Operative Techniques in Otolaryngology (2013) 24, 45-54
Reconstructive options for the neck after resection of cutaneous malignancies Neerav Goyal, MD, MPH, Fred G. Fedok, MD, FACS From the Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, The Pennsylvania State University, Milton S. Hershey Medical Center, Hershey, Pennsylvania. KEYWORDS Neck defect; Skin graft; Deltopectoral flap; Pectoral flap; Cervicopectoral rotation; Latissimus dorsi flap; Reconstruction
Cutaneous defects of the neck require a different algorithm for reconstruction as compared to facial defects. Depending on the location and size of the defect, a variety of reconstructive techniques can be used, from secondary healing to pedicled or free flaps. Additionally, patient co-morbidities can negatively affect the outcomes of certain reconstructive options. We will describe a variety of techniques that are available to the head and neck or facial plastic surgeon for reconstruction of neck defects. © 2013 Elsevier Inc. All rights reserved.
Head and neck surgeons and facial plastic surgeons are often responsible for reconstructing defects secondary to Mohs surgery (chemosurgery) or wide local excisions of cutaneous malignancies of the neck. Approaching neck reconstruction requires a different algorithm compared with that used in reconstructing the face to yield the best functional and cosmetic outcome. This chapter will focus on the variety of techniques available to the surgeon in reconstructing defects of the neck, with specific focus on skin grafts, local flaps, and regional flaps. Although there is a well-established literature defining the aesthetic units of the face, a similar consensus does not exist regarding the neck. In his 1994 report, Angrigiani1 considered the neck as the anterior and posterior neck regions, with the separation between these 2 regions demarcated by an imaginary line from the earlobe to the middle of the clavicle. He defined the anterior neck as going from the lower border of the mandible to the sternal notch. Zhang et al2 defined aesthetic units of the neck, as it related to patients who suffered burns to the neck, and chose to subdivide the anterior neck unit into the
suprahyoid and infrahyoid aesthetic units by defining the hyoid as a “pivot point of the neck”.
Patient evaluation Location/size In evaluating a defect and developing a reconstructive plan, the location, depth, and size of the defect all play a significant role. Larger defects may not be amenable to closure with a skin graft or local flap and will likely require a regional flap. Similarly, defects that involve exposure of the great vessels will need a vascular flap of significant bulk (usually a regional flap) to ensure adequate coverage of the great vessels. The location of the defect will dictate reconstructive options on the basis of proximity to certain regional or local flaps, as well as in determining color and texture match of a graft.
Host factors/recipient site factors Address reprint requests and correspondence: Fred G. Fedok, MD, FACS, Division Chief of the Division of Otolaryngology-Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, PA. E-mail address: ffedok@hmc.psu.edu 1043-1810/$ -see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.otot.2013.01.001
The method of reconstruction is dependent not only on the defect itself but also on the patient’s ability to heal and incorporate the reconstruction. The deleterious effects of
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Figure 1
Reconstructive ladder. Figure of options for reconstruction from least to most invasive. (Color version of figure is available online.)
radiation on local tissue diminish the vascularity, induce fibrosis, and reduce the ability of the skin to repair and heal. Additionally, nutritional factors and other comorbidities as well as patient lifestyle can adversely affect the success of a reconstructive surgery. Patients with hypoalbuminemia or general malnutrition will have delayed wound healing and an increased likelihood of wound breakdown. Moreover, comorbidities such as hypercholesterolemia, peripheral vascular disease and coronary arterial disease can affect the patency, compliance, and resilience of pedicled flaps and decrease the success of grafts and free flaps. Additionally, research shows that diabetics have significant intracellular metabolic defects that lead to delays in signaling to limit tissue destruction and to initiate the reparative processes within the body.3 Patients undergoing free-flap reconstruction with a diagnosis of diabetes have been found to be more likely to have a negative outcome.4 Smokers are also associated with greater flap and healing complications secondary to the vasoconstrictive effect of nicotine and the higher likelihood of small-vessel disease, although these changes are thought to be reversible.5
Reconstructive options When considering options for reconstruction, we can use the reconstructive ladder to guide our options to manage a soft-tissue defect. The ladder consists of closure by secondary intention, primary closure, delayed primary closure, split-thickness skin graft, full-thickness skin graft, tissue expansion, random flaps, axial flaps, and, finally, free flaps
(as shown in Figure 1). When there is exposure of the great vessels, the wound may need to be closed immediately.
