|Year : 2017 | Volume
| Issue : 3 | Page : 73-81
Versatility of locoregional flap for reconstruction in head and neck cancer surgery
Mahendra I Katre1, Prashant Keche1, Pramod Dhanajkar1, Sunil Deshmukh1, Arvind Gaikwad2
1 Department of ENT and Head Neck Oncology, Government Cancer Hospital, Aurangabad, Maharashtra, India
2 Department of Preventive Oncology, Aurangabad, Maharashtra, India
|Date of Web Publication||29-Oct-2018|
Dr. Mahendra I Katre
Department of ENT and Head Neck Oncology, Government Cancer Hospital, Aurangabad, Maharashtra
Source of Support: None, Conflict of Interest: None
Head and neck cancers are major causes of morbidity and mortality worldwide. In India, oral cancers account for approximately 30% of all new cases annually. Ablative surgery is the main stay of treatment, followed by reconstructive surgery. In the head and neck region, there is much concern about function and structural integrity and aesthetic look, and reconstructive surgery is challenging to achieve these. Microvascular surgery revolutionized oncoplastic reconstruction, but this requires great expertise even in tertiary cancer centers and is not possible many times due to long wait or patient's condition. Hence, locoregional pedicled flap has a role to play. This article attempts to share our experience and review our current understanding about reconstruction in different subsites in the head and neck region with locoregional pedicled flaps.
Keywords: Head and neck cancer, pedicled flap, reconstruction
|How to cite this article:|
Katre MI, Keche P, Dhanajkar P, Deshmukh S, Gaikwad A. Versatility of locoregional flap for reconstruction in head and neck cancer surgery. Arch Int Surg 2017;7:73-81
|How to cite this URL:|
Katre MI, Keche P, Dhanajkar P, Deshmukh S, Gaikwad A. Versatility of locoregional flap for reconstruction in head and neck cancer surgery. Arch Int Surg [serial online] 2017 [cited 2020 Jul 12];7:73-81. Available from: http://www.archintsurg.org/text.asp?2017/7/3/73/244404
| Introduction|| |
Oral cancer is the eleventh most common cancer globally. There is wide geographical variation in the incidence of oral cancer, with approximately two-thirds of patients in the developing countries of southeast Asia, Eastern Europe, and Latin America. In India, oral malignancy accounts for 35% of total malignancy. Limited access to cancer care, relative lack of health care providers, and financial resources are some of the challenges in the management of oral cancer in India despite improvement in diagnostic techniques and management strategies. A high prevalence of tobacco consumption either in the form of smoking or smokeless tobacco and related products is responsible for oral cancers (various subsites) and cancers of the oropharynx, hypopharynx, larynx, nose, and sinuses cancer. Surgical excision of the tumor and neck dissection forms the mainstay of treatment, followed by adjuvant chemotherapy and radiotherapy. The resulting anatomical defect, functional loss, cosmetic disfigurement, and accompanying psychosocial effect jeopardizes the quality of life of patients. Reconstructive surgery plays a crucial role in improving the quality of life by restoring anatomical deficit, achieving functional rehabilitation and aesthetic outcome. Mc Gregor introduced temporalis muscle flap for covering midface and lower defects. Bakamjian in 1965 described the deltopectoral flap for coverage defect of the lower third of the face as well oral and esophageal defects. In 1979, Ariyans described the pectoralis major myocutaneous flap for lower third of the face, subsequently it became the work horse flap for major oral reconstruction.
Microvascular free radial artery flap which was described by Yang in 1981 revolutionized head and neck reconstruction. It requires great surgical expertise which is often not available for every case even in tertiary cancer centers due to long wait periods. Where plastic and reconstructive surgeon is not available, our age old locoregional pedicled flaps are available to ablative surgeon for immediate reconstruction. Reconstruction should be tailored to fill the requirement of functional and aesthetically acceptable outcomes.
