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Hemilaryngeal reconstruction using an axial island cheek flap supported by marlex and stainless steel wire mesh
SCIENTIFIC PAPERS
Hemilaryngeal Reconstruction Using an Axial Island Cheek Flap Supported by Marlex and Stainless Steel Wire Mesh Thomas G. Winek, MD*,Truman M. Sasaki, MD, David Luallin, MD, David W. Cook, MD, William T. Galey, MD, Harvey W. Baker, UP, Portland,Oregon
The defect that remains after an extended hemilaryngectomy continues to be a challenge to the reconstructing surgeon. The reconstruction ideally must provide airway protection against aspiration, allow for phonation, and provide a durable mucosal surface. It also must be accomplished in one stage. Nine Labrador dogs underwent successful reconstruction of the hemilarynx using an axial island cheek flap based on the facial artery and vein. Adequate laryngeal function was demonstrated by maintenance of body weight, normal barium swallows, return of strong bark, and no evidence of aspiration pneumonia. Pathologic review confirmed a viable mucosal surface and incorporation of the Marlex | and stainless steel wire mesh in a fibrous reaction. We have concluded that this method of reconstruction provides a result superior to currently used techniques.
herapy of squamous cell carcinoma of the glottis or T supraglottic region is dependent on stage of presentation. While radiation therapy is curative in over 90 percent of TI and for the majority of T2 lesions, more advanced primary cancers, recurrent lesions, and radiation failures are best treated surgically. Some may only require partial laryngectomy, thereby preserving speech [I]. However, after hemilaryngectomy the surgeon is faced with a difficult reconstruction problem. The repair must protect the airway against aspiration, provide an airtight seal, and preserve speech. The cheek axial island flap has been a useful, durable reconstructive graft in head and neck reconstruction [2,3]. We hypothesized that this flap, when backed by Marlex | and stainless steel From the Departmentof Surgery, Portland Veterans Administration Medical Center and Oregon Health Sciences University, Portland, Oregon. * Dr. Winekis the recipientof the 1988ResearchResidentAward of the Societyof Head and Neck Surgeons. Requests for reprintsshould be addressedto Truman Sasaki, MD, Department of Surgery, Portland Veterans Administration Medical Center,3710SW UnitedStates VeteransHospitalRoad,PO Box 1034, Portland, Oregon97217. Presented at the 34th Annual Meeting of Head and Neck Surgeons, New Orleans, Louisiana,May 22-26, 1988.
wire mesh, would fulfill the requirements for a successful laryngeal reconstruction. This method provides an ideal mucosal surface reinforced with substantial scaffolding. MATERIAL AND M E T H O D S Nine Labrador dogs were given a general anesthetic. A transverse cervical incision was made from the point of the jaw to the lower third medial border of the sternocleidomastoid muscle. Dissection was carried through the skin and platysma. The facial vein was identified and freed from the subcutaneous tissue. The external carotid artery was identified and the facial artery followed over the mandible to where it enters the cheek. In freeing the facial artery, the omohyoid and digastric muscles were divided. The hypoglossal, lingual, and vagus nerves were identified and preserved (Figure 1, top left). Next, the cheek flap was harvested with its vascular pedicle. As much as 5 by 7 cm of mucosa can be obtained in this fashion (Figure 1, top right). After removal the edges were inspected for free bleeding. Subsequently, an extended hemilaryngectomy was performed. The standard defect results from removal of the entire ipsilateral thyroid cartilage and its perichondrium and the ipsilateral arytenoid cartilage. The cheek flap was then rotated 180 degrees and used to cover the defect (Figure 1, bottom left). It was sewn in place with nonabsorbable sutures. No. 4 stainless steel wire was then woven through standard Marlex mesh in parallel rows 1 cm apart. The mesh was cut to an appropriate size to cover the graft. Several interrupted absorbable sutures were then used to secure the mesh to the cheek flap. A protective tracheostomy was then performed, and a drain was placed in the neck for 48 hours. Antibiotics were given preoperatively and twice a day for 5 days. The animals were dependent on the tracheostomy for approximately 1 week. They were allowed water during the first 24 hours and then advanced to a regular diet. RESULTS A total of nine Labrador dogs had this procedure. There was one perioperative death at three days from acute airway obstruction. Two dogs were sacrificed at 7 and 9 days to assess early healing. Direct laryngoscopy showed an open airway with the cheek flap not extending past the midline. Six dogs were allowed long-term survival from 3 to 15 months. Prior to sacrifice all dogs had barium swallows which did not show aspiration (Figure 2). They were given methylene blue in their drinking water at 1 week with no dye being found at the tracheostomy site. At 2 weeks the tracheostomies were occluded with airtight
