Cervical Flap Research Articles

Application of Less Invasive Reconstruction using Cervical Local Flap

Application of Less Invasive Reconstruction using Cervical Local Flap

ステノン管原発扁平上皮癌の1例

A case of squamous cell carcinoma originating in Stensens’duct is presented. A 62-year-old man visited our hospital because of a swelling in his right cheek. At presentation, palpation of the lesion revealed a hard, elastic spherical mass 30 mm in diameter in the right cheek. Adhesion to the skin was found. However, the mobility of the surrounding tissue was poor. The buccal mucosa showed no abnormalities macroscopically. However, salivary flow was slightly poor. An aspiration biopsy revealed atypical keratinocytes, leading to the diagnosis of Class V,and squamous cell carcinoma was suspected. MRI revealed a 15-mm mass located mainly on Stensen’s duct. Neck dissection and resection of the parotid gland lamina superficialis resulted in complications which required further resection of the superficial layer of the masseter muscle and part of the skin of the cheek region. A platysma cervical flap was used to repair the defect. Histopathological examination of the resected tissue revealed a welldifferentiated squamous cell carcinoma. The patient received adjuvant postoperative radiotherapy at a total dose of 40 Gy. As of 14 months after operation, there has been no recurrence or sequelae.

Excessive expansion of cervical skin to repair lower hemifascial scar

Objective To explore the reconstruction effects of lower hemifascial scar by cervical skin excessive volume expansion. Methods Single 100 ml or 150 ml standard volume tissue expander was implanted under the cervical skin in 50 patients with lower hemifascial scar. After the tissue expanders were injected with 4-5 times than the designed volume, the scar was resurfaced with the expanded flap. Results The excessively expanded cervical flaps of 50 patients all were successfully used to reconstruct the facial scar. The expanded flap was matched well with surrounding skin after 3-12 months following-up. No obvious contracture was observed. The district recontrueted by expended flaps have the normal expression aetivities. Conclusion Excessive expansion of cervical skin can promote the efficiency in the reconstruction of the lower hemifascial scar. Key words: Tissue expander; Facial scar

Reconstruction by Lateral Cervical Flap of Perioral and Oral Cavity

These clinical studies include 75 patients, followed up for 2 to 5 years: 37 females and 38 males. Age ranged between 5 and 81 years (median, 46 years). These cases were seen during a period of 6 years. There were 61 cases of oral squamous cell carcinoma; these cases include 25 cases of well-differentiated squamous cell carcinoma, 24 cases of moderately differentiated squamous cell carcinoma, and 12 cases of poorly differentiated squamous cell carcinoma. These cases were treated by adjuvant chemotherapy with radical surgery and deep x-ray therapy. In 23 cases, the lateral cervical flap (LCF) was used as an excess for radical resection of supraomohyoid neck dissection; in 10 cases, the LCF was used for reconstruction of cases with posttraumatic missile injuries, and in 4 cases, platysma muscle flap was used for reconstruction of underdeveloped masseter muscle in cases with mild hemifacial microsomia. Experimental studies were performed on rabbits for reconstruction of the lateral side of the tongue and submental region to assess the viability of LCF. In conclusion, the flap proved to be an ideal and most reliable flap for reconstruction of both perioral and oral defects after radical cancer surgery and posttraumatic missile injury deformities.

The need for a complete platysma component for platysma myocutaneous flaps?-an introduction of the expanded cutaneous-dominant platysma flap for facial defect reconstruction