Nasal reconstruction involves restoration of tip, dorsum, columella, and paired alae and sidewalls. Recommended option for reconstruction is the forehead flap. The exact pattern of the defect is marked on the median forehead region, for loss of large portion of the nose, flap needs to be large while harvesting. A short flap will result in foreshortened nose. It is based on the supratrochlear artery. The forehead has been acknowledged as the best match for nasal skin because of its superb color and texture match. Well vascularized and lying adjacent to the nose it is the ideal donor material.
The origins of forehead rhinoplasty (the Indian method) are obscure, but it has been performed in India since 1440 AD and probably long before the birth of Christ. The flap is raised based on the supratrochlear artery and sutured to the defect; this is a two-stage procedure. After 3 to 4 weeks the pedicle is divided and contoured at the superior aspect of the defect. The proximal pedicle is untubed and repositioned back to the medial brow and sutured as an inverted “V,” as shown in [Figure 1].
|Figure 1: Basal cell cancer of the nose, Stage 1: forehead rotation flap; Stage 2: 4 weeks postoperative|
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There is laxity of skin over the cheek, and hence, local advancement flap (rotational flap) is preferred unless sufficient skin is unavailable. In old age, skin laxity is more such that big defects can be covered with this type of flap. Since its first description by Mustarde, the cheek advancement-rotation flap has been widely used for reconstructing cheek defects. However, this flap is raised in a subcutaneous plane in its original description or one of the several modifications, the flap includes a random pattern blood supply, and hence, needs to maintain a wide pedicle, which reduces its mobility. Consequently, the flap is often sutured under tension, and it is not uncommonly associated with distal age necrosis. The deep plane cervicofacial flap (DPCFF), first described by Barton and Zilmer and popularized by Kroll et al., represents a significant modification of the original technique. The DPCFF is a musculo-fascio-cutaneous flap with an axial blood supply. An anteriorly based flap derives its blood supply from the submental and perforating branches of the facial vessels whereas a posteriorly based flap is supplied by the perforating branches of the superficial temporal vessels.
[Figure 2] shows a 65-year-old lady with basal cell carcinoma of the cheek with nasolabial fold and ala of nose defect covered with posterior based deep plane cervicofacial flap. The last picture shows well-healed wound with an acceptable result.
|Figure 2: Basal cell carcinoma of the cheek with nasolabial fold; ala of nose reconstruction done with deep plane cervicofacial rotation flap|
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| Deltopectoral Flap for Cheek Defect|| |
Vascular supply of this flap derives from the second to fourth musculocutaneous perforator of the internal thoracic artery. The flap extends horizontally from 2 cm lateral to the parasternal border and follows infraclavicular line beyond the deltopectoral groove on to the anterior shoulder inferior border parallel to it and may lie in the 4th costochondral junction. The flap is raised from the distal to proximal direction in subfascial plane, including pectoral fasia, keeping pectoral muscle behind. The distal portion is sutured to the defect and the proximal portion is tubed. The pedicle portion can be divided after 3 to 4 weeks. The flap can only be extended beyond the anterior border of deltoid with flap delay technique. This can be done 10 days prior to the main surgery. It may be used for unexpected complication of radiotherapy such as skin loss with the exposed lower jaw as the field of radiation being away from flap harvesting site. It may be used for unexpected complication of radiotherapy such as skin loss with the exposed lower jaw as the field of radiation being away from flap harvesting site [Figure 3].
Bakamjian first described the deltopectoral flap in 1965 as a head and neck reconstructive option. Deltopectoral flap can be used for closing the orocutaneous fistula and for pharyngeal reconstruction. Post radiation skin loss, as in the above case, and covering neck defects in case of laryngeal or pharyngeal cancer involving skin is shown in [Figure 4].
|Figure 4: Deltopectoral flap for neck defect in laryngeal cancer with skin involvement|
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| Oral Cavity|| |
Buccal mucosa is a common site for oral cancer, and the reconstruction options depends upon the site and size of defect. Small lesions up to 2 cm can be closed primarily. It also depends on the depth of invasion; very superficial lesion can be covered with split skin graft. When defect extends from sulcus to sulcus with or without alveolectomy, forehead flap, nasolabial flap, submental flap, platysamal flap, or temporalis muscle flap can be done. If hemimandible or post-segmental mandibulectomy is done, pectoralis major myocutaneous flap can be tunneled into the oral cavity which can be modified depending on the extent of invasion, either single paddle or bipaddle in case of composite resections. Microvascular reconstruction such as free radical forearm flap and free fibula for mandibular reconstruction revolutionized oral reconstruction which requires great expertise. Some options for buccal mucosa are discussed below.
