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

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260 Continuous Validity of Pedicled Myocutaneous & Myofascial Flaps In our study (PMMC) flap was used in 84 cases with a very high success rate (98.8%), whether this success was primary without any complications (79.8%) or secondary to successful management of minor complications that delayed healing (19%). Major flap loss requiring salvage reconstruction by latissimus dorsi flap occurred in only one case. Different series had reported varying incidences of complications, 63% [18], 58% [19], 36.1% [2]. Fewer complications were reported when using the myofascial flap only [18,20]. The incidence of major or total flap loss was varying from 0% [21], to 1.5% [4], to 2.4% [2,18]. The main indications in our study were oral and partial pharyngeal defects. In an old series done in the Egyptian NCI in 1985 [4], pedicled (PMMC) flap was used for pharyngoplasty after total laryngopharyngectomy in 50 patients and in another series done in 1986 [10], latissinus dorsi myocutaneous flap was used for the same purpose in 28 cases. In our study, pedicled (PMMC) flap was used in only one case for reconstruction after this kind of surgery in a patient with poor general condition that could not withstand neither free jejunal flap nor gastric pull up. Pedicled myocutaneous flaps are rarely used nowadays to reconstruct the pharynx after total laryngopharyngectomy as this method has many disadvantages that includes development of fistula and stenosis and due to the evolution of gastric pull up and free jejunal flaps and their established use in such cases. Gastric transposition is more commonly used after pharyngolaryngo-oesophagectomy in our institute, owing to increased multidisciplinary experience in this form of surgery and in relation to the advanced pathological stage of hypopharyngeal carcinoma at presentation in which total esophagectomy is needed to obtain proper lower safety margin [22]. In our study the (PMMC) flap was used to reconstruct the anterior wall of the pharynx after total laryngectomy in 12 cases receiving prior radiotherapy (In 2 cases the mucosa was closed primarily & the muscle flap was used as a buttress to augment the suture line and replace the skin defect, and in 10 cases the skin island was used to repair the mucosal defect). In the latter group, intentional pharyngostomy was done after resection in 7 cases, and 3 cases developed major fistulae after trial of primary closure. In these 10 cases, the skin island of the (PMMC) flap was used to reconstruct the mucosal defect and the skin defect was reconstructed by deltopectoral fasciocutaneous flaps. The latissimus flap was used for this purpose in only one case in a female with large breast. Iginio Tansini in 1896 [23] was the first surgeon who performed the pedicled latissimus myocutaneous flap. He used it in reconstructing skin defects after surgery of breast cancer. However, this procedure was put to rest when Halsted started his radical mastectomy using thin skin flaps instead of removing wider skin area. Olivari in 1976 [24] rediscovered this flap and since then it gained its popularity in reconstruction of major defects that occurred after radical surgery for malignancies in the breast, chest wall and head & neck areas. Its blood supply is based on the thoraco dorsal vessels that run 8-14cm before entering the muscle just above the mid point of its free border. Its cranial vascularity allows it to have wide arc of rotation that it can cover any defect from the sternum anteriorly to the midline posteriorly and it can reach to the upper border of the ear [10]. When the donor site is less than 10x12 cm, it can be closed primarily but wider defects will need skin grafts. The largest reported size of this flap was 35x20 cm [25]. Olivari 1979 [26] proved the presence of 27 perforating arteries going between the muscle and the overlying skin. One of the greatest advantages of the latissimus dorsi flap over other regional myocutaneous flaps as the pectoralis major flap is that one can control the thickness of the muscle due to the anatomical fact that the main arterial supply runs along the lateral thin border of the muscle and gives its branches to the bulk of the muscle medially [10]. Elevation of the skin island overlying the latissimus dorsi muscle and dissecting the dominant perforating vessel, permit independent positioning of the skin island in relation to the muscle (razor flap) thus decreasing the donor site morbidity [27].