Platysma flaps have been successfully used for the reconstruction of variety of facial defects as musculocutaneous. This concept had been changed by a recent anatomical investigation revealing the inherently fasciocutanous nature of the platysma flap. In the study, it was observed that all of the arterial branches furnishing the anterlateral neck skin penetrate the platysma but do not run along in the platysma layer. The switch made it possible for us to design cervical skin flaps with limited participation of muscular platysma composition in clinical practice. The platysma flap is considered to be an ideal donor source due to its thin, pliable and sufficient colour matched skin nature. When combined with the tissue expansion technique, this flap can provide adequate donor tissue that is particularly valuable for large facial defect repairs without leaving any modalities on the neck donor site. In our report, we designed and used the expanded platysma myocutaneous flap as a cutaneous-dominant skin flap for large facial defect repairs. In operation, the cervical flap is elevated at the intermediate layer between the platysma and the superficial adipofascia. A small amount platysma muscular tissue is recruited only in the area surrounding these facial artery perforators at the flap peddle region. As anticipated, the result was successful. We conclude that the expanded cutaneous-dominant platysma flap peddled by facial artery perforators provides a useful alternative for the reconstruction of facial defects and should be a valuable addition to facial reconstructive surgery.

Clinical application of expanded submental island flap in facial soft tissue defect

To investigate the application of the expanded submental island flap in facial soft tissue defect. 12 patients with facial soft tissue defects were treated with the expanded submental island flaps during September 2004 to September 2008. At the first stage, soft tissue expander was implanted in the neck. At the second stage, the submental island flap was designed to repair the facial soft tissue defect. The largest size of the flap was about 16 cm x 9 cm. All flaps survived well except for one case of partial epidermal necrosis at the distal part of the flap. The wound healed with dressing. 4 patients were followed up for 6-24 months with satisfactory results. The submental artery was a constant branch of facial artery. Large cervical flap with high quality tissue can be provided after expansion. The expanded submental island flap is a good choice for repairing the facial soft tissue defect.

Reconstruction of the Upper Aerodigestive Tract with the Submental Artery Flap

: The submental artery flap has rekindled interest in using cervical flaps for reconstruction of head and neck defects. In this article, the authors present their experience with this flap for defects of the upper aerodigestive tract. : This is a retrospective study of 21 patients who underwent upper aerodigestive tract reconstruction with submental artery flaps from 1997 to 2005. The flap was used primarily to reconstruct defects after tumor extirpation, severe infections, and burns. In one case, the flap was used to close an esophagocutaneous fistula. Nine patients had irradiation. Three patients had flap prelamination before transfer. : The flaps in all 12 patients who had not undergone irradiation survived. With the exception of a small fistula in one patient and transient marginal mandibular nerve palsy in another, none of these patients experienced any major complications. In contrast, six of the nine patients who had been irradiated experienced major complications. These included total flap loss in one, partial flap losses in two, and scar contractures in another three. The difference in major complication rates between these two groups was statistically significant (0 percent versus 67 percent, p < 0.01). : In nonirradiated tissues, the submental artery flap is an excellent choice for reconstruction of moderate-sized defects of the upper aerodigestive tract because of its reliability and versatility and the ease with which it can be applied.

Prefabricated Cervical Flap for Facial Reconstruction

Prefabricated Cervical Flap for Facial Reconstruction

Two-Stage Tracheal Reconstruction of Primary Tracheal Non-Hodgkin Lymphoma With Nitinol Mesh Stent and Cervical Myocutaneous Flap

Primary tracheal non-Hodgkin lymphoma is an extremely rare entity without consensus management strategy. We present a case of primary tracheal lymphoplasmacytoid lymphoma masquerading as asthma with wheezing and progressive dyspnea. A patented nitinol mesh stent was implanted in the right lateral cervical region 3 weeks before tumor resection. After 5.5-cm-long segmental tracheal resection, a neotracheal tube was constructed with cervical myocutaneous flap sandwiched around the implanted mesh stent, which was then anastomosed with the residual of the patient's trachea. The patient has been well for 30 months.

