Midface soft tissue reconstruction with the facio-cervico-pectoral flap

Journal of Cranio-MaxillofiTcialSurgery (1997) 25, 39-45

© 1997EuropeanAssociationfor Cranio-MaxillofacialSurgery

Midface soft tissue reconstruction with the facio-cervico-pectoral flap Francisco Soler-Presas, Matias Cuesta-Gil, Alfonso Borja-Morant, Carlos Concejo-Cfitoli, Julio Acero-Sanz, Carlos Navarro-Vila*

C/Costa Brava, 39, Esc. Derecha 2 ° B, Madrid 28034, Spain

S U M M A R Y. The reconstruction of large soft tissue defects in the orbital and maxillomalar region is a difficult task. A good functional and aesthetic result has to be achieved. The cervicopectoral rotation flap has many advantages; it is easy, rapid and safe to harvest, compatible with cervical dissection and radiotherapy. It is an anatomical unit, with skin properties similar to the rest of the facial skin. This is our pedicle flap of choice for large soft tissue defects in the midface, specially in elderly patients. We use it in association with the temporalis myofascial flap in cases of orbital exenteration. In large defects, the alternatives to these flaps are microsurgical free flaps or other pedicled flaps. These flaps require more complex techniques, are time consuming surgically, have greater morbidity and equal or worse functional and aesthetic results. In this paper we present our experience. Twenty-two patients with large soft tissue defects in the maxillomalar and orbital regions have had reconstructions with these flaps (facio-cervico-pectoral rotation flap and temporalis myofascial flap) in the last 8 years.

the myofascial temporalis flap was utilized in order to fill the orbit and give support for the cutaneous reconstruction. Tumour origin and histological type are shown in Table 1. The most frequent pathological diagnosis in our series (12 cases) was basal cell carcinoma. Soft tissue defects after tumoral ablation ranged between 7 x 5 cm up to 13 x 10 cm. Five patients underwent ipsilateral neck dissection in the same operation, four of whom needed postoperative radiotherapy. Five cases also required underlying bone resection, which included the malar bone and the anterior wall of the maxillary sinus in four patients, and a radical maxillectomy in one patient. When negative margins were proved, the reconstruction of the defect was planned. The inferior extension of the flap towards the pectoral area depends upon the size of the defect. Broad defects require adequate mobilization of the flap in order to achieve tension free closure. In these cases, a pectoral extension was necessary. The design of the medially-based facio-cervicopectoral flap is as follows:

INTRODUCTION The reconstruction of large soft tissue defects in the orbital and maxillomalar region is a difficult task. A good functional and aesthetic result demands reconstruction of the defects with soft tissue of similar characteristics. The surgical treatment of malignant tumours of this region often requires extensive surgery, and orbital exenteration may be needed. Defects of the cheek surface, of 30% or less, can be adequately repaired by direct closure or by local flaps, which give better aesthetic results than free skin grafts (Stark and Kaplan, 1972; Patterson et al., 1984; Wallis and Donald, 1984). In larger defects more complex surgical techniques are required. The association of the facio-cervico-pectoral rotation flap with the temporalis myofascial flap to fill the orbit is an excellent alternative to other pedicled or microsurgical free flaps (Cook et al., 1991). In this paper we present our experience in the use of the facio-cervico-pectoral flap and the temporalis myofascial flap to repair large orbito-facial defects.

MATERIAL AND METHODS

1. Superior line: A line from the superior attachment of the ear to the eyebrow, 5 mm above the lateral canthus (we fix the flap at this point to the temporalis fascia with a tension suture to avoid ectropion due to gravity). Then, the line sweeps downward to the superolateral limit of the soft tissue defect in the maxillomalar area. 2. Lateral line: A preauricular incision similar to that performed in rhytidectomy. The incision

In the last 8 years, 22 patients (14 males, 8 females) have had reconstructions using the facio-cervicopectoral flap. In 6 cases, due to orbital exenteration, *Maxillofacial Surgery Department (Professor and Chairman of the Department of Head and Neck Surgery; Chairman of the Department of Maxillo-Facial Surgery), General Hospital Gregorio Marafi6n, Madrid, Spain. 39

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Table 1 - Tumour origin and histological type Case

Age (years)