The buccal fat pad flap is an axial flap and may be used to fill small-to-medium-sized soft tissue and bony defects in the palate, superior, and inferior alveoli and buccal mucosa. It is often encountered as it bulges into the surgical field during surgery in the pterygomandibular region. A pedicled buccal fat pad (BFP) flap was first described in 1977 by Egyedi for closiing oroantral communications after oncological resections. In 1983, Neder utilized the buccal fat pad as a free graft in oral cavity. In 1986, Tideman et al. showed that the pedicled buccal fat pad flap is epithelized within 3 to 4 weeks and resembles oral mucosa; hence, it made skin grafts obsolete. Rapidis et al., Hao, and Dean et al. used pedicled BFP flaps for reconstruction of medium-sized postsurgical oral defects for malignant lesions. In 2005, Amin showed how effectively a buccal fat pad can be utilized in post partial maxillectomy defects following resection of the neoplastic disease of palate.
The limitation of using this flap in case of oral malignancy is a deep invasive tumor involving buccal fat or a part of it as it needs to be removed to get a clear margin as in case when tumor involves masseteric space. Flap failure can occur when there is excessive stretching of fat pad while delivering it, causing trauma to the vascularity of fat pad. In such cases, locoregional or free flap is an option for reconstruction. In our cases, we observed the epithelialization of the buccal fat pad graft after the second week with complete epithelialization in 4 to 6 weeks [Figure 5]. The indications of buccal fat grafting are reconstruction of small-to-medium-sized (<5 cm) congenital or acquired soft tissue and bony defects in the oral cavity. This includes oronasal and oroantral communications following dental extraction, surgical defects following tumor excision, excision of leukoplakia and submucous fibrosis, and primary and secondary palatal clefts. In our series, we observed near normal mucosa seen at end of 2 months and subsequent follow-up; even sensation of flap was taken as it withstands with adjuvant radiotherapy. Here we emphasize on buccal fat pad as an option of flap for reconstruction of buccal or palatal defects when situation fulfill demands to harvest it.
|Figure 5: Buccal fat grafting in verrucous lesion of buccal mucosa; intraoperatively and 4 weeks postoperatively|
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Masseteric muscle flap
The masseter muscle has been widely used for reanimation in facial nerve palsy; on the other hand, it has been seldom reported for oral cavity and oropharyngeal reconstruction. Conley and Gullane in 1978 first introduced the masseter muscle flap as a reconstructive method for managing oropharyngeal defects. The masseteric branches of the maxillary artery (MbMA), facial artery (MbFA), transverse facial artery (MbTFA), and superficial temporal artery (MbSTA) supply the masseter. Based on its diameter, frequency of occurrence, and distribution area, the MbTFA can be considered the main branch supplying the masseter muscle. This artery is never encountered during standard comprehensive or selective neck dissection; this makes the harvest of the flap perfectly reliable even after previous or concomitant neck dissection as long as the external carotid artery is not transected. Venous drainage of the masseter muscle is provided by the facial vein which flows into the internal jugular vein; in case of previous neck dissection, the pterygoid venous plexus will provide venous drainage as long as the internal jugular vein is preserved.
