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Immediate reconstruction of oral cavity and oropharyngeal defects using microvascular free flaps
SClENTlFlC PAPERS
Immediate Reconstruction of Oral Cavity and Orophatyngeal Defects Using Microvascular Free Flaps Robert D. Acland, FRCS (Eng), Louisville, Michael
Kentucky
B. Flynn, MB, BCh, FACS, Louisville,
Kentucky
‘be acceptability of excisional surgery f’or intraoral cancer is determined in part by the quality of t.he sul~seqrrent reconstruction. The ideal method of reconstruct ion would provide excellent function, would he immediate, reliable, and versatile, and would result in no local cosmetic deformity. lmproved prdicled skin flaps, notably the f’orehead, dc~ltopectoral, and sternomastoid flaps, have signif’ic,mtly advanced this ideal. ‘I‘ttr possibility of immediate distant skin flap t r Insf’er hy microvascular anastomosis has become a clinical reality in the last five years [I-31. The technic hits thr potential of providing immediate flap c’(veragrl to any location where a suitable artery and vc in can he found. When microvascular “free” flap trnnst’er was I’irst, introduced, it was regarded as hazardous. with some justification. Steady advances in microsurgical instrumcnt~ation, knowledge of v:.scuIar anatonl. technical simplification, and the tic~\~eioptnent (4 microsurgic*nl centers have made free tissue t r;rnst’rr an inc.reasingly dependable and sit raiqht t’orwurd technic. ‘I’tir ttsc’ ot’ free flaps to resurface intraoral defects has alreatl~ I)ecn reported [J,S]. In the present. paper WI: drscrit)e a series of nineteen patients in whom f’ree fI:tps wcrt’ used ftrr immediate reconst.ruction after resec,t ion of’ int raorat and oropharyngeal carcinoInit. Material
and Methods
‘l’he site\ 01 the exci\ic,nal
defects
included
the floor of
Fleprmt requests should be addressed to Robert D. Acland, FRCS, Department of Surgery. Umverslty of Louisville School of Medicine. Health Sciences Center. Loulsvllle. Kentucky 40202. Presented at the Joint Meeting of the Amerccan Society for Head and Neck Surgery and the Society of Head and Neck Surgeons. Toronto, Ontario, Canada May 29 31. 1978
Volume 136, October 1976
t’reoprratior Planning. Prior to the operation, the patient was examined jointly hy extirpativr and reconstructive t.eams, usually while anest.hrt.ized. so that the surgical options could he fully discussed and a definite plan of’ action determined. The extent of’ the defect. the management of’ the neck, the choice of recipient vessels, and the flap site can all be predicted with a fair degree of accuracy during the preoperative planning. Anestksia and Positioning of thrj Patierzt. Induction of general anesthesia was preceded by tracheostomy under local anesthesia. To enable the microsurgical work to be carried out with the microsurgeon sitting, the position of the patient on the table was reversed so that the head of the patient was at the foot of the table. The anesthesiologist was situated on the side opposite the expected vessel repair. Both teams began operating at the same time unless an especially lengthy extirpation was expected. K~s~ction of the Primary 7’umor. Excision of the primary tumor was carried out in accordance with good ow cologic principles and the dictatrs of the clinical sit.uation. The adequacy of the resection was monitored by frozen section histologic examination of the margins of the defect. Every eff’ort was made to achieve complete hemostasis. Manclg:c~mr~nt o/ tlze N~c,fi. LVhen clinically positive nodes were present, radical neck dissection with preservation 01’the eleventh nerve was carried out. When one side of the neck was radically dissected, rit her the transverse cervical vchssels on the same side wart’ preserved for recip ient vessels or the opposite side of the neck was entered, If the neck nodes were clinically negative. upper neck dissection was performed for Ihe dual purposes of sampling nodes and identifying recipient vrsselh. If on sampling, histologically positive nodes were rtsportcid. radical neck dissection was carried out as mentioned M[7ncz,q:c~rnc~ntfjf Ilcclpif~n/ Vf~.ssc~/s. ‘I’hr ;3vailal)le reSpirnt vessrls are the external maxillary. lingual. superior (hyroid. and transverse cervical vessels. ‘I’he selected vessels were located and minimally disset,red by the extirpative teatn. (Figure 1, left.) Magnif’ic.ation, using operating loupes, ~21s helpful in carrying out atraumatic dissection. The vessels were left intact and running unless their division was necessary to the planned ablation. ~/rxalion of t/z<>b’rw t;‘lup. ItI preparing the lree flap, the sul)&ing vessels were located first, and then the flap WIS out linrd and raised. The vascular pedicle of’ the flap must t)r Iotlg enough to reach the rec.ipitlnt L’~WC~IS wit bout
