Myocutaneous Island Flap Research Articles

The sternomastoid island myocutaneous flap for oral cancer reconstruction.

To evaluate the usefulness of the sternomastoid island myocutaneous flap for reconstruction of defects after excision of oral cancer. One hundred eleven superiorly based sternomastoid island myocutaneous flaps were used for one-stage primary reconstruction in 110 consecutive patients with oral cancer during a 53-month period from June 1985 to November 1989. Ninety-eight patients had radiation therapy before surgery. One hundred six flaps were used for mucosal lining of the mouth and six flaps were used for providing skin cover. Flap-related complication developed in 38 patients (34.5%). Total flap loss occurred in eight patients (7.3%). Radical irradiation before surgery significantly increased flap-related complications. Low-molecular-weight dextran did not improve flap survival. After a minimum follow-up of 24 months, nine patients (8.2%) had recurrences in the ipsilateral neck. The flap could easily reach the oral cavity without producing tension on the suture line. The flap also did not produce excessive bulk in the mouth or on the face. In a selected group of patients with a clinically N0 neck, the sternomastoid island myocutaneous flap is oncologically safe and it gives satisfactory cosmetic and functional results with no lasting morbidity.

Neue Methode der Zungenrekonstruktion mit neurovaskulären infrahyoidalen Muskelfaszienlappen*

Surgical treatment of tongue cancer can lead to extended defunctionalization, depending upon the size and localisation of the defect. Great problems of swallowing arise after total glossectomy or extensive resections of the base of the tongue even after reconstruction with myocutaneous island flaps or free flaps. We developed a neuromuscular island flap derived from the infrahyoidal musculature to reconstruct a total tongue or large defects of the tongue base. This fasciomuscular flap is formed by the M. sternothyroideus, M. sternohyoideus and the upper part of the M. omohyoideus. The axial blood supply arises from the A. thyroidea sup. The innervation is derived from the Ansa cervicalis N. hypoglossi. In case of total glossectomy we took this flap from both sides of the neck. With this new method we reconstructed total tongues after glossectomy in two patients and large defects of the tongue base in six patients. In the present paper the new surgical method and the functional results are described.

The sartorius myocutaneous island flap

The vascular supply to the distal part of sartorius m. was studied in 37 limbs by dissection under magnification and after black ink and latex injections. The muscle or myocutaneous island flap pedicled on the saphenous artery (SA) is supplied by a retrograde circulation through anastomoses of the SA with the perforating branches of the posterior tibial artery and the medial inferior genicular artery. Three different vascular patterns were defined. Retrograde injection also showed good perfusion of the SA. The flap is useful for covering around the knee, the proximal and middle thirds of the lower leg, and the end of the amputation stump. Raising of the flap has not resulted in any functional or cosmetic defect. Eighteen operations have so far been performed, six using the muscle island flap and twelve using the myocutaneous island flap, and all survived completely.

Closure of mediastinal wounds with deepithelialized rectus abdominis musculocutaneous flaps.

Deep and narrow mediastinal defect after sternal debridement can be effectively obliterated by deepithelialized vertical rectus abdominis musculocutaneous flaps, based on the superior epigastric vessels. This composite flap has sufficient mass to obviate the need for additional vascularized tissue and is, therefore, offered as an alternative to multiple flap procedures. It offers a superior cosmetic appearance and better chest stability than a traditional island myocutaneous flap. Eleven patients had their mediastinal wounds repaired by this method with a low complication rate and good final results.

Platysma Myocutaneous Flap for Intraoral and Surface Reconstruction

Different procedures have been described for facial and oral reconstruction after malignant tumor removal, such as skin grafts and local and distal staged flaps. Myocutaneous island or free flaps are the method of choice for these reconstructions. Our experience concerns the use of the platysma myocutaneous flap in 12 patients after intraoral and extraoral malignant tumor resection. Six patients had squamous cell carcinomas, i.e., 2 malignant melanomas of the skin and 4 squamous cell carcinomas of the oral mucosa. The complete tumor resection was controlled by frozen-section biopsy in all patients, but for 7 of them a functional or radical neck dissection was performed. We suggest including in the flap the external jugular vein. The results were evaluated from an oncological, functional, and aesthetic point of view. We noticed 2 recurrences in a minimum follow-up of 4 years. The functional and aesthetic results were quite satisfactory and no serious complications were noticed in our series. However, the primary disadvantage of this interesting flap is that the dominant vasculature derived from the submental branch of the facial artery is seldom visualized. In spite of this, it should be regarded as very useful for limited intraoral or surface coverage problems in an arc extending 10 cm from the level of the facial artery at the mandible. This arc includes the cheek, the lower lip, the chin, the floor of the mouth, and the mastoid area.