Sex

Location

Diagnosis

1

63

M

Preauric. skin

2

57

M

Cheek

Metastasis squamous cell carcinoma Dermatofibrosarcoma

3

77

M

Cheek

Basal cell carcinoma

4

73

M

Lids, orbit

Basal cell carcinoma

5

49

M

Lower lid, orbit

Fibrosarcoma

6

83

F

Cheek

Melanoma

7

61

M

Maxillary sinus, skin

Squamous cell carcinoma

8

92

M

Cheek

9

71

M

Lower lid, cheek

Squamous cell carcinoma Basal cell carcinoma

10

79

M

Preauric. parotid

11

70

M

Malar, orbit

12

68

F

Lower lid, cheek

Basal cell carcinoma

13

72

M

Lower lid, malar, orbit

Squamous cell carcinoma

14

45

F

Parotid, skin

15

84

F

Orbit

16

58

M

17

36

M

18

85

F

19

68

F

Temporal and preauric, skin Maxillary sinus, cheek Auricular and parotid skin Lower lid, cheek

Metastasis of temporal skin melanoma Malignant pleomorphic adenoma of lacrimal gland Basal cell carcinoma

20

55

M

Cheek

21

13

F

22

65

M

Nose, cheek, lower lid, upper lip Mandibular and submandib. skin

Recurrent parotid mucoepidermoid carcinoma Squamous cell carcinoma

Malignant angiopericytoma Tricholemoma Basal cell carcinoma Squamous cell carcinoma Haemangioma Skin necrosis Complication of treatment of nonHodgkin's Lymphoma

Defect

Neck

Flap

RT

Complication

Yes

CPF

Postop

No

No

CPF

No

Ectropion

No

CPF

No

No

No

CPF+MTF

No

No

No

CPF + MTF

Postop

No

No

CPF

No

No

Yes

CPF+MTF

Postop

S~nloss

No

CPF

No

No

No

CPF

No

No

No

CPF

Postop

No

Yes

CPF + MTF

No

Dehiscence

No

CPF

No

No

Yes

CPF + MTF

Postop

Distal necrosis

Yes

CPF

Postop

No

10 x 9 cm Skin, orbit, bone

No

CPF + MTF

No

No

8 x 6 cm Skin 8 x 5 cm Skin 12 x 8 cm Skin 7 x 5 cm Skin 8 x 6 cm Skin 13 x 13 cm Skin

No

CPF

No

No

No

CPF

No

No

No

CPF

Postop

No

CPF

No

Distal necrosis No

No

CPF

No

No

No

CPF

No

No

8 x 5 cm Skin

No

CPF

No

No

7 x 6 cm Skin 8 x 7 cm Skin 7 x 7 cm Skin 10 x 8 cm Skin 11 x 8 cm Skin, orbit, bone 8 x 6 cm Skin 12 x 8 cm Skin, orbit, bone 7 x 7 cm Skin 8 x 7 cm Skin 8 x 6 cm Skin 8 x 8 cm Skin, orbit, bone 7x5cm Skin 10x9cm Skin, orbit, bone 8x6cm Skin

Abbreviations: CPF: cervicopectoral rotation flap, MTF: miofascial temporal flap, RT: radiotherapy. proceeds to the insertion of the sternocleidomastoid on the mastoid and follows the anterior border of the trapezius (2 cm behind the anterior b o r d e r ) t o t h e l a t e r a l t h i r d o f t h e clavicle, extending into the pectoral region up to the 4-5 intercostal area. 3. M e d i a l r e l e a s i n g i n c i s i o n : O n c e t h e f l a p size h a s b e e n o u t l i n e d , t h e l a t e r a l i n c i s i o n is e x t e n d e d medially which allows appropriate rotation.

T h i s m e d i a l r e l e a s i n g i n c i s i o n is p l a c e d a t t h e p e c t o r a l level i f a b i g f l a p h a s b e e n h a r v e s t e d o r a t t h e m i d - c e r v i c a l level i f it is a m e d i u m s i z e d flap. T h e u s e o f a free s k i n g r a f t t o c l o s e a n i n f r a - c l a v i c u l a r d e f e c t a f t e r r o t a t i o n o f t h e flap w a s n o t r e q u i r e d i n a n y c a s e ( F i g . 1). A less c o m m o n v a r i a t i o n o f t h i s f l a p c a n b e d e s i g n e d as a l a t e r a l l y p e d i c l e d o n e , w h e r e t h e i n c i s i o n

Midface soft tissue reconstruction

41

shifting to a subplatysmal plane in the cervical region to improve blood flow to the flap. We also raise the flap under the pectoralis fascia in the infraclavicular area, to avoid injury to the parasternal perforators.