Delayed reconstruction Delayed reconstruction can be of significant utility in cases where there is concern for recurrence or positive margins from the initial resection. In these cases, a temporary split-thickness skin draft or other biological dressing can be used. As noted previously, delayed reconstruction usually cannot be entertained when there is exposure of the great vessels.
Closure by secondary intention Closing by secondary intention can be a reliable method of closing, especially along defects that lie over well-vascularized tissues and without exposure of the great vessels of other critical structures. Additionally, convex structures and areas with lax skin are more amenable to closure by secondary intention. This can yield healing that is cosmetically and functionally acceptable in many circumstances. It is not universally used and is of generally limited application. This method of closure might be used in patients who prefer not to have another surgery, when there are comorbidities or contraindications to other methods of closure. To aid with healing by secondary intention, Dhir et al6 describe the use of vacuum-assisted closure (VAC) systems for neck wounds. In their case series, the VAC dressings were used mostly in patients who experienced a wound dehiscence of a neck dissection incision.
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47 grafts contain a portion of the dermis, whereas full-thickness skin grafts contain the whole dermis. There are 3 major steps in the integration of a skin graft: imbibition, inosculation, and neovascularization. Imbibition or “drinking” involves “plasmatic circulation” and capillary action as well as direct diffusion of nutrients from the recipient wound bed into the graft.8 This phase lasts between 24 and 48 hours. After this, the donor and recipient capillary ends realign to establish a preliminary vascular network through a process known as inosculation or “kissing.” By 4 to 7 days of skin graft placement, the graft enters the third phase—neovascularization—where new vessels grow into the graft.
Figure 2 Primary closure. This image demonstrates the typical elliptical incision that is fashioned around a neck lesion (A) with a primary closure of the resulting defect (B). (Color version of figure is available online.)
Primary closure Give the redundancy inherent in many patients’ neck softtissues, there is enormous latitude of the size of defects that can be closed by simple advancement and closure. Defects ⬎4 cm in vertical dimension can be closed with ease in many patients. The laxity of the neck skin and the ability to undermine the tissues surrounding the defect allow for a significant variety of defects of the neck to be closed primarily. Ideally, the long axis of the defect should lie along a relaxed skin tension line, and also have an elliptical shape. A 3:1 ratio of the long axis to the short axis for the ellipse is an ideal proportion, and often undermining the equivalent of one width of the defect should be undertaken around the entire defect.7 Figure 2 demonstrates an example of a primary closure.