Reply to the Letter to the Editor of R. Navarro et al. concerning “Infrahyoid muscle flap for pharyngeal fistulae after cervical spine surgery: a novel approach —report of six cases” (by R.O. Seidl et al., Eur Spine J (2007) 16: 501–505)

Dear Editor, We would like to thank you for your contribution to the discussion and meanwhile take the opportunity to take up a number of points: It is true that closing of injuries to the pharyngeal wall using the sternocleidomastoid muscle (SCM) via the incision, is a technically straightforward method. Nevertheless, pharyngeal defects following surgery to the cervical spine are in most cases located on the anterior part of the pharynx. Even with skilled preparation, the SCM, which must be placed between the pharynx and spine, still remains a rounded muscle bundle. The SCM therefore restricts the pharynx and can thus be an additional factor in triggering swallowing disorders. This is, in our opinion, reflected in the significantly longer period for which feeding tubes remain in place where pharyngeal defects are reconstructed using the SCM. An infrahyoid flap (IHF) is no thicker than the pharynx musculature and barely restricts the pharynx, as is shown by the CT images in our publication. In addition, the superior fascia cervicalis of the IHF, which is included when preparing the IHF, forms a sliding layer between the pharynx and spine. This sliding layer facilitates movement of the pharynx against the spine. We have discussed the necessity of this sliding layer in a previous publication [2]. It represents an additional reason for the reduction in the period for which feeding tubes remain in place. All cervical muscle flaps which are innervated by nerves, which were not damaged in the course of the spinal cord injury further curtail the patient’s already restricted motor possibilities. This applies as much to the SCM as to the IHF. Both muscles play a similar role in breathing, so that this function is equally diminished with both flaps. From the short period for which feeding tubes remained in place as per our results, it can be concluded that the IHF does not restrict swallowing. To date, it has not been possible to establish a link between swallowing disorders following injury to the cervical spine and the degree of damage to the spinal cord or the attached nerves (ansa cervicalis) [1, 3], so that the loss of the IHF on one side is clearly not a factor in the development of a swallowing disorder. In the opinion of the authors, preparation of the IHF presents no particular difficulties for the surgeon. The flap can be prepared via the incision used to access the spine and pharynx. After receiving the necessary training, an experienced surgeon will have no difficulties preparing the ansa cervicalis or the thyroid artery and vein. One of the authors is a neurosurgeon who performs the preparation alone. Should, however, technical problems arise, then interdisciplinary collaboration to the benefit of the patient should be aimed. The significantly shorter period for which feeding tubes remain in place and the associated earlier resumption of oral feeding in our opinion represent significant benefits for the patient and for this reason make the IHF the first choice in the treatment of post-operative pharyngeal defects.

Versatility of the Bilobed Cervical Skin Flap for Total Ear Reconstruction in the Unfavorable Temporoauriculomastoid Region

The unfavorable temporoauriculomastoid region is a serious clinical problem that makes total ear reconstruction a real challenge. In patients who have it, all local flap solutions to provide skin coverage to the cartilage frame are precluded because of loss and/or severe scarring of the regional skin in association with loss of the axial vascularity of the region. In the current literature, all available techniques for these patients are lengthy and risky free flap procedures that can provide a poor quality of skin coverage with no aesthetic harmony at best. In this article, the authors describe the use of the bilobed cervical flap as a new technique for providing skin coverage in total ear reconstruction for patients with an unfavorable temporoauriculomastoid region. Over a period of 6 years, the technique was used in seven patients between the ages of 19 and 52 years. In all patients, the entire skin of the temporoauriculomastoid region was either lost or badly scarred. Moreover, use of the ipsilateral temporoparietal fascia was not possible because of impaired axial vascularity of the region. Except for mild venous congestion at the distal part of the primary flap, the flaps healed uneventfully in all patients. The patients were followed up for 1 to 4 years. The results were excellent in all patients. Providing a thin, pliable, hairless, and well-vascularized skin cover with a perfect color match, the bilobed cervical flap seems to be a useful solution to overcome the skin coverage dilemma in patients with an unfavorable temporoauriculomastoid region.

