Sternocleidomastoid Flap Research Articles

Recurrent cervical esophageal stenosis after colon conduit failure: Use of myocutaneous flap

A 53-year-old male developed cervical esophageal stenosis after esophageal bypass surgery using a right colon conduit. The esophageal bypass surgery was performed to treat multiple esophageal strictures resulting from corrosive ingestion three years prior to presentation. Although the patient underwent several endoscopic stricture dilatations after surgery, he continued to suffer from recurrent esophageal stenosis. We planned cervical patch esophagoplasty with a pedicled skin flap of sternocleidomastoid (SCM) muscle. Postoperative recovery was successful, and the patient could eat a solid meal without difficulty and has been well for 18 mo. SCM flap esophagoplasty is an easier and safer method of managing complicated and recurrent cervical esophageal strictures than other operations.

Causes, Treatment and Prevention of Esophageal Fistulas in Anterior Cervical Spine Surgery

To evaluate the causes, treatment and prevention of esophageal fistulas after anterior cervical spine surgery. Between January 2004 and December 2011, 5 of 2348 patients who underwent anterior cervical surgery in our hospital developed esophageal fistulas (three male and two female patients, average age 34 years). Their diagnoses were cervical injuries (three), cervical spondylosis (one) and cervical tuberculosis (one). Their esophageal fistulas were treated by debridement and exploratory surgery, primary suturing of the perforation and/or sternocleidomastoid myoplasty. If conservative treatment failed or esophageal fistula recurred, plate removal was offered. Postoperative treatment included esophageal rest, enteral nutrition, wound drainage, and antibiotics. Methylene blue was used to evaluate results. An esophageal fistula was discovered during anterior cervical surgery in one patient and primary suturing performed. In four patients, fistulas were diagnosed after anterior cervical decompression and fusion. In one of these, only debridement and exploratory surgery were required. In another, a perforation was sutured during debridement and exploratory surgery. In the third, internal fixation was removed because of failure of prolonged conservative treatment. In the fourth, the esophageal fistula recurred repeatedly; he required removal of the hardware and reinforcement with a sternocleidomastoid muscle flap. At 6-48 months follow-up, all patients were in good condition, symptom free, and without cervical instability or infectious spondylitis. Successful management of esophageal fistula after anterior cervical spinal surgery depends on primary closure of the perforation with or without muscle flaps, surgical drainage, esophageal rest and nutritional support, and removal of hardware if necessary. Prevention consists of careful surgery and gentle tissue handling.

Blood supply to the human sternocleidomastoid muscle and its clinical implications for mandible reconstruction

The use of the sternocleidomastoid (SCM) flap for reconstructive surgery of the mandible seems to be a practicable although underestimated option. This study was conducted on 15 cadavers that had been neoprene-latex injected in the middle and inferior pedicles. Lengths of the SCM were equally divided into upper, middle, and lower thirds. Each third was then subdivided into numbered quadrants. This procedure defined six levels in the SCM, each corresponding to two quadrants: one medial and the other lateral. For each third of the SCM, the origin of the main pedicles was recorded. The quadrants where neoprene-latex was detected were reported in the dissection book. The upper third of the SCM muscle was constantly supplied by branches of the occipital artery. The middle third of the SCM muscle received its blood supply from a branch of the superior thyroid artery (right SCM/left SCM: 53%/53%), the external carotid artery (27%/20%), or branches of both (20%/27%). The lower third of the muscle was supplied by a branch arising from the suprascapular artery (73%/73%), the transverse cervical artery (7%/13%), the thyrocervical trunk (13%/13%), or the superficial cervical artery (7%/0%). The neoprene-latex injected into the subclavian artery reached the four lower levels in all SCMs studied (the middle third of the SCM). In 13% of the SCMs, this injection also reached level II (the upper third of the SCM). With a double injection (inferior and middle pedicles), levels I and II were reached in 100% of the cases. This study shows that, used alone, the lower pedicle does not have the ability to ensure the full vascularization of the SCM muscle. A composite flap might be safely raised only if the integrity of both inferior and middle pedicles is respected.

Expert's comment concerning grand rounds case entitled ''postoperative pharyngocutaneous fistula: treated with sternocleidomastoid flap repair and cricopharyngeus myotomy'' (by V.A. Iyoob).