THE AMERICAN JOURNAL OF SURGERY VOLUME156 OCTOBER1988 235
WINEK ET AL
, ~ ~
,locatioofn
digostric~ , ~
~common corotid a./~/
ext. jugulorv~
Figure 1. Top left, the axial island cheek flap based on the facial artery and vein. The digastrlc muscle has been divided. Top right, the cheek flap is raised and the desired pedicle length obtained by careful dlssecUon of the facial vessels. An extended hemilaryngectomy is performed. Bottom left, the cheek flap Is rotated 180 degrees and sewn in place. A tracheostomy is performed and the oral mucosal defect closed primarily. dressings with no dog having respiratory difficulty. All dogs gained or maintained body weight. One dog had a second operation to close the tracheostomy. Postoperatively, its activity was normal and its bark strong. Pathologic examination demonstrated a preserved and incorporated mucosal membrane. The flap adhered to the mesh in a dense fibrous reaction. Gross examination of the lung showed no evidence of aspiration or pneumonia. There were three complications. One dog had acute tracheostomal obstruction from a mucus plug on day 3 and died; one dog had development of a seroma after pulling out the drain, and another dog required early revision of the tracheostomy because of excessive skin folds which partially obstructed the airway.
Figure 2. A lateral view of a barium swallow demonstrating the Marlex and stainless steel reinforced cheek flap with no evidence of aspiration. 9,36
THE AMERICAN JOURNAL O F S U R G E R Y
COMMENTS Hemilaryngectomy is a standard method of surgical treatment for certain squamous cell carcinoma lesions of the glottic and supraglottic regions. Standard hemilaryngectomy includes resection of the lateral portion of the larynx, including the true and false vocal cords, the ventricle, and a portion of the thyroid cartilage. An extended hemilaryngectomy differs from a standard hemilaryngectomy in that the arytenoid cartilage is removed in addition to most or all of the thyroid cartilage. Closure of this posterior arytenoid defect requires that some form of bulk be added to prevent aspiration. This has been accomplished by a variety of methods including composite grafts using skin, fat and tendon, muscle, cartilage, and pericbondrium [4-8]. Conley [4] described a technique of regional skin flaps to reconstruct the larynx after subtotal resection. In the procedure, local flaps consisting of skin and underlying platysma are elevated, advanced, and sewn into the glottic defect. Complications include maceration, hair growth, stenosis, and airway obstruction. Dedo [5] alternatively used free fat and fascia ob-
VOLUME 156
OCTOBER 1988
HEMILARYNGEAL RECONSTRUCTION
tained from the hyoid region. This is placed posteriorly in the defect and then covered by advancing mucosa of the pyriform sinus and perichondrium. The shortcomings of this procedure include the inability to predict the amount of shrinkage of fat and facial tissue as well as the variable availability of adequate mucosal tissue for complete coverage of this graft. Both free and pedicled muscle grafts have also been used [6-8]. These grafts provide bulk to the posterior arytenoid area by rotating one of the strap muscles into the defect. Attempts are then made to cover this exposed muscle with mucosa derived from pyriform sinus. Problems with this technique include shrinkage of the muscle grafts and inadequate available mucosal tissue for coverage; thus a raw nonmucosal surface is common. Perichondrial and cartilage grafts have also been used. Their drawbacks include poor vascularity and shrinkage. They also fail to provide a mucosal surface. The cheek axial island flap with Marlex and stainless steel wire mesh provides posterior bulk, a highly vascularized aerodigestive mucosa, and strength for airway protection. In our experience infection, shrinkage, or breakdown did not occur with this composite flap, and
aspiration was avoided, The flap firmly adhered to the mesh in about 1 week and therefore, did not occlude the airway. The animals regained a strong bark within about 3 weeks.
