Cervical Skin Flap Research Articles

Factors Associated with Complications after Total Pharyngo-Laryngo-Esophagectomy and Free Jejunal Flap Reconstruction

Introduction: Free jejunal flap (FJF) reconstruction is a standard procedure for pharyngeal and cervical esophageal defects resulting from head and neck cancer resection. However, improvements in patients’ quality of life after surgery require a further statistical approach. Methods: An observational, retrospective, multivariate analysis was designed to report the incidence of postoperative complications and their association with clinical factors in 101 patients who underwent total pharyngo-laryngo-esophagectomy and FJF reconstruction for head and neck cancer at a university hospital between January 2007 and December 2020. Results: Postoperative complications were observed in 69% of patients. In the reconstructive site, anastomotic leak, observed in 8% of patients was associated with vascular anastomosis in the external jugular vein system (age-adjusted odds ratio [OR]: 9.05, p = 0.044) and anastomotic stricture, observed in 11% of patients was associated with postoperative radiotherapy (age-adjusted OR: 12.60, p = 0.02). Cervical skin flap necrosis was the most common complication (34%) and was associated with vascular anastomosis on the right cervical side (age- and sex-adjusted OR: 4.00, p = 0.005). Conclusion: Although FJF reconstruction is a useful procedure, 69% of patients suffer a postoperative complication. We suppose that anastomotic leak is related to the low blood flow resistance of the FJF and inadequate drainage of the external jugular venous system, and anastomotic stricture is related to the vulnerability of the intestinal tissue to radiation. Furthermore, we hypothesized that the location of the vascular anastomosis may affect the mesenteric location of the FJF and the dead space in the neck, leading to the development of cervical skin flap necrosis. These data contribute to increasing our knowledge about postoperative complications related to FJF reconstruction.

Risk factors and Incidence of wound dehiscence after neck dissection in patients with head and neck cancer

Background: Wound dehiscence is a complication after neck dissection (ND) in patients with head and neck cancer (HNC). We investigated the incidence, risk factors, and etiology of wound dehiscence among patients who underwent ND. Methods: A retrospective cohort study was performed on HNC patients, excluding those with thyroid cancer, who underwent surgery first in GSVM medical college, Kanpur. Results: The clinical charts of 60 patients were reviewed, 38 were male (63.33%) and 22 female (36.6%). The demographic and clinical characteristics are presented in Table I. out of 60 patient 12 take neoadjuvent CT and 2 neoadjuvent Rt. Out of 60 patients, 54 (90%) did not develop any complications, while 6 (10%) experienced some type of wound complication. The major complications that required surgical revision were wound dehiscence (6 cases, 10%).four patients who had previously received CRT and who developed wide cervical skin flap necrosis required secondary closure 8-10 day post surgery. No major vessel rupture was observed. Conclusions: Based on our results, we predict that certain groups of patients are at high risk for wound dehiscence after major HNC surgery. Preventive measures or close monitoring in these patients may be required to reduce the likelihood of postoperative wound dehiscence. Furthermore, even though additional research is required, we would consider changing the prophylactic antibiotic regimens according to the causative organisms.

A Novel Pharyngolaryngectomy Technique Using Cervical Skin Flap, Thyroid Cartilage, and Thyroid Gland Flap

A Novel Pharyngolaryngectomy Technique Using Cervical Skin Flap, Thyroid Cartilage, and Thyroid Gland Flap

Prefabricated maxillofacial and excessively expanded cervical skin flap for aesthetic unit reconstruction in the cheek

Objective To explore a method for repairing the appearance and function of the cheek aesthetic unit. Methods A single volume of 100 ml to 150 ml of tissue expander was implanted at the lower edge of the injury area on the cheek. The first injection was performed 5 days after the operation and twice a week after the injection. It took an average of about 4 months to complete the expansion, with 3-5 times over-expanded. The lesions were resurfaced with the expanded flaps, and long-term follow-up was observed for flap survival. Results 17 cases of cheek lesions had been successfully reconstructed, with the color, texture of the expanded flaps well matched to the surrounding skin after 3-12 months follow-up. The facial expression functions and configurations were satisfied. Conclusions Excessive expansion of the prefabricated skin flap of the jaw and neck can repair the cheek aesthetic unit successfully, which is a practical method and meets the needs of aesthetic unit repair. Key words: Cheek; Aesthetic unit; Skin flap; Tissue expander