419
Acland and Flynn
Figure 1. Lefl, the external maxillary vessels have been exposed prior to excision of a buccal carcinoma. Middle, after complefion of fhe vascular anastomosis. the free flao _~~ to be placed in fhe defect. Right, reconstruction is complefed , is about by s&we of fhe f/ap to the defect. ’ tension. The flap was designed in consultation with the extirpative team to conform in size and shape to the defect. Once the flap was raised, it was left in situ to establish its viability, attached only by its vessels, for at least 20 minutes. In all cases the vascular pedicle consisted of one artery and one vein only. The dorsalis pedis flap was raised, as described by Robinson [6]. The groin flaps were raised more laterally than has previously been recommended [7], the medial margin being placed 2 to 5 cm lateral to the femoral artery. In this way a long vascular pedicle was obtained, and the redundant bulk of the more medial area was avoided. Microvascular Anastomosis. When the flap had been raised and the resection completed, the reconstructive team moved to the head. The recipient artery and vein were precisely dissected under magnification (X 4 to 10) to enable the anastomosed vessels to lie without tension or kinking. After this dissection, the artery was allowed to dilate before it was divided. The vessels of the flap were now divided at their origin. The flap was brought to the head and anchored in a convenient temporary position while the vessels were anastomosed. The flap vessels were not washed out or perfused. The donor and recipient vessels should be approximately the same size; disparity of more than 2:l is unacceptable. The anastomoses were carried out using a Zeiss Mark 6 microscope (magnification X 4 to 25) and Acland approximator clamps [8]. Interrupted sutures of 9-O monofilament nylon on a flat-bodied microvascular needle were used for the anastomoses. The vessel that lay deepest was anastomosed first. Both anastomoses were completed and then all the vascular clamps removed. (Figure 1, middle.) The anoxic interval varied from 50 to 75 minutes. On completion of the anastomoses, the flap was observed for 10 minutes before being sutured into place. Reconstruction of the Defect. When possible, a two layer watertight closure of 3-O chromic catgut was used to approximate the margin of the flap to the defect. Care must be taken to avoid compromising the vascular pedicle while
420
suturing the flap into the defect. Provided that compression of the flap tissue is avoided, the flap can be freely contoured to conform with the defect. The course of the vessels of the flap varied with the site of the defect. For defects of the buccal mucosa, the vessels ran in the space between the mandible and the cheek flap. (Figure 1, right.) In the case of an oropharyngeal defect in which mandible was excised, the vessels ran across the mandibular defect. (Figure 2.) With defects of the floor of the mouth and tongue, where the mandibular arch was intact, the vessels ran under the mandible to avoid compression. (Figures 3 and 4.) The hyomandibular musculature was split to provide an opening through which the flap was drawn once the anastomoses had been completed. (Figure 4.) When the defect included a margin of the mandible, the vascular pedicle of the flap was positioned within the arch if the defect was principally lingual and outside it if the defect was principally buccal. Care was taken to position the flap so that the vascular pedicle was not compressed against the bone. Management of the Donor Area. The defects of the dorsum of the foot were resurfaced with meshed splitthickness skin grafts. The groin defects were closed primarily in two layers after flexing the hip. Postoperative Management. Continuous suction drains were carefully placed and secured to avoid contact with the vessels. No special effort was made to immobilize the head. No anticoagulants, antithrombotics, or plasma expanders were used. Results Nineteen free flaps were used to reconstruct defects of the oral cavity and oropharynx in eighteen patients ranging in age from fourteen to eighty-four years. The anatomic site of the defect, the flap donor area, and the recipient vessels for the vascular anastomoses are shown in Table I. Nine patients had
The American Journal of Surgery
Oral Cavity
and Oropharyngeal
Rciconstruction
Figure 2. Use of the free flap in reconstruction of a tonsillar fossa defect.