REFERENCES 1. Lawson W, Biller H. Glottic and subglottic tumors. In: Thawley S, Panje W, eds. Comprehensive management of head and neck tumors. Philadelphia: WB Saunders, 1987: 991-1013. 2. Sasaki TM, Taylor L, Martin L, Baker HW, McConnell DB, Vetto RM. Correction of cervical esophageal stricture using an axial island cheek flap. Head Neck Surg 1983; 6: 596-9. 3. Winek TG, Sasaki TM, Baker HW, McConnell DB, Yeager RA, Canepa CS. Repair of limited or segmental defects of the cervical esophagus with mucosa-lined flaps. Am J Surg 1987; 154: 130-3. 4. Conley J. Regional skin flaps in partial laryngectomy. Laryngoscope 1975; 85: 942-9. 5. Dedo H. A technique for vertical hemilaryngectomy to prevent stenosis and aspiration. Laryngoscope 1975; 85: 978-84. 6. Ogura JH, Biller H. Conservative surgery in cancer of the head and neck. Otolaryngol Clin North Am 1969; 2: 641-50. 7. Quinn H. Free muscle transplant method of glottic reconstruction after hemilaryngectomy. Laryngoscope 1975; 85: 985-6. 8. Bailey B. Partial laryngectomy and laryngectomy: a technique and review. Trans Am Acad Ophthalmol Otolaryngol 1966; 70: 559-74.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 156 OCTOBER 1988
237
Hemilaryngeal Reconstruction Using an Axial Island Cheek Flap Supported by Marlex and Stainless Steel Wire Mesh Thomas G. Winek, MD*,Truman M. Sasaki, MD, David Luallin, MD, David W. Cook, MD, William T. Galey, MD, Harvey W. Baker, UP, Portland,Oregon
The defect that remains after an extended hemilaryngectomy continues to be a challenge to the reconstructing surgeon. The reconstruction ideally must provide airway protection against aspiration, allow for phonation, and provide a durable mucosal surface. It also must be accomplished in one stage. Nine Labrador dogs underwent successful reconstruction of the hemilarynx using an axial island cheek flap based on the facial artery and vein. Adequate laryngeal function was demonstrated by maintenance of body weight, normal barium swallows, return of strong bark, and no evidence of aspiration pneumonia. Pathologic review confirmed a viable mucosal surface and incorporation of the Marlex | and stainless steel wire mesh in a fibrous reaction. We have concluded that this method of reconstruction provides a result superior to currently used techniques.
herapy of squamous cell carcinoma of the glottis or T supraglottic region is dependent on stage of presentation. While radiation therapy is curative in over 90 percent of TI and for the majority of T2 lesions, more advanced primary cancers, recurrent lesions, and radiation failures are best treated surgically. Some may only require partial laryngectomy, thereby preserving speech [I]. However, after hemilaryngectomy the surgeon is faced with a difficult reconstruction problem. The repair must protect the airway against aspiration, provide an airtight seal, and preserve speech. The cheek axial island flap has been a useful, durable reconstructive graft in head and neck reconstruction [2,3]. We hypothesized that this flap, when backed by Marlex | and stainless steel From the Departmentof Surgery, Portland Veterans Administration Medical Center and Oregon Health Sciences University, Portland, Oregon. * Dr. Winekis the recipientof the 1988ResearchResidentAward of the Societyof Head and Neck Surgeons. Requests for reprintsshould be addressedto Truman Sasaki, MD, Department of Surgery, Portland Veterans Administration Medical Center,3710SW UnitedStates VeteransHospitalRoad,PO Box 1034, Portland, Oregon97217. Presented at the 34th Annual Meeting of Head and Neck Surgeons, New Orleans, Louisiana,May 22-26, 1988.