Skin grafts Skin grafts consist of epidermis and a variable amount of dermis that is transferred to the defect. Split-thickness skin
Split-thickness skin graft A split-thickness skin graft typically varies between 0.012 and 0.030 inches in thickness and consists of both epidermis and a variable thickness of dermis. The thicker the dermis is the better the skin texture and, at times, the color of the skin graft will be to the surrounding skin. Additionally, the thicker the dermis, the less overall contracture of the graft, although the degree of immediate contracture is less, as there is less elastin in the transferred dermis. An electric dermatome is often used to harvest the graft. The donor site should be marked with an additional 15% to 20% length to account for graft shrinkage.9 Often the thigh is used as a donor site, as it is an easily concealed region. To lubricate the skin, mineral oil or chlorhexidine can be used. After this, traction counter to the dermatome should be applied with a pair of skin hooks. The dermatome is lightly pressed against the skin and advanced forward. While the graft is being elevated, forceps can be used to prevent the graft from being caught in the dermatome. As the graft is being completed, the dermatome should be tapered off the skin while running. Lidocaine- and epinephrine-soaked gauze can be placed over the donor site while the skin graft is placed in the defect. The donor site can be dressed with a sterile clear watertight dressing such as a translucent surgical adhesive dressing. A split-thickness graft can be ideal for larger superficial cutaneous defects that cannot be completely covered by local flaps, or regions where there is concern for recurrence. It should be used selectively for deeper subplatysmal defects, and cannot provide suitable coverage of the great vessels. An absorbable suture placed in a running or interrupted fashion is used to secure the graft to the recipient bed. Intermittent small incisions can be placed to allow for drainage through the graft and prevent hematoma formation, which is often referred to as “pie-crusting.” Additionally, a bolster is often placed on top of the skin graft to ensure adequate contact with the wound bed. Bolsters can be fashioned from foam or xeroform and tied in place to apply pressure to the graft. Additionally, the use of VAC systems over split-thickness skin grafts acts as an airtight bolster.10 Full-thickness skin graft A full-thickness skin graft is similar to the split-thickness skin graft but it involves harvesting the entire dermis. It can provide a better color and texture match to the native skin. Owing to its thicker dermis, it often undergoes more sig-
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nificant immediate contracture due to the increased elastin, but it does not suffer from as much secondary contracture. As a result, it contracts less than a similarly sized splitthickness skin graft.9 Full-thickness grafts require a more vascularized wound bed for survival and potentially have a lower survival rate as compared with split-thickness grafts11 Common donor sites include the supraclavicular, preauricular, and postauricular regions. The supraclavicular region is especially versatile, as a large full-thickness skin graft can be obtained from this region and the donor site can still be primarily closed. The major limitation of the size of graft being used is the size of the resultant donor defect. In obtaining a full-thickness skin graft, a region should be marked slightly larger than the defect to allow for contracture. Creating “corners” when shaping the defect can reduce the chance of a trap-door deformity or pincushioning.9 Once the tentative graft design and size is marked out on the donor area, an incision can be made to the level of the subcutaneous fat. Facelift scissors can be used to dissect in a subdermal plane underneath the entirety of the graft. After this, the graft can be excised with broad cuts using the scissors with one tine in and one tine out of the wound. The graft should be defatted such that the shiny dermal surface is exposed. The graft can then be secured to the recipient site with slight redundancy with either absorbable or nonabsorbable sutures. Figure 3 demonstrates a posterior neck lesion that was resected and reconstructed with a full-thickness skin graft.
Local flaps If the defect is small enough, often a local flap will be sufficient to allow for an esthetic closure of the wound. This involves tissue rearrangement using the surrounding skin. Local flaps can be categorized as one or a combination of 3 types: an advancement flap, a rotation flap, or a transposition flap. An advancement flap involves advancing tissue in a linear vector, whereas a rotation flap uses a radial vector to advance tissue along a pivot point. A transposition flap is similar to a rotation flap; however, the tissue is rotated over a bridge of normal tissue. In comparison with a rotation flap, a transposition flap is often smaller and is able to be moved more freely along its pivot point. The biomechanics of the neck skin allow for the frequent use of advancement and transposition flaps.
Regional flaps Regional flaps can provide significant reconstructive options for larger neck defects with good outcomes. Additionally, they allow the surgeon to harvest tissue for regions that may have been spared from irradiation. In discussing reconstruction of cutaneous defects of the neck, the major regional flaps are fasciocutaneous and musculocutaneous flaps. The fasciocutaneous flaps incorporate epidermis, dermis, subcutaneous fat, and fascia overlying a muscle, whereas the musculocutaneous flaps also incorporate the muscle. Deltopectoral The deltopectoral flap is a fasciocutaneous transposition flap that is versatile and can help provide coverage of large
Figure 3 Full-thickness skin graft. Here we see the demarcated lesion with appropriate margins (A). The patient underwent a resection and placement of a full-thickness skin graft (B— before bolstering). The last picture (C) shows a 6-week follow-up (photo credit: Todd Cartee, MD; Penn State Milton S. Hershey Medical Center, Department of Dermatology). (Color version of figure is available online.)