Risk factors for wound complications in head and neck reconstruction: 773 free jejunal reconstruction procedures after total pharyngolaryngoesophagectomy

Most studies that examined risk factors for wound complications after head and neck reconstruction analyzed various complications collectively. Moreover, they included a wide variety of resection areas and reconstruction materials. To overcome these limitations, both the resection area and reconstruction method were constrained in the present study. Patients who underwent free jejunal graft reconstruction after pharyngolaryngoesophagectomy for hypopharyngeal cancer were enrolled. The outcomes of interest were abscesses, fistulas, and cervical skin flap necrosis. Abscesses, fistulas, and cervical skin flap necrosis developed in 19.3%, 11.3%, and 8.2% of 773 patients, respectively. A significant relationship was found between use of an open drain and abscess formation and between a longer operation time and cervical skin flap necrosis. Our findings suggest that use of an open drain, cardiovascular disease, and a longer operation time are significant risk factors for abscess formation, fistula formation, and cervical skin flap necrosis, respectively.

Prefabricated Cervical Skin Flaps for Hemi-Facial Resurfacing: Elucidating the Natural History of Postoperative Edema Using Indocyanine Green.

The increases in capillary wall permeability and capillary hydrostatic pressure are considered to be the causes for the acute swelling seen in flaps; however, disruption of the circulating flap lymphatics could be another contributory factor. In this study we monitor the development of flap edema in a series of 18 prefabricated flaps and aim to delineate the natural history of this phenomenon by use of lymphography. Postoperative swelling was monitored in a series of 18 pre-expanded prefabricated cervical skin flaps used for hemi-facial burns-scar resurfacing. Time to spontaneous resolution, presence or absence of venous congestion, and clinical outcome were recorded. In two cases, indocyanine-green (ICG) lymphography was used to monitor the dermal backflow pattern until swelling had completely resolved. Average moving velocity of ICG after injection as well as flap thickness was also recorded over the follow-up period. The average moving velocity of ICG in the flap lymphatics improved from 0.48 cm/min to 1.5 cm/min in the first 12 days after flap transfer. The dermal backflow pattern was stardust in the first 12 days, indicating moderate lymphedema, transforming to splash from week three, and a robust collecting lymphatic vessel occurring from the fifth month, indicating mild lymphedema and lymphatic channel recovery, respectively. Transient swelling was observed in all prefabricated flaps in our series. We postulate that this is mostly secondary to lymphatic disruption that subsides as lymphangiogenesis takes place. ICG lymphography is an inexpensive, safe, and easy-to-use imaging technology that could be used in the monitoring of postoperative lymphedema seen in prefabricated flaps.

An algorithm for using expanded cervical flaps to resurface facial defects based on five different methods

BackgroundFor patients with healthy skin in the cervical region, the expanded cervical flap method is highly recommended for resurfacing facial skin defects. Many methods exist that use an expanded cervical flap. However, a gold standard for selecting the appropriate method for each patient is lacking. Here, we introduce 5 basic principles for how to use an expanded cervical flap and an algorithm for selecting the appropriate method. MethodsThe authors reviewed the medical records for all patients treated with an expanded cervical flap to restore a facial skin lesion in Shanghai's Ninth People's Hospital between 2010 and 2015. ResultsWe summarized the 5 techniques according to different types of facial deformities: (1) an advancement of the expanded cervical flap; (2) an expanded cervical flap that is rotated toward the temporal side (the rotation pivot is located in the angle of the mandible); (3) an expanded cervical flap that is rotated toward the nasal side (the rotation pivot is located in the mentum; (4) an expanded cervical flap that is rotated cephalically along the midline toward the lower third of the face (the rotation pivot is located in the bilateral angle of the mandible); and (5) a prefabricated cervical flap that is used with superficial temporal vessels. ConclusionBy using this algorithm and following five basic principles, all facial defects except for those on the nose and forehead can be resurfaced using an expanded cervical skin flap.