Platysma Myocutaneous Flap for Intraoral and Surface Reconstruction

Different procedures have been described for facial and oral reconstruction after malignant tumor removal, such as skin grafts and local and distal staged flaps. Myocutaneous island or free flaps are the method of choice for these reconstructions. Our experience concerns the use of the platysma myocutaneous flap in 12 patients after intraoral and extraoral malignant tumor resection. Six patients had squamous cell carcinomas, i.e., 2 malignant melanomas of the skin and 4 squamous cell carcinomas of the oral mucosa. The complete tumor resection was controlled by frozen-section biopsy in all patients, but for 7 of them a functional or radical neck dissection was performed. We suggest including in the flap the external jugular vein. The results were evaluated from an oncological, functional, and aesthetic point of view. We noticed 2 recurrences in a minimum follow-up of 4 years. The functional and aesthetic results were quite satisfactory and no serious complications were noticed in our series. However, the primary disadvantage of this interesting flap is that the dominant vasculature derived from the submental branch of the facial artery is seldom visualized. In spite of this, it should be regarded as very useful for limited intraoral or surface coverage problems in an arc extending 10 cm from the level of the facial artery at the mandible. This arc includes the cheek, the lower lip, the chin, the floor of the mouth, and the mastoid area. Papadopoulos ON, Gamatsi IE. Platysma myocutaneous flap for intraoral and surface reconstruction. Ann Plast Surg 1993;31:15-18

The Microcirculation of Myocutaneous Island Flaps in Pigs Studied with Radioactive Blood Volume Tracers and Microspheres of Different Sizes

In order to further improve the understanding of hemodynamic changes in the immediate postoperative phase after elevation of myocutaneous flaps, regional blood flow and arteriovenous (A-V) shunting were measured in rectus abdominis island flaps in 8 pigs. Radioactive microspheres of two sizes (15 and 50 micron) were used. Approximately half (53.4 +/- 6 percent) of the 15-micron microspheres and one-fourth (24.1 +/- 6 percent) of the 50-micron microspheres entering the flap appeared in the venous outflow. Compared with the control area, A-V shunting was significantly increased in muscle and substantially more pronounced in skin. Nutritional blood flow, total blood flow, and vascular volume were increased in muscle and unchanged in skin and subcutis. The lowest tissue hematocrit of 7 +/- 1 percent was found in skin as compared with a central hematocrit of 35 +/- 2 percent. Tissue hematocrit in flap muscle was decreased to 17 +/- 2 percent when compared with control muscle (22 +/- 3 percent), and the mean transit time for blood was correspondingly decreased. Thus vasodilation provided increased perfusion through muscular capillaries and through A-V shunts. Shunting of 15-micron microspheres appeared to take place not only in skin, but also in subcutis and muscle, which challenges the widespread belief that A-V shunting does not occur in muscle.

The Microcirculation of Myocutaneous Island Flaps in Pigs Studied with Radioactive Blood Volume Tracers and Microspheres of Different Sizes

The Microcirculation of Myocutaneous Island Flaps in Pigs Studied with Radioactive Blood Volume Tracers and Microspheres of Different Sizes

Fuel Metabolism in a Pig Myocutaneous Island Flap Model

Unilateral denervated myocutaneous island flaps based on the superior epigastric vessels were raised in 24 pigs and the metabolic changes during the first 6 postoperative hours were monitored. Secondary to flap elevation, decreased arteriovenous (A-V) differences in oxygen, glucose, and alanine levels were observed, indicating the opening of A-V shunts and increased arterialization of the venous blood. Venous outflow increased during the first 3 hours, but the A-V differences in all metabolites were constant over the entire 6-hour observation period. Exchange of intermediary metabolites therefore increased within the first 3 hours, after which a steady state was established. The main flap fuels seemed to be fatty acids, muscle proteins, and glycogen, whereas blood-borne carbohydrates and ketone bodies played only a minor role as energy sources. Anaerobic metabolism was increased secondary to flap elevation from 2 to 6 percent as compared with preelevation values. No changes were found in concentrations of plasma catecholamines, which were constantly high. An average weight gain of 3 to 4 percent per hour was equally distributed to skin, subcutis, panniculus carnosus, and muscle. Thus the flap seemed to adapt to the new perfusion pattern within a few hours by a slightly increased anaerobic metabolism, but still with an oxidative metabolism of more than 90 percent.