neck defects. Additionally, it can be used without sacrificing the ability to simultaneously raise another flap such as the pectoralis major flap. It was first described by Bakamjian12 in 1965 for pharyngoesophageal reconstruction. It provides a
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regional pedicled flap that can often be harvested from outside of an irradiated field. The vascular supply for this flap arises from the first, second, third, and fourth perforating branches of the internal mammary artery. A more specific analysis by Daniel et al13 found that whereas the flap from the sternum to the deltopectoral groove is supplied by these perforators, the portion of the flap overlying the deltoid is supplied by perforators from the deltoid itself, and also that a portion of the flap is supplied by the thoracoacromial artery. This flap can cover a large variety of defects on the ipsilateral neck. The flap can be raised in 1 or 2 stages. The advantage of delayed flap is to allow for improved survival of the distal aspect of the flap and also to allow the surgeon to extend the distal aspect of the flap onto the shoulder. Designing the flap involves marking the infraclavicular line beyond the deltopectoral grove onto the anterior shoulder or to the tip of the shoulder if the flap is being delayed.14 The inferior aspect of the flap is parallel to this superior line and is marked a few centimeters above the nipple. The base of the flap is centered over the second, third, and fourth coastal cartilages, thus capturing the perforators from the internal mammary artery. An incision should be made through the epidermis and dermis and subcutaneous tissues down to the fascia of the deltoid along the designed flap. If the flap is going to be delayed, the distal aspect of the flap that lies beyond the deltopectoral groove is elevated and then inset back into the donor bed, with the final raising of the flap occurring 10 to 14 days later. When elevating the flap to reconstruct the defect, the flap is elevated in a plane just over the deltoid muscle and deep to the fascia of the deltoid muscle. This bloodless plane is carried out over the deltoid, deltopectoral groove, and the pectoralis major. Dissection should be stopped approximately 5 to 6 cm from the midsternal line to avoid skeletonization of or trauma to the perforators. The flap can then be tunneled in a subcutaneous plane to cover the neck defect with deepithelialization of the subcutaneous aspect of flap, or it can be inset above the bridge of skin such that the pedicle is divided at a later date. Part of the donor site may be able to be primarily closed, whereas the remainder can be covered with a split-thickness skin graft.15 Figure 4 illustrates the relevant anatomy for this flap. Cervicopectoral rotation The cervicopectoral flap is a fasciocutaneous rotational flap that can be used to cover large neck defects and can also be used on the lower parts of the face. This flap was first described by Becker in 1978 and is designed similarly to the deltopectoral flap. It is also an axially-based flap off of the internal mammary perforators, but instead of extending laterally beyond the deltopectoral groove, it extends superiorly on the neck. The supraclavicular portion is a randomlybased flap. Again the plane of dissection is just deep to the fascia overlying the pectoralis major, as well as deep to the platysma and deep to the superficial layer of the deep cervical fascia.16-18 This flap can then be rotated into place to cover the defect and secured through primary closure with interrupted sutures. There will likely be a dog-ear
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Figure 4 Deltopectoral flap. (A) The illustration demonstrates a neck defect and the outlined incision for a deltopectoral flap with the location of the internal mammary perforators. (B) This demonstrates the location of the flap after rotation and inset.
deformity secondary to the rotation that can be trimmed. Authors advocate the use of closed suction drains underneath the flap, and usually there is no need for extra tissue coverage of the donor site.17 Figure 5 displays a patient who underwent a large cervicopectoral rotation to close a preauricular defect. Pectoralis major flap (thoracoacromial artery) The pectoralis major flap is a muscular or musculocutaneous flap that can provide significant soft-tissue coverage as well as bulk for neck defects. Additionally, it is a hearty flap
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Figure 5 Cervicopectoral rotation flap. (A) The preauricular defect is exposed and the raised cervicopectoral rotation flap can be seen in its original anatomic location. (B) This shows the completed closure using the rotation flap with multiple suction drains in place. (Color version of figure is available online.)