been previously treated with external megavoltage irradiat,ion to a dose of at least 6,000 rads over six weeks. In fourteen patients, the flap remained totally viable. In two of these, salivary fistulas developed which closed spontaneously. One partial failure occurred (HC), in that the superficial skin sloughed while the deeper tissues remained viable and provided coverage for a heavily irradiated mandible. In fo:_u patients the flap became nonviable and necrotic and was removed. Complications in the flap donor area occurred in nile patients. Poor take of the skin graft on the darsum of the foot occurred in all except one of the patients with dorsalis pedis flaps. Wound seromas occurred in two of the ten patients with groin flaps. One death due to myocardial infarction occurred. In three patients, local recurrence required further resection, irradiation, or both. In one patient (DS), the subsequent appearance of nodal disease required neck dissection. Hospital Sta3’. The average hospital stay was 25.5 days. Comparison was made with nineteen consecutive patients with similar defects of the upper aerodigestive tract reconstructed by deltopectoral, forehead, or tongue flaps. For patients with these conventional flap reconstructions, the mean hospital stay was 37.8 days. The latter group had been treated at this center during the period immediately prior to this series by the same group of surgeons. Special Features. In two cases (HG, AW) the ve:;sels of the flap pedicle did not easily reach the Volume 136, October 1976
Figure 3. Resurfacing of a defect of the tongue and floor of the mouth with ftap draped over the rim of the mandible. Note position of the vessels.
recipient vessels. Interpositional vein grafts were used to bridge the gap, with failure in one case due to compression of the recipient artery. In one patient (AT), an attempted double free flap reconstruction of a large full thickness oral cavity defect was performed using both an intraoral free groin flap and a tensor fascia lata free flap for external coverage. The former became necrotic and was excised, while the latter remained viable. In another patient (AW)? a large full thickness defect involving the tonsillar area, the parotid gland, and the adjacent cheek was reconstruct,ed using an intraoral groin flap together with a standard deltopectoral flap for external coverage. Kinking proximal to the microvascular anastomosis resulted in free flap failure and removal. In one patient (DS), the vascular pedicle of the flap was deliberately divided in the course of’ radical neck dissection. Clinically positive nodes had become evident eight weeks after rese,ction of the primary. No alteration of the viability of the transplant.ed tissue occurred. Full thickness reconstruction of the lower lip was carried out in one patient (CY) using a free groin flap folded upon itself. To prevent sagging, t.he flap was draped over a fascia lata sling. (Figure 5.) A fistula temporarily formed and eventually closed. and this patient now has a functioning continent oral cavity. 421
Acland and Flynn
Figure 4. Flap being drawn through a tunnel in the hyomandibular musculature.
Comments The approach described to major head and neck resection and reconstruction calls for considerable planning and involves a large numer of skilled people. Although the operative time is not much longer than with standard reconstructive methods, the number of skilled man-hours is almost doubled. Clear benefit must be demonstrated to justify this extraordinary effort. Although the functional results are at least as good as those with conventional methods, the principal benefit is cosmetic. The absence of an unsightly
TABLE I
Patient Data Me
Patient
(yr)
cs
61 52 65 65 73 56 14 61 a4 65 67 58 53 51 60 68 60 52 70
WL HC CY ES DS TT DM EV CY HG AS DJ JE LH AT AW MT BJ
422
secondary deformity is so dramatic that the advantage is self-evident,. The ability to perform consistently successful microvascular anastomoses is so basic, that without this capability immediate free flap reconstruction probably should not be attempted. Microvascular skills should be developed to a high degree before incorporating them in this very complicated surgical undertaking. Similarly, the excisional team must consist of seasoned head and neck oncologic surgeons. It is predictable that in the absence of a high level of professionalism the method may fall into disfavor either from inappropriate use or high failure rates. Whether the dorsalis pedis or the groin flap is used depends to some extent upon the site of the defect. The dorsalis pedis flap is thin and supple; it can be readily contoured and folded upon itself, and it is therefore particularly valuable for defects involving the floor of the mouth and oral tongue. The laterally placed groin flap, even with careful thinning, is more bulky and is less suitable in these locations. Its bulk is an advantage in the reconstruction of buccal and tonsillar defects which are often deep and accommodating. Neither of the flaps is easy to raise. Each requires patient and time-consuming dissection and exact anatomic knowledge. The ultimate limits of this type of reconstruction have not been determined. Reconstruction of large full thickness defects was attempted using double free flaps and a free flap in combination with a conventional flap. In both cases the intraoral flap failed, and in both cases technical factors were at fault. Although success in this extended reconstruction appears to surpass our present capability, it remains a reasonable goal for the future.