RESULTS

F i g . 1 - The medially-basedfacio-cervicalflap, with possible extension to the pectoral area.

follows a medial line through the nasolabial fold extending to the cervical region around the mandibular area: It is a laterally-based rotation flap (Crow and Crow, 1976) (Fig. 2). We prefer the medially-based rotation flap because the skin of the midline of the neck is more pliable, allowing better rotation of the flap, and the scar in the preauricular region and lateral neck is easily hidden. In all our flaps we have used a supra-superficial musculo-aponeurotic system (SMAS) dissection plane in the face (just above the parotid fascia) and

All flaps were viable, and functional results were excellent in most patients. Except in two cases that required wide bone resection, the aesthetic result was satisfactory with good colour matching and contour. No sagging was demonstrated; we believe this is because all the flaps were suspended to the temporal fascia with a non-resorbable tacking suture. The operating time required for soft tissue reconstruction was on average 1 h and 15 min. The length of hospitalization after surgery was a median rate of 6 days (longer in patients with delayed healing). The postoperative radiotherapy did not increase the rate of complications. We had five complications; three were partial necrosis or delayed healing, one case of dehiscence and one postoperative ectropion (Fig. 3). The treatment for each patient is detailed in Table 2.

DISCUSSION The facio-cervico-pectoral flap, extensively described by Becker (1978), is an association of Mustard6's rotation flap and Bakamjiam's deltopectoral flap (Bakarnfiarn, 1971; Mustardd, 1980; Wallis and Donald, 1984; Kroll et al., 1994). Due to the size of the defects that we reconstructed, the large flaps used in our series were a combination of both of these. This flap has a mixed axialrandomized vascular pattern, with an extraordinarily wide pedicle, rich in subdermal anastomoses, derived from multiple branches of the cervicopectoral arteries: facial-transverse cervical-suprascapular-parasternal perforators (Wallis and Donald, 1984). It is a safe flap, easy to harvest and compatible with the principles of oncologic resection, since it may be combined with cervical dissection associated with resection of the primary lesion. It also allows early postoperative radiotherapy (Kaplan and Goldwyn, 1978; Shestak et al., 1993). Primary closure was always achieved; we did not Table 2 - Patient treatment

Fig. 2 - The laterally-basedfacio-cervicalflap.

Case

Complication

Treatment

2 7 11 13 18

Ectropion Skin loss Dehiscence Distal necrosis Distal necrosis

Bipedicledupper lid flap Local cure Local cure Local cure Local cure

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Journal of Cranio-Maxillofacial Surgery

Fig. 3 - (A) Dermatofibrosarcoma of the cheek. Preoperative view and flap outline. The lateral incision was modified afterwards. (B) The flap has been secured to the temporoparietal fascia with a tension suture (the lateral limit of the eyebrow). Direct closure of the pectoral extension without a free skin graft. (C) Postoperative ectropion. (D) Final result after bipedicled flap from the upper lid.

Midface soft tissue reconstruction

43

Fig. 4 - (A) Pleomorphic adenoma of the lacrimal gland. Frontal view. (B) Postoperative result, after facio-cervico-pectoral flap and temporalis myofascial flap. Frontal view.

need to skin graft the infraclavicular area, as some authors suggest (Wallis and Donald, 1984). In relation to its design, we follow certain principles in order to achieve the best result: 1. If we preserve the eyeball, it is essential to suspend the highest portion of the flap to the temporoparietal fascia with non-resorbable sutures; this secures the flap against the pull of gravity and allows a tension free closure at the lower lid, thereby avoiding postoperative ectropion. Eventhough it is sometimes necessary to do a lateral canthoplasty, similar to that carried out in paralytic ectropion cases (Cook et al., 1991; Kroll et al., 1994). 2. We raise the flap just above the parotid fascia (supra-SMAS) in the face, and under the platysma (sub-SMAS) below the mandible. Some authors (Patterson et al., 1984; Kroll et al., 1994) recommend the use of sub-SMAS dissection of the flap in the parotid area in order to prevent distal cutaneous necrosis due to possible damage to the subdermal vessels. We believe that a subSMAS dissection of the facial flap can be useful and necessary in patients with a tenuous dermal blood flow (post radiotherapy or in heavy smokers) and we recommend it in these cases, although it is unnecessary in other cases. Only 3 out of the 22 patients operated on in our department had this problem and it resolved with conservative treatment. The temporalis myofascial flap prevents the collapse of the facio-cervico-pectoral flap in the eye