with a low major complication rate. It can be raised in a single stage and reach the anterior neck as well as the midline over the pretracheal area.14 The dominant vascular supply for the pectoralis major flap is from the thoracoacromial, although it is also supplied laterally by the lateral thoracic artery and medially by the perforators of the internal mammary. Occasionally, the lateral thoracic artery is the dominant pedicle to this flap. Designing the flap requires incorporation of the thoracoacromial artery and vein. The pedicle can be identified by drawing a line from the acromion to the xyphoid and then drawing a perpendicular line from this line to a point on the ipsilateral clavicle such that one-third of the clavicle is lateral to the point and two-thirds of it lies medial to the point. The skin paddle should be designed superior and medial to the nipple along the line between the acromion and xyphoid, although it can extend below the inferior aspect of the pectoralis muscle if abdominal fascia is harvested with the flap. After designing the skin paddle, an incision can be made along the lateral aspect of the skin paddle down to the pectoralis fascia and carried to the axilla. After this, blunt dissection can be used to identify the lateral border of the pectoralis muscle. Using this guide, the inferior border of the pectoralis should also be identified. The rest of the skin paddle incision can be dissected to the level of the muscle. If the paddle extends below the inferior border of the pectoralis major, care should be taken to include rectus abdominus fascia in the flap—this portion of the paddle will have a random vasculature. The inferior border (including rectus ab-
dominus fascia if necessary) should then be identified and elevated. Shearing forces on the skin paddle should be minimized, and tacking sutures into the muscle can help prevent this.11 Blunt dissection between the pectoralis major and minor can be carried superiorly until the pedicle is identified. Both the medial and lateral aspects of the pectoralis major can be freed, with care taken to identify the perforators of the internal mammary as well as the lateral thoracic artery. Often the lateral thoracic artery needs to be ligated to allow for sufficient rotation of the flap. The lateral pectoral nerve (or lateral anterior thoracic) arises medial to the pectoralis minor and can be transected to allow for muscular atrophy and avoid synkinesis. After elevation of the flap, the flap is often rotated and tunneled in a subplatysmal plane to the neck defect (Figure 6). If there is significant bulk, the skin and adipose can be removed from the flap and replaced with a skin graft. Depending on the size of the skin paddle, the donor site may need a secondary flap or a split-thickness skin graft to close.11 Trapezius flap (transverse cervical, dorsal scapular, occipital) The trapezius flap is a versatile musculocutaneous flap that can also provide carotid coverage and help to reconstruct neck cutaneous defects. It has a robust vascular supply with contributions from the transverse cervical artery as well as the dorsal scapular and occipital arteries.14 Depending on how the flap is designed, a different pedicle will provide the dominant supply to the flap. An inferiorly-based
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Figure 6 Pectoralis major flap. (A) Resection of primary tumor in an en bloc fashion (B) Resulting defect with evidence of exposed great vessels. (C) Elevation of pectoralis major flap. (D) Completed inset of pectoralis flap with placement of closed suction drains. (Color version of figure is available online.)