Date of Operation 3177 4177 4177 5177 6177 7177 7177 9177 10177 III77 1 II77 II78 If78
1178 3178 4178 4178 4178 5178
Defect Site Buccal mucosa Tonsil Floor of mouth Floor of mouth Tongue Tongue Buccal mucosa Floor of mouth Buccal mucosa Lip Oropharynx Tongue Floor of mouth Floor of mouth Floor of mouth Oral cavity Oropharynx Floor of mouth Floor of mouth
Donor Site Groin Groin Dorsalis Dorsalis Dorsalis Dorsalis Groin Groin Groin Groin Groin Dorsalis Dorsalis Dorsalis Groin Groin Groin Dorsalis Groin
pedis pedis pedis pedis
pedis pedis pedis
pedis
Recipient Vessels
Previous Irradiation
External maxillary Lingual External maxillary External maxillary External maxillary External maxillary Lingual External maxillary External maxillary External maxillary Transverse cervical External maxillary External maxillary External maxillary External maxillary External maxillary Transverse cervical External maxillary External maxillary
No Yes Yes Yes
No No No No No Yes Yes
Yes No Yes
No Yes Yes
No No
Result
Success Partial failure Success Success Success Success Success Success Success Success Success Success Failure Success Failure Failure Success Failure
The American Joumaf of Surgery
Oral Cavity and Oropharyngeal
It is clear that previous radiat,ion therapy decreases the margin of’ safety of this form of reconstruction. N.ne patients had previously been treated to full therapeutic doses of radiat.ion. (One patient [CY] underwent reconstruction with 2 free flaps at separate procedures.) In each the microvascular anastom:)sis involved vessels within the radiation field. In four of the irradiated patients (including CY), one of whom had received more than 7,000 rads, the flap survived completely. In the remaining five irradiated patients, one partial and four complete failures occurred. In each case, exploration of the vascular pedicle revealed some technical explanation for the failure of the flap. It is difficult to assess the effect of radiation on the microvascular anastomosis. We believe that previous irradiation should be regarded not as a contraindication but as a cause for particular caution in the management of the vascular pedicle. The possible adverse effect of intraoral contamination on the microvascular anastomoses was initially a cause for concern. In our experience, this does not seem to be any more of a problem than it is with other forms of reconstruction involving the upper aerodigestive tract.. Other than assuring a careful watertight mucosal closure, no special effort need be made to protect the vascular pedicle from salivary ccntamination. In carrying out the extirpation, the principal modification of technic concerns the careful preserva.tion of the proposed recipient vessels. Sacrifice of vessels such as the external maxillary vessel simply for convenience must be avoided. Their importance changes considerably with the prospect of becoming recipient vessels for a free flap. Obviously such considerations must be abandoned if preservation of the vessels would conflict with completion of a satisfactory ablative procedure. It is already evident that, intraoral free flap reconstruction constitutes a highly significant advance. The tissue for reconstruction is brought from a #distant site in a single procedure without producing any deformity. The method is suitable for defects of any site and size within the mouth and throat; it can be used after full radiation therapy and in conjunction with a reasonable program of neck management. If its reliability continues to improve, it is foreseeable that microvascular free flap transfer will become the preferred method of reconstruction.
Summary
Eighteen patients struction of defects oropharynx with free One partial and four
Volume 136, October 1976
underwent immediate reconinvolving the oral cavity and groin and dorsalis pedis flaps. complete failures occurred. In
Reconstruction
Figure 5. Full thickness lower lip reconstruction, with free flap folded upon itself over a fascia lata ding.
the successfully reconstructed patients, the functional results were equal to conventional flaps while the cosmetic improvements were dramatic. Acknowledgments: We wish to thank t.he members of the microsurgical nursing team of Norton Childrens Hospital and Dr. William Gegg of the University of Louisville Department of Anesthesia for their indispensable help; Dr. Gerald Verdi and Dr. Larry Florman for permission to include two patients treated in conjunction with them; and Mrs. Katherine Bauscher for preparing the illustrations. References 1. Harii K: Current clinical experience in vascularized free skin flap transfers, p 45. Symposium on Microsurgery (Daniller A, Strauch B, eds). St. Louis, CV Mosby, 1976. 2. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomoses. Plast Reconstr Surg 52: 111, 1973. 3. Serafin D, Georgiade NG: Microsurgical composite tissue transplantation. A new method of immediate reconstruction of extensive defects. Am J Surg 133(6): 752, 1977. 4. Leeb DC, Ben-Hur N, Mazzarella L: Reconstruction of the floor of the mouth with a free dorsalis pedis flap. Plasf Reconstr surg 59(3): 379, 1977. 5. Panje WR, Krause CJ, Bardach J: Microsurgical techniques in free flap reconstruction. Laryngoscope 87(5): 692, 1977. 6. Robinson DW: Microsurgical transfer of the dorsalis pedis neurovascular island flap. Br J Plast Surg 29(3): 209, 1976. 7. Taylor GI, Daniel RK: The anatomy of several free flap donor sites. P/ad Reconstr Surg 56: 243, 1975. 8. Acland RD: Instrumentation for microsurgery. Orthop C/in North Am 8(2): 281. 1977.