Nasolabial myocutaneous island flap for reconstruction of palatal fistula. (A case report)

With better understanding of microcirculation of the flaps and with the introduction of the concept of myocutaneous flaps, nasolabial flap has regained its past popularity. Although it has been used increasingly for oral defects, its use for reconstruction of palatal defects has not been reported. Large anterior fistulae of palate are commonly produced when a wide cleft of palate is being repaired in an adult patient, especially by a beginner in plastic surgery, and are difficult to treat surgically. We have used superiorly based nasolabial myocutaneous island flap in one such case and report it here.

Arteriovenous Shunting and Regional Blood Flow in Myocutaneous Island Flaps

In eight pigs, total blood flow, regional capillary blood flow distribution, and arteriovenous (AV) shunting were studied during the first 4 postoperative hours after elevation of a myocutaneous rectus abdominis island flap. Capillary blood flow and AV shunting were measured using radioactive microspheres before flap creation and 1 and 4 hours after surgery. Total blood flow, measured continuously as venous outflow, increased in the first postoperative hour (p less than 0.05). Elevation of the flap caused a slight decrease in skin capillary blood flow (p less than 0.05), whereas muscular capillary blood flow increased (p less than 0.01). AV shunting accounted for 50 percent of the total flap blood flow, whereas it was negligible in the abdominal wall prior to flap elevation. Thus stalk blood flow, skin appearance, and skin temperature may be poor indicators of nutritional capillary perfusion. However, the clinical and nutritional consequences of these findings remain to be established.

Critical Ischemia Times and Survival Patterns of Experimental Pig Flaps

Previous work on critical ischemia time suggested (1) a greater susceptibility of myocutaneous flaps over skin flaps to the ischemia reperfusion injury and (2) that duration of ischemia may affect the survival area of a flap. Using a pig model, 55 animals were operated on and the critical ischemia times and survival patterns of the buttock skin (n = 85) and latissimus dorsi myocutaneous (n = 88) island flaps were determined after being submitted to 0, 2, 4, 6, 8, 10, 12, 14, and 16 hours of normothermic ischemia. The average critical ischemia times (CIT50) were determined to be 9 and 10 hours for the buttock skin and latissimus dorsi myocutaneous flaps, respectively. Percentage of total area surviving (%TAS) in those flaps which did survive was adversely affected by increases in the ischemic interval in both flap models. A statistically significant decrease in percentage of total area surviving was found after 6 and 8 hours of ischemia for the buttock skin and latissimus dorsi myocutaneous flaps, respectively.

Critical Ischemia Times and Survival Patterns of Experimental Pig Flaps

Previous work on critical ischemia time suggested (1) a greater susceptibility of myocutaneous flaps over skin flaps to the ischemia reperfusion injury and (2) that duration of ischemia may affect the survival area of a flap. Using a pig model, 55 animals were operated on and the critical ischemia times and survival patterns of the buttock skin (n = 85) and latissimus dorsi myocutaneous (n = 88) island flaps were determined after being submitted to 0, 2, 4, 6, 8, 10, 12, 14, and 16 hours of normothermic ischemia. The average critical ischemia times (CIT50) were determined to be 9 and 10 hours for the buttock skin and latissimus dorsi myocutaneous flaps, respectively. Percentage of total area surviving (%TAS) in those flaps which did survive was adversely affected by increases in the ischemic interval in both flap models. A statistically significant decrease in percentage of total area surviving was found after 6 and 8 hours of ischemia for the buttock skin and latissimus dorsi myocutaneous flaps, respectively.