flap will rely on the transverse cervical and dorsal scapular, whereas a superiorly-based flap will rely on the occipital artery and paraspinous perforators. Additionally, a lateral trapezius flap can be created based on the transverse cervical artery.11 It is important to note whether a patient has had a previous ipsilateral neck dissection, as this could raise the possibility of a previously transected transverse cervical artery and limit the surgeon to using a superiorly-based flap. Patients need to be in the lateral decubitus position for designing and harvesting these flaps. The superiorly-based flap is the most reliable of the flaps and does not require the transverse cervical artery. It can provide excellent coverage of ipsilateral neck defects. The flap is designed with incisions at the anterior border of the trapezius and a parallel incision is marked inferiorly, such that the paraspinous perforators are included at the base of the flap. Its arc of rotation will be limited by the inferior incision. The lateral incision lies over the shoulder. The dissection is carried out just deep to the trapezius muscle, and efforts should be made to save the transverse cervical artery and vein as they are encountered. The flap can cover
the defect with a delayed division of the pedicle or it can be tunneled underneath the skin. Often a skin graft is necessary to close the donor defect.11 The inferiorly-based, or lower, trapezius island flap has a significant arc of rotation and can reach the midline of the neck. It is important to ensure that the transverse cervical artery is intact. Skin paddle should be marked between the spine and medial border of the scapula. An incision can be marked along the medial aspect of the paddle rising superiorly to the neck. Once the trapezius is identified, it is dissected laterally off the rhomboids and then freed medially. The course of the artery should be exposed. Once the paddle is freed, it can be tunneled underneath the tissues toward the defect and the donor site can be primarily closed. Finally, the lateral trapezius flap is also based on the transverse cervical artery and vein, with the skin paddle overlying the superior lateral aspect of the trapezius. The pedicle should be identified in the posterior neck, and the paddle should be centered over this pedicle. Then the anterior border of the trapezius should be identified, and an incision can be made
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through the skin and muscle. Of note, the transverse cervical artery may be in proximity if not involved with the brachial plexus. This flap can also be extended laterally to incorporate a cervicohumeral fasciocutaneous flap to assist with further cutaneous coverage.14 The donor site will often require a skin graft, although with undermining, the defect can be partially closed primarily. Figure 7 shows the use of an inferiorly-based trapezius myocutaneous flap. Latissimus dorsi flap The latissimus dorsi flap is a muscular or myocutaneous flap that can provide the largest transferable pedicled soft-tissue for head and neck reconstruction. It is based off of the thoracodorsal artery and vein. Harvesting the flap requires the patient to be in the lateral decubitus position. The skin paddle can be drawn over the muscle, and an incision is made from the superior aspect of the incision to the axial. The muscles is then identified and released anteriorly and inferiorly, and the pedicle can be identified just medial to the anterior border of the latissimus dorsi. After freeing the inferior aspect of the mus-
cle, the entire muscle can be elevated superiorly toward the axilla. The medial attachments to the serratus anterior as well as the anterior attachments to the humerus should be freed. For additional rotation of the flap, the superior insertion of the muscle can also be transected. The flap can then be tunneled under the axilla to defects in the neck (Figure 8). Elevation of the arm for few days after the reconstruction is recommended to avoid constriction of the flap.11 Primary closure of donor site defect �10 cm is possible, otherwise closure is completed using skin grafts.11,14 A suction drain is recommended. Lesser used flaps Platysma flap (submental or suprasternal artery). The platysma flap is a muscle or musculocutaneous flap that can be used for anterior neck defects. It is supplied by either the submental or the suprasternal artery, depending on whether the flap is superiorly or inferiorly based. The reliability of the flap suffers from the occasional loss of the skin paddle
Figure 7 Trapezius flap. (A) Evidence of large exophytic tumor involving the posterior neck and scalp. (B) Defect after primary excision with margins and outlined inferiorly pedicled trapezius flap. (C) Closed defect with closed suction drains in place. (Color version of figure is available online.)