The flap can be harvested as a crossover flap by maintaining the superior zygomatic attachments or as an island flap by transecting both insertions. The only careful step is elevation of the parotid gland and terminal branches of the facial nerve from the superficial aspect of the muscle. This step, however, is easily performed with adequate exposure; the fascia of the masseter just above the angle of the mandible is incised and dissected free along with the cheek flap to preserve the branches of the facial nerve, and the muscle is freed along its posterior margin from the parotid gland. The detachment of the mandibular or zygomatic insertions is very quickly obtained with electrocautery and the muscle is ready to be transposed. In the series reported by Antoniades et al., the viability of the flap was excellent in all patients and epithelization was complete in 3 weeks. [Figure 6] shows 2 month postoperative image of a patient operated for T 2 lesion squamous cell carcinoma; wide local excision with marginal mandibulectomy was done followed by masseter muscle crossover flap. Limitation of using masseter muscle flap is its proximity to the primary tumor, which sometimes necessitates inclusion of the muscle into specimen or invasion of tumor in masseteric space which is contradiction for this flap respecting oncological principles.
Nasolabial flap is an arterialized local flap in the head and neck region with axial blood supply provided either by facial artery, transverse facial artery (inferior based), or superficial temporal artery and infraorbital artery (superior based). It was first reported at the end of the 19th century. Due to rich subdermal plexus, the flap can be used either a random flap-based or as axial pattern flap. A subcutaneous pedicled flap can be also raised as laterally or inferiorly based. It is a reliable, versatile, and easy to raise flap for a range of defects in the orofacial region. The orientation of the pedicle is usually determined by the location of the defect and the requirement of rotation or advancement of appropriate tissues to the defect. The flap thickness is also determined by the needs of the defect as well as the thickness of the donor tissue. The flap can be as thin as deep to the subdermal plexus, and as thick as superficial to the facial musculature with their nerve supply intact. The flap dissected in the supramascular plane keeping the base of the flap as thick as possible. It can be superiorly based to reconstruct defects on the cheek, side wall or the dorsum of the nose, alae, columella, and the lower eyelid. Inferiorly-based flaps can be used to reconstruct defects in the upper lip, anterior floor of the mouth, and the lower lip. The flap can be turned over and used as a lining of the nose and the lip. The proximity to the recipient defects, the best color match, and the satisfactory contour created from the relatively hairless areas utilized from the nasolabial fold are the other major advantages of this flap. The nasolabial flap can be used alone or with combination of other flaps [Figure 7] and [Figure 8].
|Figure 7: Buccal fat graft and nasolabial flap for partial maxillectomy defect intraoperatively and 4 weeks postoperatively|
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|Figure 8: Use of combined PMMC and nasolabial flap for full thickness cheek defect with commissure|
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The submental flap is submental artery island flap (SIF) is an axial fasciocutaneous flap; it includes skin, subcutaneous tissue, platysma, and fat and is pedicled on the submental artery and veins. Martin et al. has previously described the qualities of an ideal flap. They should be thin, reliable, and have a good color match. They should be easy to dissect, carry a long arc of rotation with minimum donor site morbidity. Radial forearm free flap fulfils most of these qualities; submental flaps have also been found to have thin skin paddle and have a good color match. In female patients, submental flap serves as a very good option for intraoral reconstruction, being a relatively nonhairy site, whereas problem arises in male patients with a thick beard when there is excessive hair growth in reconstructed oral cavity. This problem decreases with radiation and as flap gets accustomed to the oral cavity environment, according to our experience. The submental island flap was introduced by martin et al. in 1993. SIF can be used for skin defects of the lower two-third of the face (excellent texture and color match), buccal, cheek, lateral floor of mouth, and tongue resection [Figure 9]. It can also be used in case of oro and hypopharyngeal resection and esophageal augmentation in post-laryngectomy stenosis. After measuring the defect marking of the spindle-shaped flap with a marking pen in the submental region in a horizontal manner, place the anterior border of the skin paddle at least 1 cm behind the anterior rim mandible to hide the scar as much as possible. The length of the short axis of the skin paddle allows primary closure of the donor site defect, which can be easily determined by pinching the skin of the submental area between two fingers before outlining the flap. We prefer starting the flap elevation from the opposite side of the pedicle in the subplatysmal plane and proceeding towards the midline [Figure 10]. When the midline is reached, the dissection is carried out carefully to identify the submental artery and the vein at the medial border of the anterior belly of digastric muscle on pedicle side.