Reconstruction of nose and lips with tubed cervical flap in electrical injury: a case report

Electrical burn injuries occur worldwide and constitute 5–10% of all occupational fatalities. An analysis of human factors contributing to electrocutions has shown that carelessness is a major contributor. The management of these acute wounds has progressed over time, with the emphasis changing from a conservative approach to wound closure, then to the more aggressive doctrine of improving the functional and aesthetic outcome of the patients [1]. Factors that determine the type and extent of electrical burn injuries include voltage and current flow [1,2]. The spectrum of anatomic sites involved from electrical trauma is quite varied. The head is not a usual contact or entry point in high-tension burns but if involved, lips, nose and commissures may be affected. Young children usually aged between 1 and 3 years are frequent victims of electric burns of the lips [3]. It is rarely seen in adults. Several options are available for reconstruction of lips according to the extent of injury. Subtotal lip reconstruction can be performed using local flaps such as cross-lip and fan flaps. Total lip reconstructive efforts usually are suboptimal in providing an adequate oral sphincter, an acceptable aesthetic result or both. For total upper, lower or extensive combined soft-tissue defects that include both lips, traditional methods of reconstruction include the use of regional flaps such as the deltopectoral flap [4,5]. A more recent application is the use of the folded forearm flap to replace both the skin and inner lining, simultaneously, in full-thickness cheek and lip defects [6].

A medially based cervical transposition flap for soft tissue coverage of the cheek

A new flap for cheek reconstruction is presented. It is a medially based axial pattern flap that is elevated on the SMAS or including the SMAS and thus is of good thickness and stability for coverage of even large defects of the cheek without significant contour irregularities. It is planned like a traditional transposition flap and harvested in such a way that the scar of the secondary defect lies under the edge of the mandible and, thus, on the border between two aesthetic units and along the relaxed tension lines. The donor site scar is aesthetically acceptable.

Endoscopic-assisted face lift: review of 200 cases.

The use of endoscopic techniques in facial esthetic surgery has gained increasing popularity in the last decade. Endoscopic forehead rejuvenation became a reliable technique and an attractive option for both the surgeon and the patient. The use of the endoscope in face and neck lift surgery did not gain the same popularity, as explained by the relative few indications for this technique. In this study, we retrospectively review a series of 200 patients who underwent endoscopic-assisted face-lifts alone or in combination with other esthetic procedures. We divided the patients into 4 groups according to the type of incisions and the surgical approach used in each of them. We also reviewed the current status of using the endoscope in face and neck lift surgery. The technique described in this study uses limited access incisions (limited postauricular, submental, and temporal scalp) to reposition the ptotic facial elements, while avoiding the preauricular and postauricular scarring when indicated. Under endoscopic visualization, the composite face-lift flap elevates the malar fat pad above the zygomaticus muscle to the nasolabial fold. The lower-lid orbicularis oculi muscle is incorporated and lifted with composite flap through the lower blepharoplasty incision. The jowl area is contoured by tangential excision and tightening of the lateral platysma. Pretunneling and hydrodissection defines the plane of dissection and helps to reduce the bleeding during facial and cervical flap elevation. In this study, endoscopic techniques were applicable in selected patients undergoing facial rejuvenation with goals of decreased scarring. Indications for using the technique include young patients (eg, less than 50 years) with a relatively small amount of skin excess or older patients with thick skin and minimal skin redundancy. The technique is particularly attractive to the male patient, by avoiding the preauricular incision and the disruption of the beard line. Patients with excess skin underwent the standard cervicofacial incision. In this group the endoscope was used as a tool for better magnification and illumination.

Venous drainage of the platysma myocutaneous flap

Objectives The platysma myocutaneous flap offers a regional reconstruction option for relatively small soft tissue defects in the head and neck area. However, epidermolysis of its skin paddle with resultant fibrosis and tongue tethering has been documented. This has been attributed to arterial and/or venous vascular compromise. We investigated the venous drainage patterns of this flap in a cadaveric study. Study design and setting We made selective Microfil dye injections into the external and internal jugular veins of 5 cadavers. A wide cervical flap was then raised, and anatomic dissection of the superficial and deep venous systems was performed to identify the dominant draining veins of the platysma flap. Results Universally, small communicating veins from the internal jugular venous system were noted to drain the platysma flap anteriorly. The external jugular vein was noted to drain the flap posteriorly. Conclusions Although it is difficult to preserve the anterior communicating veins with 180° flap rotation, the results of this study suggest a possible benefit of external jugular vein harvest in continuity with the platysma flap. Further clinical studies are needed to assess whether flap venous congestion, epidermolysis, and resultant fibrosis can be minimized with this technique.