423
Immediate Reconstruction of Oral Cavity and Orophatyngeal Defects Using Microvascular Free Flaps Robert D. Acland, FRCS (Eng), Louisville, Michael
Kentucky
B. Flynn, MB, BCh, FACS, Louisville,
Kentucky
‘be acceptability of excisional surgery f’or intraoral cancer is determined in part by the quality of t.he sul~seqrrent reconstruction. The ideal method of reconstruct ion would provide excellent function, would he immediate, reliable, and versatile, and would result in no local cosmetic deformity. lmproved prdicled skin flaps, notably the f’orehead, dc~ltopectoral, and sternomastoid flaps, have signif’ic,mtly advanced this ideal. ‘I‘ttr possibility of immediate distant skin flap t r Insf’er hy microvascular anastomosis has become a clinical reality in the last five years [I-31. The technic hits thr potential of providing immediate flap c’(veragrl to any location where a suitable artery and vc in can he found. When microvascular “free” flap trnnst’er was I’irst, introduced, it was regarded as hazardous. with some justification. Steady advances in microsurgical instrumcnt~ation, knowledge of v:.scuIar anatonl. technical simplification, and the tic~\~eioptnent (4 microsurgic*nl centers have made free tissue t r;rnst’rr an inc.reasingly dependable and sit raiqht t’orwurd technic. ‘I’tir ttsc’ ot’ free flaps to resurface intraoral defects has alreatl~ I)ecn reported [J,S]. In the present. paper WI: drscrit)e a series of nineteen patients in whom f’ree fI:tps wcrt’ used ftrr immediate reconst.ruction after resec,t ion of’ int raorat and oropharyngeal carcinoInit. Material
and Methods
‘l’he site\ 01 the exci\ic,nal
defects
included
the floor of
Fleprmt requests should be addressed to Robert D. Acland, FRCS, Department of Surgery. Umverslty of Louisville School of Medicine. Health Sciences Center. Loulsvllle. Kentucky 40202. Presented at the Joint Meeting of the Amerccan Society for Head and Neck Surgery and the Society of Head and Neck Surgeons. Toronto, Ontario, Canada May 29 31. 1978
Volume 136, October 1976
t’reoprratior Planning. Prior to the operation, the patient was examined jointly hy extirpativr and reconstructive t.eams, usually while anest.hrt.ized. so that the surgical options could he fully discussed and a definite plan of’ action determined. The extent of’ the defect. the management of’ the neck, the choice of recipient vessels, and the flap site can all be predicted with a fair degree of accuracy during the preoperative planning. Anestksia and Positioning of thrj Patierzt. Induction of general anesthesia was preceded by tracheostomy under local anesthesia. To enable the microsurgical work to be carried out with the microsurgeon sitting, the position of the patient on the table was reversed so that the head of the patient was at the foot of the table. The anesthesiologist was situated on the side opposite the expected vessel repair. Both teams began operating at the same time unless an especially lengthy extirpation was expected. K~s~ction of the Primary 7’umor. Excision of the primary tumor was carried out in accordance with good ow cologic principles and the dictatrs of the clinical sit.uation. The adequacy of the resection was monitored by frozen section histologic examination of the margins of the defect. Every eff’ort was made to achieve complete hemostasis. Manclg:c~mr~nt o/ tlze N~c,fi. LVhen clinically positive nodes were present, radical neck dissection with preservation 01’the eleventh nerve was carried out. When one side of the neck was radically dissected, rit her the transverse cervical vchssels on the same side wart’ preserved for recip ient vessels or the opposite side of the neck was entered, If the neck nodes were clinically negative. upper neck dissection was performed for Ihe dual purposes of sampling nodes and identifying recipient vrsselh. If on sampling, histologically positive nodes were rtsportcid. radical neck dissection was carried out as mentioned M[7ncz,q:c~rnc~ntfjf Ilcclpif~n/ Vf~.ssc~/s. ‘I’hr ;3vailal)le reSpirnt vessrls are the external maxillary. lingual. superior (hyroid. and transverse cervical vessels. ‘I’he selected vessels were located and minimally disset,red by the extirpative teatn. (Figure 1, left.) Magnif’ic.ation, using operating loupes, ~21s helpful in carrying out atraumatic dissection. The vessels were left intact and running unless their division was necessary to the planned ablation. ~/rxalion of t/z<>b’rw t;‘lup. ItI preparing the lree flap, the sul)&ing vessels were located first, and then the flap WIS out linrd and raised. The vascular pedicle of’ the flap must t)r Iotlg enough to reach the rec.ipitlnt L’~WC~IS wit bout
419
Acland and Flynn