Application of a bioengineered composite neotrachea in a dog model

BackgroundSurgical treatment of extensive tracheal lesions remains a major challenge because of lack of an ideal airway substitute that is well vascularized, rigid, and autologous. We describe a novel surgical technique of tracheal reconstruction using a combination of a polypropylene mesh material and anterior cervical myocutaneous flap in a dog model. Materials and methodsA 3.5–4 cm length of cervical trachea was resected in 16 dogs and replaced with a myocutaneous cervical neck flap wrapped around the plain polypropylene tube (group 1, n = 7) or wrapped around a composite of polypropylene tube with an implanted Z-type metallic-covered stent (group 2, n = 9). The cervical tracheal defect was repaired with the previously mentioned substitute that was directly sutured to the remaining tracheal ends. Dogs were followed up using bronchoscopy and x-rays and euthanized at predetermined times for histologic examination. ResultsIn group 1, four dogs died within 2 wk from respiratory failure with varying degrees of airway collapse and difficulties in expectoration. In group 2, eight dogs survived, whereas one died of anastomotic dehiscence 1 wk after surgery. Necropsy and histologic examination of the anastomotic sites revealed good healing tissue. Pathologic examination also revealed excellent healing of the squamous epithelium of the neotrachea and the columnar epithelium of the native tracheal mucosa. ConclusionsThe tissue compatibility of the polypropylene mesh material and anterior cervical myocutaneous skin flap makes this a promising therapeutic substitute for treatment of patients with extensive tracheal lesions.

Autologous tracheal replacement: From research to clinical practice

Despite numerous attempts, synthetic materials and heterologous tissues failed to replace durably the trachea. Autologous tracheal substitution (ATS) without synthetic material or immunosuppression was investigated to replace extended tracheal defect. We present our experience regards to this innovative challenge. After a previous research study, we developed a novel reconstruction technique for extended tracheal defects on animals. Through a single stage operation, a tube from a forearm free fascio-cutaneous flap vascularized by radial vessels is re-anastomosed to cervical vessels. This flap is reinforced by rib cartilages interposed transversally in the subcutaneous tissue. It provides also a reliable ATS. Twelve patients benefits from an extended tracheal resections, 7-12 centimeter (mean 11 cm) long. Indications were eight Primary tracheal Neoplasms (including 5 adenoid cystic carcinoma [ACC] and 3 squamous cell carcinoma [SCC]), three secondary tracheal neoplasms (including 1 thyroid carcinoma and 2 lymphoma) and one post-intubation tracheal destruction after long history of stenting. Daily bronchoscopy and transitory tracheotomy was associated due to absence of mucociliary clearance. The research work leads to present the first described animal model for tracheal resection and replacement with an autologous conduit. It was constructed from costal cartilages and a pediculed cervical skin flap. From 2004 to 2012, 12 patients have had ATS with associated resections in four cases. All patients were extubated on the first postoperative days; eight patients are alive at 2 to 94 months (mean=36) postoperatively, with no respiratory distress. The two patients with ATS after resection extended to the carina died due to pulmonary infection. No airway collapse has been detectable, either by endoscopy, dynamic CT scan or spirometry. Two patients still have a tracheotomy because performed too low at the level of the proximal anastomosis. One patient with a chronic severe respiratory insufficiency required recently a distal and short stent. ATS is actually a good, durable tracheal substitute that can resist respiratory pressure variations because of their transverse rigidity without any immunosuppression. The limits of this technique are probably, chronic respiratory insufficiency and cartilage calcifications. Research to develop a method for lining the neo-trachea with ciliated respiratory epithelium is needed.

A Modified Frontolateral Partial Laryngectomy with Laryngeal Framework Reconstruction

Objectives: Endoscopic resection and radiotherapy are organ-preservation strategies for glottic cancer because of the high local control and quality of voice after the therapy. However, frontolateral partial laryngectomy is still needed in some cases. This procedure has the complication of hoarseness. Therefore, we applied the theories of laryngeal framework surgery to partial laryngectomy with reconstruction using strap muscles and skin flap in order to improve postoperative voice qualities. Methods: We performed a modified frontolateral partial laryngectomy in three selected cases (rT1a, T3 cases). The retrospective analysis of voice qualities (PPQ, APQ, NHR, MPT) was performed in 10 frontolateral partial laryngectomy cases (7 conventional and 3 modified methods). Surgical procedure: Frontolateral vertical partial laryngectomy with tumor-free margin was performed via laryngofissure approach. After tumor resection, approximation laryngoplasty was performed using sternothyroid muscle flap that was inserted into posterior dead space to gain better contact of the posterior vocal fold on the reconstructed vocal ridge. After these procedures, a reverted sternohyoid muscle was placed inside the preserved outer perichondrium to reduce dead space and externally medialize cervical skin flap, which shaped new vocal fold. Results: No recurrence was observed in any case. No aspiration and laryngeal stenosis were observed in any case. The postoperative voice qualities were improved over pretreatment qualities in modified cases. PPQ after modifying this method was better than conventional methods. Conclusions: It is better for voice quality to treat selected glottic cancers with this modified frontolateral partial laryngectomy.