Biomechanical and viscoelastic properties of skin, SMAS, and composite flaps as they pertain to rhytidectomy.

Previous studies have focused on biomechanical and viscoelastic properties of the superficial musculoaponeurotic system (SMAS) flap and the skin flap lifted in traditional rhytidectomy procedures. The authors compared these two layers with the composite rhytidectomy flap to explain their clinical observations that the composite dissection allows greater tension and lateral pull to be placed on the facial and cervical flaps, with less long-term stress-relaxation and tissue creep. Eight fresh cadavers were dissected by elevating flaps on one side of the face and neck as skin and SMAS flaps and on the other side as a standard composite rhytidectomy flap. The tissue samples were tested for breaking strength, tissue tearing force, stress-relaxation, and tissue creep. For breaking strength, uniform samples were pulled at a rate of 1 inch per minute, and the stress required to rupture the tissues was measured. Tissue tearing force was measured by attaching a 3-0 suture to the tissues and pulling at the same rate as that used for breaking strength. The force required to tear the suture out of the tissues was then measured. Stress-relaxation was assessed by tensing the uniformly sized strips of tissue to 80 percent of their breaking strength, and the amount of tissue relaxation was measured at 1-minute intervals for a total of 5 minutes. This measurement is expressed as the percentage of tissue relaxation per minute. Tissue creep was assessed by using a 3-0 suture and calibrated pressure gauge attached to the facial flaps. The constant tension applied to the flaps was 80 percent of the tissue tearing force. The distance crept was measured in millimeters after 2 and 3 minutes of constant tension. Breaking strength measurements demonstrated significantly greater breaking strength of skin and composite flaps as compared with SMAS flaps (p < 0.05). No significant difference was noted between skin and composite flaps. However, tissue tearing force demonstrated that the composite flaps were able to withstand a significantly greater force as compared with both skin and SMAS flaps (p < 0.05). Stress-relaxation analysis revealed the skin flaps to have the highest degree of stress-relaxation over each of five 1-minute intervals. In contrast, the SMAS and composite flaps demonstrated a significantly lower degree of stress-relaxation over the five 1-minute intervals (p < 0.05). There was no difference noted between the SMAS flaps and composite flaps with regard to stress-relaxation. Tissue creep correlated with the stress-relaxation data. The skin flaps demonstrated the greatest degree of tissue creep, which was significantly greater than that noted for the SMAS flaps or composite flaps (p < 0.05). Comparison of facial flaps with cervical flaps revealed that cervical skin, SMAS, and composite flaps tolerated significantly greater tissue tearing forces and demonstrated significantly greater tissue creep as compared with facial skin, SMAS, and composite flaps (p < 0.05). These biomechanical studies on facial and cervical rhytidectomy flaps indicate that the skin and composite flaps are substantially stronger than the SMAS flap, allowing significantly greater tension to be applied for repositioning of the flap and surrounding subcutaneous tissues. The authors confirmed that the SMAS layer exhibits significantly less stress-relaxation and creep as compared with the skin flap, a property that has led aesthetic surgeons to incorporate the SMAS into the face lift procedure. On the basis of the authors' findings in this study, it seems that that composite flap, although composed of both the skin and SMAS, acquires the viscoelastic properties of the SMAS layer, demonstrating significantly less stress-relaxation and tissue creep as compared with the skin flap. This finding may play a role in maintaining long-term results after rhytidectomy. In addition, it is noteworthy that the cervical flaps, despite their increased strength, demonstrate significantly greater tissue creep as compared with facial flaps, suggesting earlier relaxation of the neck as compared with the face after rhytidectomy.

