chicarilli ZN: Replantation of a totally amputated ear bymeans of a platysma musculocutaneous “sandwich” flap. Plast Recon-str Surg 78:385-389, 1986

6. de Mello-Filho FV, Mamede RC, Koury AP: Use of a platysmamyocutaneous flap for the reimplantation of a severed ear: experiencewith five cases. Sao Paulo Med J 117:218-223, 1999

7. Sodeyama H, Matsuo K, Ishizaka K, et al: Platysma musculocutaneousflap for reconstruction of trachea in esophageal cancer. Ann ThoracSurg 50:485-487, 1990

8. Ariyan S: The pectoralis major myocutaneous flap: A versatile flap forreconstruction in the head and neck. Plast Reconstr Surg 63:73-81,1979

9. Conley JJ, Lanier DM, Tinsley P Jr: Platysma myocutaneous flaprevisited. Arch Otolaryngol Head Neck Surg 112:711-713, 1986

0. Hurwitz DJ, Rabson JA, Futrell JW: The anatomic basis for theplatysma skin flap. Plast Reconstr Surg 72:302-312, 1983

1. McGuirt WF, Matthews BL, Brady JA, et al: Platysma myocutaneousflap: Caveats reexamined. Laryngoscope 101:1238-1244, 1991

2. Ruark DS, McClairen WC, Schlehaider UK, et al: Head and neckreconstruction using the platysma myocutaneous flap. Am J Surg165:713-719, 1993

3. Talmi PY, Wolf M, Badrin L, et al: Preservation of the facial artery inexcision of the submandibular salivary gland. Br J Plast Surg 56:156-

ntinued.

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274 Operative Techniques in Otolaryngology, Vol 16, No 4, December 2005

4. Cannon CR, Johns ME, Atkins JP, et al: Reconstruction of the oralcavity using the platysma myocutaneous flap. Arch Otolaryngol HeadNeck Surg 108:491-494, 1982

5. Koch WM: The platysma myocutaneous flap: Underused alternativefor head and neck reconstruction. Laryngoscope 112:1204-1208,2002

6. Verschuur HP, Dassonville O, Santini J, et al: Complications of themyocutaneous platysma flap in intraoral reconstruction. Head Neck20:623-629, 1998

7. Ariyan S: The transverse platysma musculocutaneous flap for head andneck reconstruction: An update. Plast Reconstr Surg 111:378-380,2003

8. Uehara M, Helman JI, Lillie JH, et al: Blood supply to the platysma

muscle flap: An anatomic study with clinical correlation. J Oral Max-illofac Surg 59:642-646, 2001

9. Rabson JA, Hurwitz DJ, Futrell JW: The cutaneous blood supply of theneck: Relevance to incision planning and surgical reconstruction. Br JPlast Surg 38:208-219, 1985

0. Persky MS, Kaufman O, Cohen ML: Platysma myocutaneous flap forintraoral defects. Arch Otolaryngol Head Neck Surg 109:463-464, 1983

1. Neito CS, Galtego LL, Galan Cortes JC: Reconstruction of the poste-rior wall of the pharynx using a myocutaneous platysma flap. Br J PlastSurg 36:36-39, 1983

2. Ramon ME, Brian BB, William RC, et al: The platysma myocutaneousflap- indications and caveats. Arch Otolaryngol Head Neck Surg 120:

32-35, 1994