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Figure 8 Latissimus dorsi flap (illustration as an example). This shows an outlined latissimus dorsi flap with the skin paddle demarcated.
due to its variable venous supply through anterior communicating veins. Additionally, this flap may not be able to be used on patients who have had extensive neck dissections or previous neck operations secondary to transaction of its vascular supply during those operations. Irradiated necks will also have a decreased viability of this flap. Whether the flap design is inferiorly or superiorly based, the skin paddle should be designed in an elliptical fashion along the axis of a relaxed skin tension line. For superiorlybased flaps, the skin paddle design can be placed as inferiorly as the clavicle, allowing for significant length and arc of rotation. Once the skin is incised around the paddle, dissection is carried out superficial to the platysma.19 Care should be taken to preserve the submental artery (a branch of the facial artery) or the suprasternal artery depending on how the flap is based. Once this has been ensured, a subplatysmal dissection should be carried out toward the base of the flap. Care should be taken to include the superficial layer of the deep cervical fascia and a width of at least 4 cm of platysma should be included in the pedicled flap. The anterior jugular and external jugular veins should be dissected with the flap. The donor site can often be closed primarily.14 Sternocleidomastoid flap. The sternocleidomastoid flap is another muscular or musculocutaneous flap that is supplied by the occipital artery and suprascapular artery. Similar to the platysma flap, a proximally- or distally-based flap will allow coverage to different regions of the neck.
Figure 9 Free flap. This patient had a resection of a large posterior neck/scalp lesion (A), resulting in a large soft-tissue defect (B). Reconstruction was performed using a latissimus dorsi free flap, which can be seen attached to the wound bed (C). Postoperatively, the flap healed well (D). (Color version of figure is available online.)
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The skin paddle of this flap can be designed with a superiorly- or inferiorly-based pedicle. After designing the flap, the incision should be made through the skin and platysma to the level of the sternocleidomastoid muscle. The anterior fascial layer of the muscles should be left intact. After defining the borders of the skin paddle, it is advised that the paddle be tacked to the muscle to avoid shearing or avulsion of the skin, given the relatively tenuous blood supply to the skin from the muscle perforators.20 The flap should be elevated, leaving the posterior fascia of the sternocleidomastoid in the donor bed, thus avoiding exposure of deeper structures. Additionally, care should be taken to avoid transecting the spinal accessory nerve or injuring the internal jugular vein.14 Once the skin paddle has been sufficiently freed and can be mobilized to the defect site, the muscle should be sutured to the defect, thus decreasing the tension applied to the skin. This is to decrease the risk of epidermal loss.20
Free flaps Over the past few decades, there has been an increased use of free-tissue transfer for the reconstruction of cutaneous neck defects. Kakarala et al21 demonstrate an increase in the number of free flaps with concomitant increase in efficiency and flap survival. Recipient vessels are usually available on the side of the neck to be reconstructed, unless the patient has undergone an extensive neck dissection. For relatively small defects, the radial forearm flap can be used. Larger defects can be covered with flaps, yielding a larger surface area and bulk such as the anterolateral thigh flap, latissimus dorsi, and the rectus abdominus. Figure 9 depicts an example of a free flap.
Skin expansion For patients with large skin defects, tissue expanders provide an alternative method for reconstruction and closure. This method was first described by Neumann in 1957, and involves the use of saline-filled silicone envelopes. As these envelopes are injected with more saline, they create a new local supply of skin and subcutaneous tissues. The literature describes their use for burns of the head and neck as well as for closure of scalp, face, and neck skin defects.22-24 Handschel et al22 describe expanding the envelope in a serial fashion multiple times a week until enough tissue is expanded to cover the defect. Complications include dehiscence over the expander as well dehiscence after explantation of the expanders. Lasheen et al24 describe the use of an external expander that uses negative pressure to cause the skin to grow to cover the defect.
Conclusions Defects of the neck after resection of cutaneous lesions can yield varying size defects. It is important to include secondary intention as a possibility for closure of a cutaneous defect of the neck. Having a variety of options to reconstruct these defects will allow the surgeon to carefully evaluate
each scenario to determine the best reconstructive method for the individual defect.