Yes to a tight neck, no to a rhytidectomy

Many patients emphatically refuse a face lift to improve the shape of the cervico-mandibular angle, but are nevertheless not prepared to put up with ugly skin folds and the platysma bands. As an alternative we can offer a platysmaplasty in combination with a submental skin excision, often used with liposuction in the chin and cheek area. From December 1995 to April 1999, 20 patients between the ages of 33 and 82 (mean age 57), 12 female and eight male were operated on using a submental incision. A cervical skin flap with a thin layer of fat was raised. It was taken down to the larynx and its length was 4–5 cm. Most of the fat was taken off the platysma muscle up to the external jugular vein, where this crosses the sternocleidomastoid muscle. The platysma edges were raised and joined in the midline, using a running suture. Any excess skin was excised in a spindle-shaped fashion. In 14 cases additional liposuction above the mandible was necessary. In three cases no platysma tightening was indicated, and on 3 occasions a midline skin excess was excised incorporating a Z-plasty. In summary, the operations are performed under local anesthesia and therefore do not cause the patient too much stress. If necessary, subplatysmal fat can also be removed in the same operation. The median platysma muscle edges are approximated in the midline starting at the mandibular symphysis, and this is continued at least down to the middle of the neck above the larynx. In female patients the approximation is done above that level to avoid the prominence of the larynx. A small horizontal incision below the suture line will eliminate the bowstring effect. A platysma duplication above the submandibular gland can make it less obvious.

頚部島状筋皮弁による口腔内再建 筋皮弁の基部と血流について

頚部島状筋皮弁による口腔内再建 筋皮弁の基部と血流について

Management of the jowl

Dr. Gerber: The first patient is a 52-year-old woman who complained of a loss of jaw line (Figure 1). She gained weight after she quit smoking 7 months ago. Dr. Little, how would you create mandibular definition and reposition the soft tissues on this patient? Dr. Little: Although I don't usually bring this up during facial rejuvenation consultations, the first question in this case is whether to enhance the appearance of her skeleton with a chin implant. She has a birdlike face now, with a sharply convex facial profile. I would suggest a wide-based implant as a nice way to balance her face. The key issue is to get a good neck correction, whether or not an implant is used. I think the jowl is an important but secondary issue. I would elevate only the small amount of immediate sub-mandibular fat that is sagging below the jaw line. I would use the old-fashioned technique of plication, using 5.0 absorbable sutures performed through the subcutaneous approach to the face. That would move about 2 cm of fat back above the jaw line where it belongs. Diane L. Gerber, MD J. William Little, MD Dr. Gerber: Would you remove fat from the neck as well? Dr. Little: I would remove all of the neck fat down to the level of the platysma. The only remaining subcutaneous fat is about 3.5 mm that I leave on the cervical flap, which will be dissected from ear to ear. After removing the fat, I would divide her platysma transversely at the level of the thyroid, from the lateral end, until I reach the sternocleidomastoid, then swing up vertically anterior to the sternocleidomastoid and stop when I near the angle of the jaw. I always look underneath the muscle, because one third of patients have significant …

Use of a Dorsal Cervical Single Pedicle Advancement Flap in 3 Birds With Cranial Skin Defects

A ring-necked pheasant (Phasianus colchicus), a rock dove (Columba livia), and a red-tailed hawk (Buteo jamaicensis) were each presented with a large soft tissue wound on the head with exposed skull. Each bird was treated with wound debridement, removal of necrotic bone, and grafting of a single pedicle advancement flap from the adjacent dorsal cervical skin. Wounds in the pheasant and hawk healed without complication. In the rock dove, the initial flap necrosed, but a second single pedicle advancement flap, elevated from the dorsal cervical skin, was successful. The final result in all 3 birds was complete coverage of the defect with full-thickness skin. In birds, use of single pedicle advancement flaps mobilized from dorsal cervical skin may expedite healing of large soft tissue wounds of the head, especially when the skull is exposed.