Great care should be taken to minimise damage to the pharynx and upper oesophagus during an anterior approach to the cervical spine. If noticed at the time of surgery primary repair should be carried out; if noticed in the postoperative period, thorough cleaning and placement of a pharyngocutaneous drain will result in spontaneous healing of the majority of fistula. For persistent fistula secondary repair is required using well-vascularised tissue.

Postoperative pharyngocutaneous fistula: treated by sternocleidomastoid flap repair and cricopharyngeus myotomy

Pharyngoesophagocutaneous fistula (PEF) is one of the rare but serious complications of antero-lateral approach to cervical spine surgery. Because of its rarity, the true incidence of PEF is not clear. But, retrospective analysis of large series of cervical spine surgery reports 0-1.62 % incidence (Cloward in Surg 69:175-182, 1971; Elerkay et al. in J Neurosurg Spine 90(Suppl 1):35-41, 1999). Proximity to the vertebral column and thin walls makes the upper digestive tract vulnerable to injury in cervical trauma, surgical or nonsurgical. Presentation in early postoperative period is not rare and carries high morbidity and mortality (Jones and Ginsberg in Ann Thorac Surg 53(3):534-543, 1992). Various procedures for these fistulae such as simple closure, muscle flap interposition, esophageal diversion and jejunal interposition are reported. Some authors also advise removal of prosthetic plates and posterior stabilization, besides the repair of fistulae in a staged manner (Orlando et al. in Spine 28(15):E290-E295, 2003). Two similar cases of pharyngeal fistulae with similar etiology and clinical scenario are presented here, which were managed successfully with initial control of sepsis followed by delayed definitive repair with sternocleidomastoid muscle flap interposition and cricopharyngeus myotomy without removal of prosthetic plates. Postoperatively, both patients showed no evidence of any wound complications or collections until the seventh day. A contrast swallow study on seventh day showed no leak following which soft diet was started. Both patients were not having any difficulty in swallowing or aspiration. On 1-year follow-up, both patients were having no difficulty in swallowing, no episodes of aspiration and no recurrence of fistula. This case series highlights the importance of cricopharyngeus myotomy for treating PEF and the improved results with the prosthesis kept undisturbed.

Anterior Cervical Discectomy and Fusion Is Not a Benign Procedure

Objective: 1) Present 5 cases of esophageal injury following anterior cervical discectomy and fusion. 2) Discuss the existing literature on mechanism of injury, presentation, and treatment. Method: This study is a retrospective case series conducted between 2009 and 2011, reviewing the presentation, and treatment of 5 cases of esophageal injury following anterior cervical discectomy and fusion. Results: All 5 patients in the series presented with dysphagia. The esophageal injuries in 3 out of 5 cases were identified on barium swallow. In 2 of the 5 patients esophageal injury was not identified until direct laryngoscopy was performed. Four out of 5 of the patients presented in the case series were repaired with sternocleidomastoid flaps and one with endoscopic diverticulotomy alone. All patients had improvement in their symptoms and 3 of the 5 patients completely recovered esophageal function. Conclusion: With the increased number of anterior cervical disk fusion cases being performed, there are more complications that otolaryngologists must be aware of. Esophageal perforation is a very serious complication and early recognition and treatment are necessary to prevent serious morbidity and mortality. As imaging does not easily identify esophageal perforation, endoscopy is recommended to optimize identification. Management of perforation is best conducted with sternocledoimastoid flaps, which are ideal for esophageal reinforcement because of their excellent blood supply and low donor site morbidity.

Surgical Repair of Long-Segment Cervical Esophageal Injury With a Sternocleidomastoid Myocutaneous Flap

We present a useful technique for the surgical management of long-segment cervical esophageal tears using a sternocleidomastoid flap with overlying skin patch. The flap is easily accessible, customizable, and offers the ability to repair long segments of cervical and upper thoracic esophageal injuries.