socket after exenteration, improving the aesthetic result. This flap, described by Golovine (1898), is nourished by deep temporal branches from the maxillary artery. Its approach and dissection does not leave visible scars and it is a safe and easy flap to harvest. After elevation, its transposition to the orbit is carried out by performing an osteotomy on the lateral wall of the orbit (Figs. 4 & 5). It does not produce a functional deficit, and the depression in the temporal region can be masked by utilizing an acrylic filling material. According to our experience, this material is associated with a low rate of infection and wound breakdown; it is usually out of the radiotherapy field.

CONCLUSION The facio-cervico-pectoral flap is an anatomical and functional unit which comprises many aesthetic advantages: skin texture, colour and flexibility similar to the rest of facial skin. An adequate design can prevent changes in facial expression, distortion of oral commissure and ectropion, as well as location of scars in hidden areas and natural folds. Regarding the above mentioned defects, microsurgical free and pedicled flaps are the only valuable alternative. These flaps require a complex technique in their execution and are time consuming. They also have worse aesthetic results and imply a greater morbidity at the donor site. They are an adequate choice for large soft tissue and osseous defects. We recommend the combination of two flaps (facio-

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Journal of Cranio-Maxillofacial Surgery

Fig. 5 - (A) Squamous cell carcinoma of the cheek. (B) Intraoperative view. (C & D) Postoperative view.

cervico-pectoral and temporalis myofascial flap) in cutaneous and soft tissue defects of the lateral midface and orbit, especially in older patients. References Bakamjiam, V. Y.: Experience with the medially based deltopectoral flap in reconstructive surgery of the head and neck. Brit. J. Plast. Surg. 24 (1971) 174-183 Becket, D. W: A cervicopectoral rotation flap for cheek coverage. Plast. Reconstr. Surg. 61 (1978) 868-870

Cook, T. A., J. M. Israel, T. D. Wang, C. S. Murakami: Cervical rotation flaps for midface resurfacing. Arch. Otolaryngol. 117 (1991) 77-82 Crow, ~/£ L., R. N. Crow: Resurfacing large cheek defects with rotation flaps from the neck. Plast. Reconstr. Surg. 58 (1976) 196-200 Golovine, S. S.: Procede de cloture plastique de l'orbite apres l'exenteration. J. Fr. Ophtalmol. 18 (1898) 679-684 Kaplan, I., R. M. Goldwin: The versatility of the laterally based cervicofacial flap for cheek repair. Plast. Reconstr. Surg. 61 (1978) 390-393 Kroll, S. S., G. P. Reece, G. Robb, J. Black: Deep-plane cervicofacial rotation-advancement flap for reconstruction of large cheek defects. Plast. Reconstr. Surg., 94 (1994) 88-93

Midface soft tissue reconstruction Mustardd, Y. C.: Repair and reconstruction in the orbital region 2nd Ed. London; Churchill Livingstone, 1980, 111-129 Patterson, H., C. Anonsen, E. A. Weymuller, R. C. Webster: The cheek-neck rotation flap for closure of temporozygomaticcheek wounds. Arch. Otolaryngol. 110 (1984) 388-393 Shestak, K. C., A. G. Roth, N. F. Jones, E. N. Myers: The cervicopectoral rotation ftap--a valuable technique for facial reconstruction. Br. J. Plast. Surg. 46 (1993) 375-377 Stark, R. B., J. M. Kaplan: Rotation flaps, neck to cheek. Plast. Reconstr. Surg. 50 (1972) 230-233 Wallis, A., P. Donald: Lateral face reconstruction with the medial-

based cervicopectoral flap. Arch. Otolaryngol. 114 (1984) 729 733 Francisco Soler-Presas

C/Costa Brava 39. Esc. Derecha 2OB Madrid 28034 Spain Paper received 13 May 1996 Accepted 10 December 1996

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