References 1. Angrigiani C: Aesthetic microsurgical reconstruction of anterior neck burn deformities. Plast Reconstr Surg 93:507-518, 1994 2. Zhang YX, Wang D, Follmar KE, et al: A treatment strategy for postburn neck reconstruction: emphasizing the functional and aesthetic importance of the cervicomental angle. Ann Plast Surg 65:528-534, 2010 3. Schaper NC, Havekes B: Diabetes: impaired damage control. Diabetologia 55:18-20, 2012 4. Valentini V, Cassoni A, Marianetti TM, et al: Diabetes as main risk factor in head and neck reconstructive surgery with free flaps. J Craniofac Surg 19:1080-1084, 2008 5. Kinsella JB, Rassekh CH, Wassmuth ZD, et al: Smoking increases facial skin flap complications. Ann Otol Rhinol Laryngol 108:139142, 1999 6. Dhir K, Reino AJ, Lipana J: Vacuum-assisted closure therapy in the management of head and neck wounds. Laryngoscope 119:54-61, 2009 7. Calhoun KH, Seikaly H, Quinn FB: Teaching paradigm for decision making in facial skin defect reconstructions. Arch Otolaryngol Head Neck Surg 124:60-66, 1998 8. Psillakis JM, de Jorge FB, Villardo R, et al: Water and electrolyte changes in autogenous skin grafts. Discussion of the So-Called “plasmatic circulation”. Plast Reconstr Surg 43:500-503, 1969 9. Baker SR: Local Flaps in Facial Reconstruction. Edinburgh, Elsevier Mosby, 2007 10. Andrews BT, Smith RB, Goldstein DP, et al: Management of complicated head and neck wounds with vacuum-assisted closure system. Head Neck 28:974-981, 2006 11. Papel ID: Facial Plastic and Reconstructive Surgery. New York, Thieme, 2009 12. Bakamjian VY: A two-stage method for pharyngoesophageal reconstruction with A PRIMARY pectoral SKIN FLAP. Plast Reconstr Surg 36:173-184, 1965 13. Daniel RK, Cunningham DM, Taylor GI: The deltopectoral flap: an anatomical and hemodynamic approach. Plast Reconstr Surg 55:275282, 1975 14. Mathes SJ, Hentz VR: Plastic Surgery. Philadelphia, PA, Saunders Elsevier, 2006 15. Rebelo M, Ferreira A, Barbosa R, et al: Deltopectoral flap: an old but contemporaneous solution for neck reconstruction. J Plast Reconstr Aesthet Surg 62:137-138, 2009 16. Becker DW, Jr: A cervicopectoral rotation flap for cheek coverage. Plast Reconstr Surg 61:868-870, 1978 17. Copcu E, Metin K, Aktas A, et al: Cervicopectoral flap in head and neck cancer surgery. World J Surg Oncol 1:29, 2003 18. Shestak KC, Roth AG, Jones NF, et al: The cervicopectoral rotation flap—a valuable technique for facial reconstruction. Br J Plast Surg 46:375-377, 1993 19. Puxeddu R, Dennis S, Ferreli C, et al: Platysma myocutaneous flap for reconstruction of skin defects in the head and neck. Br J Oral Maxillofac Surg 46:383-386, 2008 20. Ariyan S: Further experience with the sternocleidomastoid myocutaneous flap. Plast Reconstr Surg 111:381-382, 2003 21. Kakarala K, Emerick KS, Lin DT, et al: Free flap reconstruction in 1999 and 2009: changing case characteristics and outcomes. Laryngoscope 22:2160-2163, 2012; Available at: http://www.ncbi.nlm.nih. gov/pubmed/22674647. Cited June 28, 2012 22. Handschel J, Schultz S, Depprich RA, et al: Tissue expanders for soft tissue reconstruction in the head and neck area-requirements and limitations. Clin Oral Investig (in press); Available at: http://www. ncbi.nlm.nih.gov/pubmed/22562078. Cited June 28, 2012 23. Motamed S, Niazi F, Atarian S, et al: Post-burn head and neck reconstruction using tissue expanders. Burns 34:878-884, 2008 24. Lasheen AE, Saad K, Raslan M: External tissue expansion in head and neck reconstruction. J Plast Reconstr Aesthet Surg 62:e251e254, 2009