Refinements of Nasalis Myocutaneous Flap

During the last 3 years, we have applied the nasalis myocutaneous island flap for reconstruction of nasal defects following excision of skin basal cell carcinoma and melanoma in 19 patients. By refinements with Z plasty, early dermabrasion, and placement of a bolster, we could minimize the trapdoor deformity, obvious scars, and blunting of the alar groove. No patients required revisional surgery, and flap survival was 100%. On the basis of our experience, the nasalis myocutaneous island flap is the solution for reconstruction of moderate-sized distal nasal defects in terms of reliability, aesthetics, and simplicity.

Sensibility and cutaneous reinnervation of pectoralis major myocutaneous island flaps: A preliminary clinical report

The cutaneous sensibility of 13 pectoralis major cutaneous island flaps has been investigated retrospectively. Although in raising the pectoralis major myocutaneous island flap sensory denervation of the skin is produced, after a mean follow-up period of 29 months (range 5 to 71 months), 68% of the cutaneous portion of the flap revealed sensibility to touch, suggesting a reinnervation from the surrounding intact oral mucosa or skin. The rate of reinnervation was found to be related to the sensibility present in the surrounding tissue.

Infected Breast Reconstruction Associated with Poland??s Syndrome

A 21-year-old woman with left breast hypoplasia associated with Poland's syndrome underwent breast reconstruction: removal of a previous implant, capsulotomy, and transverse myocutaneous island flap to the left chest. Eight weeks later, she returned with purulent drainage and cellulitis. Debridement revealed extensive fat necrosis with cultures positive for Staphylococcus epidermidis and Streptococcus viridans. There was an excellent response to antibiotic therapy after debridement

Microvascular salvage of a failing pectoralis major myocutaneous flap

While being elevated prior to reconstruction of a left-sided neck defect, a pectoralis major myocutaneous island flap was rendered ischemic by the inadvertant transection of the pectoral branch of the thoracoacromial artery. In order to save the flap, a microvascular repair between the distal end of this vessel and the ascending branch of the transverse cervical artery was performed. The flap was successfully revascularized and the patient went on to uneventful healing with 100% flap viability. This technique could be used following similar technical error in the elevation of any axial pattern flap providing that suitable vessels for repair were present.

Infected sternotomy wounds

Three babies who developed infection in their median sternotomy wounds are reported. In one child, a retrosternal abscess was drained and in the other two cases, the wounds dehisced. The wound cavities were filled with a rectus abdominis myocutaneous island flap and in each case, the wounds healed primarily. Early flap repair resolved the infection, shortened the hospital stay and provided protection to the exposed mediastinum.

Lower trapezius myocutaneous island flap.

Resurfacing of the floor of the mouth and buccal region of the oral cavity and the tonsillar region of the oropharynx may be accomplished with many variations of regional and distant vascularized flaps. Our experiences in the use of 14 lower trapezius myocutaneous island flaps are described with respect to the unique application and suitability of this flap to resurface defects in these areas, as well as the contraindications, both relative and absolute, to the use of this particular method of resurfacing. In addition, the intraoperative technique and attendant problems, as well as postoperative complications, are presented. The overall advantages and disadvantages of this flap as compared with the more traditional pectoralis myocutaneous flap are outlined. It is our belief that because of the distinct qualities of this flap, including extended scope and flap thinness, this method of reconstruction merits consideration in the preoperative planning process.

Conventional TRAM Flap versus Free Microsurgical TRAM Flap for Immediate Breast Reconstruction

Immediate breast reconstruction using the transverse abdominal myocutaneous island (TRAM) flap was performed in 54 patients over the past 3 years at our institution. This represented approximately 59 percent of patients undergoing all types of immediate breast reconstruction. In 10 patients, the abdominal island flap was transferred as a free flap based on the deep inferior epigastric pedicle. These patients were compared with the other 44 patients, in whom the flap was transferred using the conventional technique. The TRAM flap is well suited for immediate breast reconstruction because the procedure can be carried out simultaneously with mastectomy using separate operating teams and instruments. The operation is safe and relatively free of complications. The free TRAM group compared favorably with the conventional group in terms of complications, operating time, estimated blood loss, hospitalization, and return to functional baseline. The free TRAM flap appears to be as safe as the conventional technique with the advantages of a more limited rectus muscle harvest, improved medial contour of the breast due to the lack of tunneling, and perhaps a healthier flap because of the large donor vessels.