|Figure 9: Submental island flap for the retromolar area and tongue reconstruction|
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|Figure 10: Submental island flap harvested for reconstruction of the retromolar area following wide local excision marginal mandibulectomy and post-alveolectomy|
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Use of a Doppler probe can be helpful at this point. After identifying the submental vessels, the anterior belly of the digastric muscle is released from its attachments and elevated with the flap because the vascular pedicle passes deep to this muscle in most cases [Figure 10]. Harvesting the flap is continued by carefully releasing the submental artery and the vein from the surrounding tissues during their course between the submandibular gland and the mandible. The surgeon should take special care not to separate the skin paddle from the submental vessels and not to injure the marginal mandibular nerve at this point. The dissection should be discontinued when sufficient length of vascular pedicle is obtained or the junction of the submental and facial vessels is reached. The flap is then transferred and attached to the recipient site [Figure 10], and donor site is closed primarily in layers. One of the debated aspects of submental flap is its oncological safety. A cohort of 55 patients with squamous cell carcinoma of the oral cavity, in which submental flaps were used for reconstruction, was studied retrospectively by Howard et al. No recurrence was found intraorally at the site of reconstruction, even though 10% of the cases had occult metastases found at level 1. Submental island flap is contraindicated in gross level 1a and 1b nodal metastasis; low volume disease can be meticulously removed preserving pedicle.
Submental flap can be harvested with other some modifications such as hybrid flap, reverse flow flap; SIF with bone (osteomyocutaneous SIF) can be used to reconstruct small composite defects of the mandible, maxilla, and orbit. A small rim of the bone from the inferior part of the mandible in the symphysis and parasymphysis area is sectioned and kept attached to the flap. SIF can refashioned into bipaddle flap. Ramkumar et al. described a bipaddled submental flap where they used one paddle for providing the lining of the oral cavity and the other for covering the full thickness defect.
Pectoralis major myocutaneous flap
Since Ariyan first described the use of pectoralis major myocutaneous flap in 1979 for head and neck reconstruction, it has become the work horse of head and neck surgery with distinct advantage of ease of harvesting, reliable blood supply, and ability to provide bulk. Pectoralis major myocutaneous flap became great choice among majority of head and neck surgeons. Skin paddle of PMMC supplied by perforating vessel of thoraco-acromial artery. Various modifications of pectoralis major myocutaneous flap are described including unipadle, bipaddle, partial bipaddle, and osteocutaneous flap. In addition, PMMC flap covers the carotid artery and restores the contour of neck following comprehensive neck dissection., It can be used alone or with combinations of other flaps. There is minimal donor site morbidity as donor site defect can be closed primarily. Operative technique is the same over a period, as described by Ariyan, with some modifications required when deltopectoral flap is harvested simultaneously. Simple technique of harvesting, persistent anatomy of pedicle, and reliable and robust blood supply makes this flap favorite among surgeons. PMMC flap can be used to reconstruct oral cavity following resection of lateral gingivobuccal complex lesion, composite defect following segmental mandibulectomy, full thickness cheek defects, and total glossectomy defects [Figure 11]. It can be used for skin covering in neck defects or skin defect following lateral temporal bone resection and petrosectomy in ear malignancy as spiral PMMC. PMMF is a modification of PMMC when cutaneous portion is not included in flap; it can be used for lateral pharyngeal wall, tongue base, or lateral tongue reconstruction. PMMC flap can be modified into an island flap to decrease supraclavicular bulge and to gain extra length. It has been presumed that complication rates after PMMF reconstruction in female patients are higher because of the presence of more adipose tissue in the flap; still PMMC reconstruction is a reliable and cosmetically acceptable method of reconstruction in female patients for oral cavity defects following tumor ablation, as studied by Jena et al.
|Figure 11: A1 bipaddle PMMC following composite bite resection, A2 spiral PMMC following subtotal petrosectomy, a 3 PMMC reconstruction following total glossectomy|
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This flap has proved to be the true work horse flap for head neck reconstruction as it can withstand infection and even salvage surgeries of the head and neck region.