Reconstruction du tiers inférieur de l’auricule par lambeau de Crikelair

Amputation of the lower third of the ear includes full thickness earlobe defects. Earlobe reconstruction depends on the covering and scaffold technique used. The Crikelair cervical skin flap is one of the available techniques for reconstruction. We discuss its assets and drawbacks by comparing it with alternative procedures.

Improvement of tracheal flap method for laryngotracheal separation

Recurrent pneumonia due to intractable aspiration is a life-threatening disease. A tracheal flap method for children without previous tracheostomy has been previously reported. This study reports that improvements of this method and its three subtypes are widely applicable to patients with various conditions. Surgical technique study. The tracheal flap method does not involve transection of the trachea but achieves laryngotracheal separation using the tracheal, mucoperichondrial, and sternohyoid muscle, along with anterior cervical skin flaps. This method can be divided into three subtypes as follows: A-type, utilizing the tracheal flap (for patients without previous tracheostomy); B-type, utilizing the mucoperichondrial and sternohyoid muscle flaps (for patients lacking an anterior tracheal wall); and C-type, utilizing the esophageal flap (for patients with severe hypersalivation). In all three subtypes, the anterior cervical skin flap is employed. The tracheal flap method was performed in 30 patients (24 children and six adults) at risk of developing intractable aspiration pneumonia. In all 30 cases, aspiration pneumonia was prevented without severe complications. No fistula formation was observed. All three subtypes (A-, B-, and C-type) of the tracheal flap method are effective in preventing the recurrence of aspiration pneumonia. This method is applicable to diverse patient backgrounds regardless of age or previous tracheostomy. It is less invasive than Lindeman procedure. Furthermore, this method is acceptable to patients' families and improves the QOL of both patients and caregivers.

383. A Case of Thyroid Cancer of Infiltrating the Trachea - Treatment by Partial Tracheal Resection and Reconstruction with Cervical Skin Flaps

383. A Case of Thyroid Cancer of Infiltrating the Trachea - Treatment by Partial Tracheal Resection and Reconstruction with Cervical Skin Flaps

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.

Composite cervical skin and cartilage flap provides a novel large airway substitute after long-segment tracheal resection

Airway replacement after long-segment tracheal resection for benign and malignant disease remains a challenging problem because of the lack of a substitute conduit. Ideally, an airway substitute should be well vascularized, rigid, and autologous to avoid infections, airway stenosis, and the need for immunosuppression. We report the development of an autologous tracheal substitute for long-segment tracheal resection that satisfies these criteria and demonstrates excellent short-term functional results in a large-animal study. Twelve adult pigs underwent long-segment (6 cm, 60% of total length) tracheal resection. Autologous costal cartilage strips measuring 6 cm x 2 mm were harvested from the chest wall and inserted at regular 0.5-cm intervals between dermal layers of a cervical skin flap. The neotrachea was then scaffolded by rotating the composite cartilage skin flap around a silicone stent measuring 6 cm in length and 1.4 cm in diameter. The neotrachea replaced the long segment of tracheal resection, and the donor flap site was closed with a double-Z plasty. Animals were killed at 1 week (group I, n = 4), 2 weeks (group II, n = 4), and 5 weeks (group III, n = 4). In group III the stent was removed 1 week before death. Viability of the neotrachea was monitored by means of daily flexible bronchoscopy and histologic examination at autopsy. Long-term morbidity and mortality were determined by monitoring weight gain, respiratory distress, and survival. There was no mortality during the study period. Weight gain was appropriate in all animals. Daily bronchoscopy and postmortem histologic evaluation confirmed excellent viability of the neotrachea. There was no evidence of suture-line dehiscence. Five animals had distal granulomas that were removed by using rigid bronchoscopy. In group III 1 animal had tracheomalacia, which was successfully managed by means of insertion of a silicon stent. Airway reconstruction with autologous cervical skin flaps scaffolded with costal cartilages is a novel approach to replace long segments of resected trachea. This preliminary study demonstrates excellent respiratory function and survival in large animals undergoing resection of more than 50% of their native trachea. Use of cervical skin flaps buttressed with costal cartilage is a promising solution for long-segment tracheal replacement.

