Continuous Validity of Pedicled Myocutaneous and Myofascial ... - NCI

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258 Continuous Validity of Pedicled Myocutaneous & Myofascial Flaps Fig. (17-A): Operative view showing lateral and lower orbital defects. Fig. (17-B): The temporalis flap was used to reconstruct the lateral and lower orbital walls and a piece of the Lt. ear cartilage was used to reconstruct the lower eyelid tarsus. Fig. (18-A): Operative view of radical maxillectomy with lower orbital defect. Fig. (18-B): Lt. temporalis flap was used to reconstruct the Lt. lower orbital defect. Fig. (19-A): Operative view after excision of advanced recurrent B.C.C. with defect in the orbital roof. Fig. (19-B): The temporalis flap was used to cover the exposed dura in the orbital roof.
Maged M. Elshafiey, et al. 259 DISCUSSION Radical head and neck surgery may leave mucosal or skin defects and sometimes with exposed large vessels, dura mater, cartilage or bones. It should be coupled with good reconstructive surgery [4]. An ideal flap should provide high success rate, few complications, low morbidity, short hospitalization and the greatest potential for best aesthetic and functional outcome [5]. Local neck skin flaps and fasciocutaneous flaps as forehead flap described by Mc Gregor (1963) [6] and deltopectoral flap described by Bakamjian (1965) [7] were the only method for head and neck reconstruction in the 1960s and 1970s although they have many disadvantages. They have been markedly replaced by the pedicled myocutaneous flaps in the early 1980s since the pedicled pectoralis major flap was first described by Ariyan in the late 1979 [8]. Many myocutaneous flaps were described for head and neck reconstruction including pectoralis major, latissimus dorsi, trapezius, sternomastoid, temporalis and platysma [9]. The use of pedicled myocutaneous flaps and free microvascular flaps in head and neck reconstruction started early in our institute in the early 1980s and late 1980s respectively [4,10,11]. Choice of reconstructive options depends on various factors such as site of the defect, type of tissue required, functional and cosmetic implications of the defect, associated co–morbidity and availability of resources [9]. A major advantage of pedicled flaps over free flaps is their simple and standardized surgical technique requiring no further surgical qualification compared to micro vascular free flaps. Also they are reliable, safe and have high degree of resistance against infection and so can be used in irradiated patients. Free flaps are also associated with some drawbacks like the need for vigorous monitoring and reexploration if required [3]. However, all these flaps have limitations. Firstly, they have a limited reach because of which there are more chances of distal flap failure and wound gap due to tension by the downward pull of the flaps. Secondly, the type of tissue in the flap, its bulk and pliability does not always suit the defect to be reconstructed. Thirdly, it may not be possible to contour the flap to the defect in different planes. Another advantage of the (PM- MC) flap is filling the emptied side of the neck due to concomitant block neck dissection thus preserving the normal cervical contour and protect the major vessels of the neck [4]. The use of pedicled flaps is still indicated for patients in whom microsurgery is contraindicated due to the general condition of the patient or in cases of unsuccessful microsurgical flaps [1]. Despite the increasing use of microvascular reconstruction, the (PMMC) flap continues to be the most universal major flap in head and neck reconstruction [3,12]. The (PMMC) flap dimensions can be varied from a small island to a large one overlying the whole medial two thirds of the muscle, depending upon the site and size of the defect to be repaired [4]. Some modifications were described that maintains maximal donor-site function and morphology of the (PMMC) flap. Musclepreserving procedure was described taking the pectoralis major as an island flap with no muscle around the vascular pedicle and preserving the nerve supply to the clavicular and the upper sternocostal parts of the muscle [13,14]. When large skin paddle is needed some modifications were done to preserve blood supply to the skin island. Inclusion of nippleareola complex on the skin paddle stabilizes the blood circulation in the skin island [15]. The pectoralis minor muscle can be divided to preserve the lateral thoracic artery and its blood supply to the lateral distal skin island of (PM- MC) flap without compromising the pedicle length [16]. With large full thickness cheek defects. The modification adopted in bipaddling the flap was based on anatomical location of perforators to ensure good blood supply to both paddles of the flap. Placing the flap horizontally with inclusion of nipple and areola increased the reach and size of available flap. Precautions should include proper assessment of reach of the paddle, placing not more than one-third of the paddle outside the muscle and securing the skin paddle to the muscle to avoid shearing of perforators during flap raising [17].
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Continuous Validity of Pedicled Myocutaneous and Myofascial ... - NCI

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