Figure 1. Lefl, the external maxillary vessels have been exposed prior to excision of a buccal carcinoma. Middle, after complefion of fhe vascular anastomosis. the free flao _~~ to be placed in fhe defect. Right, reconstruction is complefed , is about by s&we of fhe f/ap to the defect. ’ tension. The flap was designed in consultation with the extirpative team to conform in size and shape to the defect. Once the flap was raised, it was left in situ to establish its viability, attached only by its vessels, for at least 20 minutes. In all cases the vascular pedicle consisted of one artery and one vein only. The dorsalis pedis flap was raised, as described by Robinson [6]. The groin flaps were raised more laterally than has previously been recommended [7], the medial margin being placed 2 to 5 cm lateral to the femoral artery. In this way a long vascular pedicle was obtained, and the redundant bulk of the more medial area was avoided. Microvascular Anastomosis. When the flap had been raised and the resection completed, the reconstructive team moved to the head. The recipient artery and vein were precisely dissected under magnification (X 4 to 10) to enable the anastomosed vessels to lie without tension or kinking. After this dissection, the artery was allowed to dilate before it was divided. The vessels of the flap were now divided at their origin. The flap was brought to the head and anchored in a convenient temporary position while the vessels were anastomosed. The flap vessels were not washed out or perfused. The donor and recipient vessels should be approximately the same size; disparity of more than 2:l is unacceptable. The anastomoses were carried out using a Zeiss Mark 6 microscope (magnification X 4 to 25) and Acland approximator clamps [8]. Interrupted sutures of 9-O monofilament nylon on a flat-bodied microvascular needle were used for the anastomoses. The vessel that lay deepest was anastomosed first. Both anastomoses were completed and then all the vascular clamps removed. (Figure 1, middle.) The anoxic interval varied from 50 to 75 minutes. On completion of the anastomoses, the flap was observed for 10 minutes before being sutured into place. Reconstruction of the Defect. When possible, a two layer watertight closure of 3-O chromic catgut was used to approximate the margin of the flap to the defect. Care must be taken to avoid compromising the vascular pedicle while
420
suturing the flap into the defect. Provided that compression of the flap tissue is avoided, the flap can be freely contoured to conform with the defect. The course of the vessels of the flap varied with the site of the defect. For defects of the buccal mucosa, the vessels ran in the space between the mandible and the cheek flap. (Figure 1, right.) In the case of an oropharyngeal defect in which mandible was excised, the vessels ran across the mandibular defect. (Figure 2.) With defects of the floor of the mouth and tongue, where the mandibular arch was intact, the vessels ran under the mandible to avoid compression. (Figures 3 and 4.) The hyomandibular musculature was split to provide an opening through which the flap was drawn once the anastomoses had been completed. (Figure 4.) When the defect included a margin of the mandible, the vascular pedicle of the flap was positioned within the arch if the defect was principally lingual and outside it if the defect was principally buccal. Care was taken to position the flap so that the vascular pedicle was not compressed against the bone. Management of the Donor Area. The defects of the dorsum of the foot were resurfaced with meshed splitthickness skin grafts. The groin defects were closed primarily in two layers after flexing the hip. Postoperative Management. Continuous suction drains were carefully placed and secured to avoid contact with the vessels. No special effort was made to immobilize the head. No anticoagulants, antithrombotics, or plasma expanders were used. Results Nineteen free flaps were used to reconstruct defects of the oral cavity and oropharynx in eighteen patients ranging in age from fourteen to eighty-four years. The anatomic site of the defect, the flap donor area, and the recipient vessels for the vascular anastomoses are shown in Table I. Nine patients had
The American Journal of Surgery
Oral Cavity
and Oropharyngeal
Rciconstruction
Figure 2. Use of the free flap in reconstruction of a tonsillar fossa defect.
been previously treated with external megavoltage irradiat,ion to a dose of at least 6,000 rads over six weeks. In fourteen patients, the flap remained totally viable. In two of these, salivary fistulas developed which closed spontaneously. One partial failure occurred (HC), in that the superficial skin sloughed while the deeper tissues remained viable and provided coverage for a heavily irradiated mandible. In fo:_u patients the flap became nonviable and necrotic and was removed. Complications in the flap donor area occurred in nile patients. Poor take of the skin graft on the darsum of the foot occurred in all except one of the patients with dorsalis pedis flaps. Wound seromas occurred in two of the ten patients with groin flaps. One death due to myocardial infarction occurred. In three patients, local recurrence required further resection, irradiation, or both. In one patient (DS), the subsequent appearance of nodal disease required neck dissection. Hospital Sta3’. The average hospital stay was 25.5 days. Comparison was made with nineteen consecutive patients with similar defects of the upper aerodigestive tract reconstructed by deltopectoral, forehead, or tongue flaps. For patients with these conventional flap reconstructions, the mean hospital stay was 37.8 days. The latter group had been treated at this center during the period immediately prior to this series by the same group of surgeons. Special Features. In two cases (HG, AW) the ve:;sels of the flap pedicle did not easily reach the Volume 136, October 1976
Figure 3. Resurfacing of a defect of the tongue and floor of the mouth with ftap draped over the rim of the mandible. Note position of the vessels.