Modified face-lift approach combined with a superficially anterior and superior-based sternocleidomastoid muscle flap in total parotidectomy

The authors evaluate a modified total parotidectomy performed through a modified face-lift incision integrated with a superficially anterior and superior pedicled sternocleidomastoid muscle (SASSCM) flap. Records of 86 cases of total parotidectomy were reviewed retrospectively. Clinical evaluation of cosmetic gratification, presence or absence of gustatory flushing or sweating, functional reversion of the seventh cranial nerve and great auricular nerve (GAN) were undertaken by 3 investigators independent to the operators. This group presents a mean follow-up of twenty-six months. The average scale of cosmetic gratification from patients and investigators are 7.97 and 7.56, respectively. Almost total complaints about anesthesia in upper cervical part and cheek disappeared within three months postoperatively. Neither in objective test nor from subjective complaint was gustatory sweating identified in present study. The authors' technique is esthetically pleasing and efficacious to prevention of gustatory sweating in total parotidectomy.

The Efficiacy of Sternocleidomastoid Muscle Flap on Frey's Syndrome via a Novel Test: Galvanic Skin Response.

The aim of this study was to evaluate the effects of sternocleidomastoid (SCM) muscle flap on preventing Frey's syndrome by using, Galvanic skin responses (GSR). Fourty-three patients who underwent superficial parotidectomy were randomly divided into two groups and their GSR were recorded. SCM muscle flap was applied over the surgical area only in one group. Six months after the surgery, GSRs were remeasured. In addition, the patients completed a questionnaire regarding their complaints about clinical Frey's syndrome. Four patients had symptoms of clinical Frey's syndrome. Postoperative GSR measurements revealed no significant difference between two sides in flap group (p=0.426) but higher in without flap group (p=0.003). The patients with clinical Frey syndrome had significantly higher GSR values than the remaining patients. The SCM muscle flap was an effective method in preventing Frey's syndrome. Moreover, GSR test was highly sensitive and specific for diagnosis.

Dens of Axis Metastasis from Medullary Thyroid Cancer

In 1997, a 45-yr-old female Caucasian underwent thyroidectomy with systematic lymph node dissection for a 2.5-cm large node-negative left medullary thyroid cancer (MTC). Basal calcitonin fell from 132 to 4.6 pg/ml but later climbed to 92.1 pg/ml (in 1999) and 335 pg/ml (2005). F-Dihydroxyphenylalanine (DOPA) positron emission tomography (PET), which is superior to F-fluorodeoxyglucose PET in MTC (1), revealed a 1-cm large paratracheal mass without distant metastases. Reoperation confirmed tumor invasion of the left laryngotracheal angle, anterior tracheal wall, and cricoid. A wedge resection was performed, and a sternocleidomastoid muscle flap was fashioned to cover the tracheal defect. Postoperative serum calcitonin was 176 pg/ml (2005) and 169 pg/ml (2006), with a magnetic resonance image showing scar tissue only before calcitonin started rising. F-DOPA PET (2008) and bone scintigraphy (2010) failed to spot the tumor. In 2011, basal calcitonin peaked at 648.6 pg/ml. On Gallium-DOTATOC, where DOTA is tetraazacyclododecane tetra aacetic acid and TOC is D-Phe-c(Cys-Tyr-D-TrpLys-Thr-Cys)-Thr(ol), PET-computed tomography (CT), an 8-mm large somatostatin receptor-positive, poorly demarcated osteoblastic tumor emerged in the left dens of axis, most likelyrepresentingmetastasis fromMTC(Fig.1).Falsepositive findings due to inflammation are theoretically possible with Gallium-DOTATOC but were considered highly unlikely. There was no evidence of other metastases. The lesion received 60 Gy of irradiation, and serum calcitonin decreased to 464 pg/ml, providing further support that the lesion represented metastatic MTC. DOTATOC is used for diagnostic and therapeutic purposes. Experience with Y-DOTATOC in MTC concentrating DOTATOC is limited to 12–21 patients: 0–10% achieved remission and 42–57% stable disease, whereas 33–58% sustained disease progression (2, 3). The effectiveness of Lu-DOTATOC (4) for MTC is unclear.