Maged M. Elshafiey, et al. 261 The indications of this flap in our study were those cases in whom the bulky (PMMC) flap were not satisfactory (8 cases), the (PMMC) flap was previously used and the patient developed local recurrence (1 case), the (PMMC) flap was used and the patient developed major fistula and retraction that needed salvage reconstruction (1 case) or the defect was out of the reach of the (PMMC) flap (2 cases). The inclusion of osseous parts had been described in pedicled myocutaneous flaps to be used in mandibular reconstruction including the pectoralis major osteomusculocutaneous flap including full thickness anterior bony part of the 5 th rib [11,28] and the sternocleidomastoid clavicular osteomusculocutaneous flaps whether ipsilateral [29-30] or contralateral in cases necessitating radical neck dissection [31]. The main disadvantage of the above mentioned osteocutaneous flaps is osteonecrosis of the bony part reaching 40-50% [11]. Myoosseous flaps and osteocutaneous flaps whether pedicled or free vascularized have several advantages when compared with other methods of mandibular reconstruction. Mandibular deviation and temporo-mandibular joint ankylosis can be prevented in contrast to techniques in which soft tissue replacement only is used. Also the functional and cosmetic deformity can be avoided when mandibular symphysis is included in resection [11,31]. Central complete mandibular defects should be immediately reconstructed by osseous flaps [9]. Free vascularized fibular graft is the mostly used flap for this purpose nowadays in our institute. One disadvantage of the fibula free flap is the limitations of the soft tissue component of the flap, however in anterior oral cavity defects, less tissue volume replacement is desired. In our study, we had only one case with central mandibular defect that was reconstructed with titanium plate and (PMMC) flap. It was a case of advanced carcinoma of the alveolar margin invading the lower lip and floor of mouth. Partial lateral mandibulectomy and primary soft tissue closure without osseous reconstruction is a satisfactory treatment in good hands [32,33]. This is suitable for lateral defects especially edentulous patients as deviation of the jaw is not a concern as there is no occlusion to be maintained. This is a safe, rapid and reliable procedure that leads to rapid healing and does not delay the adjuvant radiotherapy. The trapezius myocutaneous flap was first described by Demergasso and Piazza [34]. Several variations of this flap had been described. One of these variations is the lower vertical trapezius island flap [35]. Although the superior fibers have been designed as the basis for a flap for head and neck reconstruction, this flap has limited arc of rotation. However, it is possible to use only the middle and inferior portions of the trapezius as a musculocutaneous flap. This flap is based on the descending branch of the transverse cervical artery and associated veins. Further several detailed studies of the vascular anatomy of the human cadavers found that the trapezoidal branch of the dorsal scapular artery is a constant vessel to the lower trapezius muscle [5]. Its location makes it frequently the flap of choice for defects of the occipital, parotid & cervical spine areas. In addition it may be used for intraoral & anterior neck coverage but the main disadvantage is the need to change the position to the lateral decubitus [36]. If an inadequate arc of the rotation is obtained after elevation of the trapezius to the level of the first thoracic vertebra, it is possible to divide the fibers of origin and insertion of the superior portion of the trapezius muscle from the occiput and acromio-clavicular joint. This maneuver markedly increases the arc of rotation [5]. In our study, 14 cases were reconstructed by the lower (vertical) trapezius flap. The occiput was the most common site for reconstruction (9 cases). Other sites included the parotid region (2 cases), the ear pinna (one case), the external auditory meatus (one case) and the posterior neck (one case). In our current series the lower trapezius flap had many advantages. The donor site functional deficits were minimal and primarily closure was feasible in all cases. The resulting donor scar on the back had been favored over anterior chest scars by some female patients. The wide arc of rotation makes it suitable source for skin and muscle replacement for the entire neck, face and occipital region of the scalp. Its design could be the workhorse myocutaneous flap in
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Continuous Validity of Pedicled Myocutaneous and Myofascial ... - NCI

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