recipient vessels. Interpositional vein grafts were used to bridge the gap, with failure in one case due to compression of the recipient artery. In one patient (AT), an attempted double free flap reconstruction of a large full thickness oral cavity defect was performed using both an intraoral free groin flap and a tensor fascia lata free flap for external coverage. The former became necrotic and was excised, while the latter remained viable. In another patient (AW)? a large full thickness defect involving the tonsillar area, the parotid gland, and the adjacent cheek was reconstruct,ed using an intraoral groin flap together with a standard deltopectoral flap for external coverage. Kinking proximal to the microvascular anastomosis resulted in free flap failure and removal. In one patient (DS), the vascular pedicle of the flap was deliberately divided in the course of’ radical neck dissection. Clinically positive nodes had become evident eight weeks after rese,ction of the primary. No alteration of the viability of the transplant.ed tissue occurred. Full thickness reconstruction of the lower lip was carried out in one patient (CY) using a free groin flap folded upon itself. To prevent sagging, t.he flap was draped over a fascia lata sling. (Figure 5.) A fistula temporarily formed and eventually closed. and this patient now has a functioning continent oral cavity. 421
Acland and Flynn
Figure 4. Flap being drawn through a tunnel in the hyomandibular musculature.
Comments The approach described to major head and neck resection and reconstruction calls for considerable planning and involves a large numer of skilled people. Although the operative time is not much longer than with standard reconstructive methods, the number of skilled man-hours is almost doubled. Clear benefit must be demonstrated to justify this extraordinary effort. Although the functional results are at least as good as those with conventional methods, the principal benefit is cosmetic. The absence of an unsightly
TABLE I
Patient Data Me
Patient
(yr)
cs
61 52 65 65 73 56 14 61 a4 65 67 58 53 51 60 68 60 52 70
WL HC CY ES DS TT DM EV CY HG AS DJ JE LH AT AW MT BJ
422
secondary deformity is so dramatic that the advantage is self-evident,. The ability to perform consistently successful microvascular anastomoses is so basic, that without this capability immediate free flap reconstruction probably should not be attempted. Microvascular skills should be developed to a high degree before incorporating them in this very complicated surgical undertaking. Similarly, the excisional team must consist of seasoned head and neck oncologic surgeons. It is predictable that in the absence of a high level of professionalism the method may fall into disfavor either from inappropriate use or high failure rates. Whether the dorsalis pedis or the groin flap is used depends to some extent upon the site of the defect. The dorsalis pedis flap is thin and supple; it can be readily contoured and folded upon itself, and it is therefore particularly valuable for defects involving the floor of the mouth and oral tongue. The laterally placed groin flap, even with careful thinning, is more bulky and is less suitable in these locations. Its bulk is an advantage in the reconstruction of buccal and tonsillar defects which are often deep and accommodating. Neither of the flaps is easy to raise. Each requires patient and time-consuming dissection and exact anatomic knowledge. The ultimate limits of this type of reconstruction have not been determined. Reconstruction of large full thickness defects was attempted using double free flaps and a free flap in combination with a conventional flap. In both cases the intraoral flap failed, and in both cases technical factors were at fault. Although success in this extended reconstruction appears to surpass our present capability, it remains a reasonable goal for the future.