Evaluating the Efficacy of a Sternocleidomastoid Flap via Galvanic Skin Responses in Superficial Parotidectomy

In the present study, we evaluated the efficacy of flaps via measurement of galvanic skin responses (GSR) in patients who had undergone superficial parotidectomy either with or without sternocleidomastoid (SCM) muscle flaps. Retrospective study design was used. The setting included University of Uludag School of Medicine Department of Otorhinolaryngology. Eleven patients who had undergone superficial parotidectomy for benign diseases in our clinic between June 2003 and August 2006 were included in the study. SCM muscle flaps were used in four patients. The GSR of the patients were measured using a MP 30 System. The Mann-Whitney U test was used for the analysis of data. There were complaints that resembled Frey's syndrome in three patients in whom flaps had not been performed. Patients with flaps had no complaints. In patients with flaps, no significant GSR changes were observed between the control and operated sides (P>0.05). In patients without flaps, the GSR levels were significantly higher on the operated side compared to the control side (P<0.05). GSR values on the control side did not show any differences between patients with and without a flap. However, there were significantly higher GSR values for the operated side in patients without flaps compared to patients with flaps (P<0.05). Application of a SCM flap is an efficient method by which to prevent Frey's syndrome, and the GSR test is beneficial both in diagnosiing and determining the severity of the disease as well as evaluating the efficacy of surgical techniques used to prevent Frey's syndrome.

Rotational pectoral musculocutaneous flap for the repair of gastric conduit necrosis in cervical esophagogastrostomy

We experienced a case of wide necrosis of the cervical gastric conduit during esophageal cancer surgery. We attempted to repair this defect with various methods including conservative care, stents two times, and sternocleidomastoid muscle flap without successful results. Finally, we were able to reconstruct the gastric conduit defect with rotational pectoralis major musculocutaneous (PMM) flap. PMM flap is thought to be a reconstruction method applicable to the intractable gastric conduit defect.

RE: Intra-auricular modification of facelift incision with sternocleidomastoid flap - a cosmetic approach for parotidectomy: how we do it

RE: Intra-auricular modification of facelift incision with sternocleidomastoid flap - a cosmetic approach for parotidectomy: how we do it

Transection of the Aerodigestive Tract After Blunt Neck Trauma

Survival after blunt neck trauma resulting in combined tracheal and esophageal injury is uncommon. We present the case of a young boy who sustained complete transection of the trachea and subtotal transection of the esophagus after a clothes line type injury.

Intra-auricular modification of facelift incision with sternocleidomastoid flap - a cosmetic approach for parotidectomy: how we do it

Intra-auricular modification of facelift incision with sternocleidomastoid flap - a cosmetic approach for parotidectomy: how we do it

Successful repair of esophageal perforation after anterior cervical fusion for cervical spine fracture

Esophageal injury after anterior cervical discectomy and fusion (ACDF) is a rare complication that can be life threatening. The sternocleidomastoid (SCM) pedicled muscle flap has emerged as an effective and versatile tool for selected esophageal perforations. The authors report their surgical experience in three patients with an esophageal perforation after ACDF, and the steps taken to achieve successful repair using a SCM muscle flap. All three patients underwent ACDF at another hospital. Postoperatively, patients complained of severe dysphagia, neck swelling, fever, and alimentary fluid leakage. They were later referred to the author’s hospital for diagnostic evaluation and surgical treatment of an esophageal perforation. Esophageal perforation was diagnosed on esophagoscopy and esophagography, and treated by primary closure using an SCM muscle flap. Postoperatively, all patients had a good result. Surgery-related complications occurred in one patient with dysfunction of the recurrent laryngeal nerve. This study shows that esophagoscopic diagnosis and surgical treatment using a SCM muscle flap is highly effective in patients with an esophageal perforation related to ACDF.

Surgical treatment of primary tracheal tumors in 63 cases

To summarize the experience in diagnosis and treatment of primary tracheal tumors, and to improve the life quality of patients. Sixty-three patients with primary tracheal tumors treated in the First Affiliated Hospital of China Medical University during the past 40 years were included in this study, among them, there were 42 cases of malignant tumors and 21 cases of benign tumors. The 61 patients underwent surgery including tracheal sleeve resection (22), carinal resection and reconstruction (6), semi-carinal resection and reconstruction (6), tracheal resection for tracheal tumors (17); tracheostomy (4), tracheal resection, partial resection of the thyroid (goiter) and esophagomyotomy (1), tracheal tumor resection and vertical hemilaryngectomy with reconstruction of laryngeal ventricle and trachea by sternocleidomastoid flap (2), cervical trachea and laryngeal resection (1), and carinal scrape (2). Fifty-five patients had an uneventful recovery. Eight patients suffered from postoperative complications, among them 3 patients died postoperatively. Primary tracheal tumors often present atypical symptoms, are easily misdiagnosed and with poor prognosis. The main aim of treatment remains to remove the airway obstruction.