wire mesh, would fulfill the requirements for a successful laryngeal reconstruction. This method provides an ideal mucosal surface reinforced with substantial scaffolding. MATERIAL AND M E T H O D S Nine Labrador dogs were given a general anesthetic. A transverse cervical incision was made from the point of the jaw to the lower third medial border of the sternocleidomastoid muscle. Dissection was carried through the skin and platysma. The facial vein was identified and freed from the subcutaneous tissue. The external carotid artery was identified and the facial artery followed over the mandible to where it enters the cheek. In freeing the facial artery, the omohyoid and digastric muscles were divided. The hypoglossal, lingual, and vagus nerves were identified and preserved (Figure 1, top left). Next, the cheek flap was harvested with its vascular pedicle. As much as 5 by 7 cm of mucosa can be obtained in this fashion (Figure 1, top right). After removal the edges were inspected for free bleeding. Subsequently, an extended hemilaryngectomy was performed. The standard defect results from removal of the entire ipsilateral thyroid cartilage and its perichondrium and the ipsilateral arytenoid cartilage. The cheek flap was then rotated 180 degrees and used to cover the defect (Figure 1, bottom left). It was sewn in place with nonabsorbable sutures. No. 4 stainless steel wire was then woven through standard Marlex mesh in parallel rows 1 cm apart. The mesh was cut to an appropriate size to cover the graft. Several interrupted absorbable sutures were then used to secure the mesh to the cheek flap. A protective tracheostomy was then performed, and a drain was placed in the neck for 48 hours. Antibiotics were given preoperatively and twice a day for 5 days. The animals were dependent on the tracheostomy for approximately 1 week. They were allowed water during the first 24 hours and then advanced to a regular diet. RESULTS A total of nine Labrador dogs had this procedure. There was one perioperative death at three days from acute airway obstruction. Two dogs were sacrificed at 7 and 9 days to assess early healing. Direct laryngoscopy showed an open airway with the cheek flap not extending past the midline. Six dogs were allowed long-term survival from 3 to 15 months. Prior to sacrifice all dogs had barium swallows which did not show aspiration (Figure 2). They were given methylene blue in their drinking water at 1 week with no dye being found at the tracheostomy site. At 2 weeks the tracheostomies were occluded with airtight
THE AMERICAN JOURNAL OF SURGERY VOLUME156 OCTOBER1988 235
WINEK ET AL
, ~ ~
,locatioofn
digostric~ , ~
~common corotid a./~/
ext. jugulorv~
Figure 1. Top left, the axial island cheek flap based on the facial artery and vein. The digastrlc muscle has been divided. Top right, the cheek flap is raised and the desired pedicle length obtained by careful dlssecUon of the facial vessels. An extended hemilaryngectomy is performed. Bottom left, the cheek flap Is rotated 180 degrees and sewn in place. A tracheostomy is performed and the oral mucosal defect closed primarily. dressings with no dog having respiratory difficulty. All dogs gained or maintained body weight. One dog had a second operation to close the tracheostomy. Postoperatively, its activity was normal and its bark strong. Pathologic examination demonstrated a preserved and incorporated mucosal membrane. The flap adhered to the mesh in a dense fibrous reaction. Gross examination of the lung showed no evidence of aspiration or pneumonia. There were three complications. One dog had acute tracheostomal obstruction from a mucus plug on day 3 and died; one dog had development of a seroma after pulling out the drain, and another dog required early revision of the tracheostomy because of excessive skin folds which partially obstructed the airway.