Modified frontolateral partial laryngectomy without tracheotomy

Objective To investigate the feasibility of modified frontolateral partial laryngectomy without tracheotomy for patients with early-stage laryngeal cancer or dysplasia of the true vocal cord. Study Design After frontolateral partial laryngectomy, the inner side of the sternohyoid muscle was drawn into the laryngeal lumen to suture it to the incisal margin of the uninjured side and to the false vocal cord on the side of the lesion to ensure the safety without tracheotomy. A reverted sternohyoid fascial flap was used to cover the anterior area to form a new laryngeal lumen in the shape of a ladder. Subjects and Methods A total of 65 patients with early glottic carcinomas or severe dysplasia of the true vocal cord were treated with modified frontolateral partial laryngectomy without tracheotomy. Ipsilateral false vocal cord flaps and cervical skin flaps were used in 63 patients and two patients respectively to reconstruct the defect. Results Deglutition and phonation were fully recovered after 7 to 10 days postsurgery. The only postoperative complication was subcutaneous emphysema noted in nine patients. The 1-, 3-, and 5-year survival rates were all 100 percent. Conclusion Modified frontolateral partial laryngectomy without tracheostomy is an effective surgical method for early glottic carcinomas and severe dysplasia of the true vocal cord.

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.

Experience with the modified hockey stick incision for block dissection of neck

The modified hockey stick incision was originally described by Lahey in 1940. This allows elevation of a superiorly based cervical skin flap, with additional exposure of the parotid as necessary. The longitudinal portion of the incision runs from the mastoid process downward, behind the anterior border of the trapezius muscle, and curves gently at the junction of the lateral one-third and medial two-thirds of the clavicle. The transverse component extends medially, approximately 2 cm below the clavicle. When parotidectomy is required, incision is extended in front of the ear and a forward cut is made for additional exposure. We present our experience with a series of 16 patients, undergoing a total of 17 neck dissections for various pathologies. The majority (11 patients) received postoperative radiotherapy. There were two episodes of minor skin necrosis which were not related to radiotherapy, but to patient co-morbidity, and settled with conservative management. All patients had a satisfactory cosmetic result. We find the modified hockey stick incision to be cosmetically superior and provide excellent exposure of the neck, with protection of the carotid vessels.

Modification of the Superficial Cervical Axial Pattern Skin Flap for Oral Reconstruction

To describe an extended pedicle flap based on the superficial cervical artery (SCA) for closure of oral defects in dogs. Anatomic study; in vivo experimental study. Canine cadavers (13) and 3 dogs. The prescapular branch of the SCA was cannulated and perfused with a lead oxide gelatin mixture. The area perfused by 1 SCA was examined as was the rostral extent of the flap. Staged implantation was performed to evaluate flap performance in vivo. In stage 1, the flap was prepared for implantation into the oral cavity. In stage 2, the flap was fully developed to include the 1 degrees, 2 degrees, and partial 3 degrees angiosome of 1 SCA pedicle. The flap was transposed by a bridging incision and a parapharyngeal tunnel into the oral cavity. The flap was used to reconstruct a partial-thickness defect created in the palate. The territory of the contralateral SCA was captured in all cadavers. The full flap reached the level of the canine teeth in all cadavers. In live dogs, necrosis was not observed after implantation into partial-thickness defects and dehiscence was minimal. Loss of pliability secondary to de-epithelialization and staging resulted in a limitation of rostral reach of the flap. Whereas the flaps did not reach as far rostrally as anticipated, they survived well in the harsh oral environment. The flap may be modified to reconstruct full-thickness palatal defects. The extended SCA pattern flap may be adapted for closure of oral defects.

Reconstruction of a Skin and Bone Defect of the Parietal Region Using a Superficial Cervical Artery Skin Flap

Reconstruction of a Skin and Bone Defect of the Parietal Region Using a Superficial Cervical Artery Skin Flap