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

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250 Continuous Validity of Pedicled Myocutaneous & Myofascial Flaps reconstruction after resection of malignant tumors of different sites in the head and neck. The study included 121 patients with head and neck cancer operated upon at the National Cancer Institute, Cairo University and Alminia Cancer Center over 3 years duration, between July 2005 and the end of July 2008. One hundred and 2 cases receieved no previous treatment while 19 cases presented with recurrent or persistent disease after previous treatment by surgery alone in 3 cases, combined surgery and radiotherapy in 4 cases and radiotherapy alone in 12 cases. Preoperative medical assessment included routine complete blood picture, liver and kidney functions, fasting blood sugar, bleeding and coagulation profile and cardiological assessment. All the patients were biopsied before surgery and pathological diagnosis was obtained. The stage of the disease was evaluated by clinical assessment, locoregional (CT or MRI), routine CXR and other metastatic workup as indicated. The extent of surgical resection and the technique of reconstruction with its potential complications were discussed preoperatively with the patient with combined signed consent by the patient and the surgeon performing the operation. Four types of pedicled flaps were used for reconstruction namely the Pectoralis major myocutaneous (PMMC) flap (Group I), lower trapezius myocutaneous flap (LTMC) flap (Group II), Latissimus dorsi myocutaneous flap (Group III) and the Temporalis myofascial flap (Group IV). Immediate reconstruction after resection was done in 110 cases while delayed reconstruction of anterior pharyngeal defects after total laryngectomy was done in 11 cases. In one case in (Group I), major flap loss developed and was successfully salvaged by pedicled latissimus dorsi myocutaneous flap. Patients were followed-up in the outpatient clinic for detection of local or distant recurrences by clinical examination and radiological assessment as indicated and for assessment of the final functional and aesthetic results. Data regarding the type of tumor, site of tumor, stage of the disease, the type of myocutaneous flap used, postoperative complications and the total hospital stay were collected and analyzed. Utility of the different types of these flaps was reevaluated in terms of advantages, indications, and morbidity. RESULTS This study included 3 types of repair in head and neck region using 4 different types of pedicled myocutaneous or myofascial flaps ( repair of mucosal defects, repair of composite mucosal & skin defects and repair of skin only defects). Most of the cases were associated with bulky soft tissue and bone defects. In cases with combined mucosal & skin defects (29 cases) the myocuteous flaps mainly the (PMMC) flap (used in 28 cases) were used for one of the following purposes: 1- Replacing the inner mucosal layer and using the deltopectoral fasciocutaneous flap for skin closure (17 cases). 2- Replacing the outer skin layer, while the inner mucosal defect was not reconstructed (2 cases) after maxillectomy. 3- Replacing both the inner mucosal and outer skin layers using long skin territory which was folded on itself (bipaddle skin flap) in 9 cases. Primary sites of malignancy and types of defects left after excision are represented in Table (1). Oral carcinoma represented most of the cases (71 cases) and the majority were at advanced stage (T3 & T4) representing 40.8% (29/71) and 33.8% (24/71) respectively. Different types of flaps used in our study are represented in Table (2). The overall postoperative complications was 19.8% (24/121). It was 20% (17/84) in group I, 28.6% (4/14) in group II, and 25% (3/12) in group III. No flap related complications were reported in group IV. The mean hospital stay was 14 days (range, 8-27 days) in group I, 11 days (range, 8-15 days) in group II, 12 days (range, 8-16 days) in group III, and 8 days (range, 5-11 days) in group IV. The (PMMC) flap was the most commonly used flap (84 cases ). Figs. (1-9) show different operative views. The postoperative common complications in group I were mild infection
Maged M. Elshafiey, et al. 251 (15 cases), minor fistulae (11 cases), partial skin sloughing of the skin island with the underlying muscle healthy (3 cases), minor dehiscence and retraction (4 cases). All were properly managed by antibiotics, skin debridement and ryle feeding and oral hygiene in mucosal fistulae. One case with circumferential reconstruction of the pharyngeal defect after total laryngopharyngectomy developed pharyngeal stenosis and required repeated pharyngeal dilatation. In one case severe infection and major sloughing of the flap developed that was successfully salvaged by pedicled latissimus dorsi myocutaneous flap reconstruction. Table (1): Primary sites of malignancy and type of defect after excision in patients with head & neck cancer. Primary site of tumor No. of cases Skin defect only Mucosal defect only Combined mucosal & skin defects Bone defect Oral cavity: Tongue Alveolar margin Retromolar Buccal mucosa Mouth floor Lip commisure 71 24 18 11 9 6 3 – – – – – – – 58 24 15 10 4 5 – 13 – 3 1 5 1 3 71 24 18 11 9 6 3 Larynx Scalp over occipital region Maxilla Parotid Conjunctiva & lids Cheek Ear pinna Neck region External auditory meatus Post cricoid 13 9 9 7 4 2 2 2 1 1 – 9 – 7 4 2 2 2 1 1 – – 6 – – – – – – – 13 – 3 – – – – – – – – 9 9 3 1 2 2 – 1 – Total 21 28 64 29 98 Table (2): Primary sites of malignancy and type of the used flap in patients with head & neck cancer. Primary site of tumor No. of cases (PMMC) flap (Group I) (LTMC) flap (Group II) Latissimus dorsi myocutaneous flap (Group III) Temporalis myofascial flap (Group IV) Oral cavity: Tongue Alveolar margin Retromolar Buccal mucosa Mouth floor Lip commisure 71 24 18 11 9 6 3 64 22 15 11 8 6 2 – – – – – – – 8 2 4 – 1 – 1 – – – – – – – Larynx Scalp over occipital region Maxilla Parotid Conjunctiva & lids Cheek Ear pinna Neck region External auditory meatus Post cricoid 13 9 9 7 4 2 2 2 1 1 12 - 3 4 - - - - - 1 – 9 – 2 – – 1 1 1 – 1 – – 1 – – 1 1 – – – – 6 – 4 2 – – – – Total 121 84* 14 12* 12 * Two flaps were used in the same patient.
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Continuous Validity of Pedicled Myocutaneous and Myofascial ... - NCI

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