Parotidectomy for benign parotid tumors: An aesthetic approach

Background/aimsThe sternocleidomastoid (SCM) partial thickness muscle flap is among the various methods described to correct parotidectomy defects, but its indications and limitations are not clearly demonstrated in several reports. This study was done to test the aesthetic outcome of this method, its indications and limitations. The technique was combined with a face lift incision to further improve the outcome. Patients and methodsAt the National Cancer Institute, Cairo University, Egypt, 23 patients presenting with benign tumors underwent parotidectomy, 19 had superficial parotidectomy and four had total parotidectomy done. The superiorly based (SCM) muscle flap was used to correct the contour deformity. The aesthetic result was evaluated by assessing and scoring the overall appearance of the scar, the degree of symmetry of the reconstructed parotid region and the site of the donor muscle to their contralateral normal sides. The overall aesthetic appearance was then calculated by the summation of the scores of the latter three parameters. Patients’ satisfaction was assessed by patients’ questionnaire. ResultThe overall aesthetic appearance was good in 17 patients, and moderate in six patients. 16/23 patients had an overall deep satisfaction with the result. The residual hollowness of the parotid following reconstruction of the total parotidectomy defect and the poor quality of scars were the main reasons affecting the aesthetic outcome. ConclusionSuperficial parotidectomy through facelift incision with immediate reconstruction with superiorly based partial thickness SCM flap allows adequate resection of most benign parotid tumors with a satisfactory aesthetic outcome and minimal donor site morbidity.

A 10-year experience of infection following carotid endarterectomy with patch angioplasty

Although infection following carotid endarterectomy is rare, consequences of this seldom seen complication can be devastating. Polyester, polytetrafluoroethylene (PTFE), and vein patches have all been used by many institutions for patch angioplasty, each with reported cases of infection following surgery. Our institution has preferentially used PTFE for the majority of cases, and here, we report our experience with postoperative infection following endarterectomy over the last decade. From January 2000 through July 2009, we treated infections following carotid endarterectomy in 25 patients. Of the 25 patients undergoing treatment for postoperative infection, 21 had PTFE patches placed during the initial surgery. The remaining four consisted of two polyester patches and two bovine pericardial patches. Twenty-three of the 25 initial endarterectomies were performed at our institution, and the other two were referrals. The majority of cases (56%) were due to gram-positive organisms, with only two cases being polymicrobial. The interval from the original surgery to clinical presentation ranged from 7 days to 85 months, with 20 patients (80%) presenting within 60 days of the first operation. Thirteen patients underwent incision and drainage with antibiotics, and 12 patients underwent definitive surgical treatment. Four received patch excision with vein patch angioplasty, four received patch excision with vein interposition, and four received sternocleidomastoid flaps. The 30-day stroke rate was 8%, and the freedom from recurrent infection was 100% at a mean follow-up of 32 months. Infection following carotid endarterectomy occurs <1% of the time; however, the potential for morbidity is significant. Our results show that most infections following PTFE patch angioplasty occur in the early postoperative period (<60 days) and that simple drainage with antibiotics may be an adequate form of treatment in select cases.

The sternocleidomastoid myocutaneous “patch esophagoplasty” for cervical esophageal stricture

Esophageal strictures may be caused by many etiologies. Patients suffer from dysphagia and many are tube-feed dependent. Cervical esophageal reconstruction is challenging for the plastic surgeon, and although there are reports utilizing chest wall flaps or even free flaps, the use of a sternocleidomastoid (SCM) myocutaneous flap provides an ideal reconstruction in select patients who require noncircumferential "patch" cervical esophagoplasty. We present two cases of esophageal reconstruction in which we demonstrate our technique for harvesting and insetting the SCM flap, with particular emphasis on design of the skin paddle and elucidation of the vascular anatomy. We believe that the SCM flap is simple, reliable, convenient, and technically easy to perform. There is minimal donor site morbidity with no functional loss. The SCM myocutaneous flap is a viable option for reconstructing partial esophageal defects and obviates the need to perform staged procedures or more extensive operations such as free tissue transfer.