Figure 2. A lateral view of a barium swallow demonstrating the Marlex and stainless steel reinforced cheek flap with no evidence of aspiration. 9,36
THE AMERICAN JOURNAL O F S U R G E R Y
COMMENTS Hemilaryngectomy is a standard method of surgical treatment for certain squamous cell carcinoma lesions of the glottic and supraglottic regions. Standard hemilaryngectomy includes resection of the lateral portion of the larynx, including the true and false vocal cords, the ventricle, and a portion of the thyroid cartilage. An extended hemilaryngectomy differs from a standard hemilaryngectomy in that the arytenoid cartilage is removed in addition to most or all of the thyroid cartilage. Closure of this posterior arytenoid defect requires that some form of bulk be added to prevent aspiration. This has been accomplished by a variety of methods including composite grafts using skin, fat and tendon, muscle, cartilage, and pericbondrium [4-8]. Conley [4] described a technique of regional skin flaps to reconstruct the larynx after subtotal resection. In the procedure, local flaps consisting of skin and underlying platysma are elevated, advanced, and sewn into the glottic defect. Complications include maceration, hair growth, stenosis, and airway obstruction. Dedo [5] alternatively used free fat and fascia ob-
VOLUME 156
OCTOBER 1988
HEMILARYNGEAL RECONSTRUCTION
tained from the hyoid region. This is placed posteriorly in the defect and then covered by advancing mucosa of the pyriform sinus and perichondrium. The shortcomings of this procedure include the inability to predict the amount of shrinkage of fat and facial tissue as well as the variable availability of adequate mucosal tissue for complete coverage of this graft. Both free and pedicled muscle grafts have also been used [6-8]. These grafts provide bulk to the posterior arytenoid area by rotating one of the strap muscles into the defect. Attempts are then made to cover this exposed muscle with mucosa derived from pyriform sinus. Problems with this technique include shrinkage of the muscle grafts and inadequate available mucosal tissue for coverage; thus a raw nonmucosal surface is common. Perichondrial and cartilage grafts have also been used. Their drawbacks include poor vascularity and shrinkage. They also fail to provide a mucosal surface. The cheek axial island flap with Marlex and stainless steel wire mesh provides posterior bulk, a highly vascularized aerodigestive mucosa, and strength for airway protection. In our experience infection, shrinkage, or breakdown did not occur with this composite flap, and
aspiration was avoided, The flap firmly adhered to the mesh in about 1 week and therefore, did not occlude the airway. The animals regained a strong bark within about 3 weeks.
REFERENCES 1. Lawson W, Biller H. Glottic and subglottic tumors. In: Thawley S, Panje W, eds. Comprehensive management of head and neck tumors. Philadelphia: WB Saunders, 1987: 991-1013. 2. Sasaki TM, Taylor L, Martin L, Baker HW, McConnell DB, Vetto RM. Correction of cervical esophageal stricture using an axial island cheek flap. Head Neck Surg 1983; 6: 596-9. 3. Winek TG, Sasaki TM, Baker HW, McConnell DB, Yeager RA, Canepa CS. Repair of limited or segmental defects of the cervical esophagus with mucosa-lined flaps. Am J Surg 1987; 154: 130-3. 4. Conley J. Regional skin flaps in partial laryngectomy. Laryngoscope 1975; 85: 942-9. 5. Dedo H. A technique for vertical hemilaryngectomy to prevent stenosis and aspiration. Laryngoscope 1975; 85: 978-84. 6. Ogura JH, Biller H. Conservative surgery in cancer of the head and neck. Otolaryngol Clin North Am 1969; 2: 641-50. 7. Quinn H. Free muscle transplant method of glottic reconstruction after hemilaryngectomy. Laryngoscope 1975; 85: 985-6. 8. Bailey B. Partial laryngectomy and laryngectomy: a technique and review. Trans Am Acad Ophthalmol Otolaryngol 1966; 70: 559-74.
THE AMERICAN JOURNAL OF SURGERY
VOLUME 156 OCTOBER 1988
237