Date of Operation 3177 4177 4177 5177 6177 7177 7177 9177 10177 III77 1 II77 II78 If78
1178 3178 4178 4178 4178 5178
Defect Site Buccal mucosa Tonsil Floor of mouth Floor of mouth Tongue Tongue Buccal mucosa Floor of mouth Buccal mucosa Lip Oropharynx Tongue Floor of mouth Floor of mouth Floor of mouth Oral cavity Oropharynx Floor of mouth Floor of mouth
Donor Site Groin Groin Dorsalis Dorsalis Dorsalis Dorsalis Groin Groin Groin Groin Groin Dorsalis Dorsalis Dorsalis Groin Groin Groin Dorsalis Groin
pedis pedis pedis pedis
pedis pedis pedis
pedis
Recipient Vessels
Previous Irradiation
External maxillary Lingual External maxillary External maxillary External maxillary External maxillary Lingual External maxillary External maxillary External maxillary Transverse cervical External maxillary External maxillary External maxillary External maxillary External maxillary Transverse cervical External maxillary External maxillary
No Yes Yes Yes
No No No No No Yes Yes
Yes No Yes
No Yes Yes
No No
Result
Success Partial failure Success Success Success Success Success Success Success Success Success Success Failure Success Failure Failure Success Failure
The American Joumaf of Surgery
Oral Cavity and Oropharyngeal
It is clear that previous radiat,ion therapy decreases the margin of’ safety of this form of reconstruction. N.ne patients had previously been treated to full therapeutic doses of radiat.ion. (One patient [CY] underwent reconstruction with 2 free flaps at separate procedures.) In each the microvascular anastom:)sis involved vessels within the radiation field. In four of the irradiated patients (including CY), one of whom had received more than 7,000 rads, the flap survived completely. In the remaining five irradiated patients, one partial and four complete failures occurred. In each case, exploration of the vascular pedicle revealed some technical explanation for the failure of the flap. It is difficult to assess the effect of radiation on the microvascular anastomosis. We believe that previous irradiation should be regarded not as a contraindication but as a cause for particular caution in the management of the vascular pedicle. The possible adverse effect of intraoral contamination on the microvascular anastomoses was initially a cause for concern. In our experience, this does not seem to be any more of a problem than it is with other forms of reconstruction involving the upper aerodigestive tract.. Other than assuring a careful watertight mucosal closure, no special effort need be made to protect the vascular pedicle from salivary ccntamination. In carrying out the extirpation, the principal modification of technic concerns the careful preserva.tion of the proposed recipient vessels. Sacrifice of vessels such as the external maxillary vessel simply for convenience must be avoided. Their importance changes considerably with the prospect of becoming recipient vessels for a free flap. Obviously such considerations must be abandoned if preservation of the vessels would conflict with completion of a satisfactory ablative procedure. It is already evident that, intraoral free flap reconstruction constitutes a highly significant advance. The tissue for reconstruction is brought from a #distant site in a single procedure without producing any deformity. The method is suitable for defects of any site and size within the mouth and throat; it can be used after full radiation therapy and in conjunction with a reasonable program of neck management. If its reliability continues to improve, it is foreseeable that microvascular free flap transfer will become the preferred method of reconstruction.
Summary
Eighteen patients struction of defects oropharynx with free One partial and four
Volume 136, October 1976
underwent immediate reconinvolving the oral cavity and groin and dorsalis pedis flaps. complete failures occurred. In
Reconstruction
Figure 5. Full thickness lower lip reconstruction, with free flap folded upon itself over a fascia lata ding.
the successfully reconstructed patients, the functional results were equal to conventional flaps while the cosmetic improvements were dramatic. Acknowledgments: We wish to thank t.he members of the microsurgical nursing team of Norton Childrens Hospital and Dr. William Gegg of the University of Louisville Department of Anesthesia for their indispensable help; Dr. Gerald Verdi and Dr. Larry Florman for permission to include two patients treated in conjunction with them; and Mrs. Katherine Bauscher for preparing the illustrations. References 1. Harii K: Current clinical experience in vascularized free skin flap transfers, p 45. Symposium on Microsurgery (Daniller A, Strauch B, eds). St. Louis, CV Mosby, 1976. 2. Daniel RK, Taylor GI: Distant transfer of an island flap by microvascular anastomoses. Plast Reconstr Surg 52: 111, 1973. 3. Serafin D, Georgiade NG: Microsurgical composite tissue transplantation. A new method of immediate reconstruction of extensive defects. Am J Surg 133(6): 752, 1977. 4. Leeb DC, Ben-Hur N, Mazzarella L: Reconstruction of the floor of the mouth with a free dorsalis pedis flap. Plasf Reconstr surg 59(3): 379, 1977. 5. Panje WR, Krause CJ, Bardach J: Microsurgical techniques in free flap reconstruction. Laryngoscope 87(5): 692, 1977. 6. Robinson DW: Microsurgical transfer of the dorsalis pedis neurovascular island flap. Br J Plast Surg 29(3): 209, 1976. 7. Taylor GI, Daniel RK: The anatomy of several free flap donor sites. P/ad Reconstr Surg 56: 243, 1975. 8. Acland RD: Instrumentation for microsurgery. Orthop C/in North Am 8(2): 281. 1977.
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