Temporalis muscle flap
Temporalis muscle flap holds great promise for the reconstruction of various maxillofacial region defects. This flap is an axial pattern based on the anterior and posterior deep temporal arteries. The use of temporalis flap for reconstruction of ablative defects within the maxillofacial region, in 1898 with a report by Glovine on its use for the obliteration of dead space following orbital exenteration and primary maxillary reconstruction after cancer excision. Gillies reported the use of the temporalis muscle in the reanimation of the paralyzed face. The temporalis muscle is exposed by using a coronal incision with a preauricular extension. Dissection is carried out at a subgaleal level to expose the muscle. Then, it is mobilized subperiosteally from its deep origin in the temporal fossa. Anteriorly, the muscle was elevated from the lateral aspect of the orbit and inferiorly down to the temporal crest. Particular care was taken to preserve the blood vessels entering from its inferior aspect. The zygomatic arch was exposed to rotate the muscle into the oral cavity. The muscle pulled through the tunnel and sutured intraorally. A drain placed at the subgaleal plane, the coronal flap repositioned, and the incision closed in layers. This flap has some advantages as it is slim, flexible and the fascia in contact with the oral cavity epithelizes in 3 weeks makes it resistant to the proteolytic action of the saliva. We had used this flap for palatal reconstruction following total maxillectomy and orbital obliteration following orbital exenteration [Figure 12]. and cavity obliteration following lateral temporal bone resection in makignacy of external auditary canal [Figure 13].
|Figure 12: Orbital defect following orbital exenteration which obliterated with temporalis muscle flap and skin advancement|
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|Figure 13: (a) Lateral temporal bone resection for Ca external auditory canal with parotid involvement fallowed by temporalis muscle flap for obliteration split skin graft for external cover. (b) 4 weeks postoperative picture|
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| Summary|| |
Head and neck area has many functional as well as aesthetic unit, hence, cancers of this area have impact on both, making head and neck reconstruction a challenging job for reconstructive surgeon. Reconstruction should be tailored preoperatively as well intraoperatively for each case. It depends on the size of the defect, requirement for the type of tissue function appearance, associated physical condition patient, and availability of resources. Martin et al. described the qualities of an ideal flap. They are thin, reliable, and have a good color match. They should be easy to dissect, carry a long arc of rotation with minimum donor site morbidity in addition to giving consistent results, as well as being technically not very demanding and having a short operative time. Life expectancy after cancer is good if it is diagnosed early. There is fear about cancer in society due to the mutilating nature of cancer surgery fallowed by functional loss because of which affected people do not come forward and we see most cases in an advanced stage. A firm knowledge that simultaneous reconstruction is possible will make patients more compliant to treatment that may be otherwise mutilating. Offering primary reconstruction increases compliance for adjuvant treatment also and helps patient and his family to cope with the brunt of cancer. Presence of reconstructive surgeon as the second team is always the wanted back up for ablative surgeon but many times ablative surgeon has to do the job of reconstruction. Hence, better understanding of the anatomy and utility of different locoregional flaps makes the surgeons job easy for reconstruction. Lesion may involve one or more anatomical site. Here for a given defect combination of different flaps or modification of single flap require which will give optimum reconstruction restoring function with aesthetic with minimum donor site morbidity.
| Conclusion|| |
Though microvascular surgery has revolutionized the oncoplastic reconstruction, sound knowledge of locoregional flaps makes an ablative surgeon a better surgeon in offering optimum patient service in set up where microvascular facility is not available or where there is a long wait. Robust blood supply of head and neck region is a boon for the patient as well as the treating doctor for the strategic planning of different reconstructive options with restoring acceptable form and function.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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