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One-stage composite reconstruction using the latissimus myoosteocutaneous free flap
One-Stage Composite Reconstruction Using the Latissimus Myoosteocutaneous Free Flap
Douglas R. Schmidt, MD, Chicago, Illinois Martin C. Robson,MD, Chicago, Illinois
Success or failure of treatment of malignant or benign neoplasms of the head and neck frequently depends on the adequacy of resection. Especially in cases of malignant disease, adequate composite resection will result in significant defects that, if inadequately reconstructed, are both cosmetically and functionally unacceptable. Fear of being unable to manage the reconstruction of these defects has probably influenced the physician to compromise resections and, as a result, has probably contributed to the high recurrence rate of head and neck tumors. Also, inadequate reconstruction that results in a cosmetically defective or functionally incapacitated patient has led patients and physicians alike to shy away from the surgical management of difficult lesions. Adequate reconstruction of the patient who has undergone composite resection of an oral-pharyngeal lesion must restore lining, internal structural support, soft tissue bulk, and external coverage. Historically, this was done in stages with viable soft tissue being provided first, followed by an avascular bone graft which would be replaced by creeping substitution from the vascularity of the soft tissue bed in which it was placed. Recently, attempts have been made to replace lining, bulk, external coverage, and structural support in a single procedure. Cuono and Ariyan [I] reported this with the pectoralis major musculocutaneous flap with an underlying attached anterior fifth rib, and Green et al [Z] reported using the pectoralis major musculocutaneous flap to carry a portion of the sternum. With the advent of successful free flap transfer by microvascular anastomosis, several investigators have reported free transfer of skin, muscle, and bone to the head and neck in one operation [3-71. From the Section of Plastic and Reconstructive Surgery, University of Chicago and Michael Reese Medical Center, Chicago, Illinois. Requests for reprints should be addressed to Martin C. Robson, MD, Section of Plastic and Reconstructive Surgery, University of Chicago, 950 East 59th Street, Chicago, Illinois. Presented at the 28th Annual Meeting of the Society of Head and Neck Surgeons, Marco Island, Florida, April 18-23. 1982.
470
Schlenker et al [8] described multiple animal experiments applying a free latissimus dorsi myoosteocutaneous flap transferred by the thoraco-dorsal vessels to the head and neck. An initial case was reported from our head and neck service in 1980 [9]. Here we report our further experience with the latissimus dorsi myoosteocutaneous free flap for reconstruction of head and neck defects. Material and Methods The operation is performed by two teams with the patient in the lateral position. We have found it possible to do the extirpative resection or the preparation of the recipient site in secondary reconstruction at the same time that the myoosteocutaneous flap is raised. Without concern for reconstruction, a standard radical resection is designed to provide adequate margins in tumor patients. In reconstructive cases, all the scar and unhealthy tissue that remain after the original procedure are excised. At the same time, a skin island of sufficient size to fill both the intraoral and external defects is designed over the latissimus dorsi muscle at the level of the seventh, eighth, and ninth ribs. The skin is incised down to the muscle and then the skin and subcutaneous tissue are elevated off the muscle in all directions away from the island. The muscle is cut free from its origin along the spine and transected well inferiorly. The anterior border is then freed up and the muscle is elevated off the chest wall starting superiorly, taking care to include the thoracodorsal artery with the muscle. As the elevation proceeds caudadly, large perforators from the chest wall to the muscle will be encountered (Figure 1). These must be preserved. The rib lying beneath the largest of the perforators is then selected. A portion of rib long enough to span the mandibular gap is marked and the rib is transected at both ends. The rib is then dissected free from the chest through the intercostal muscles, taking care to include the intercostal vessels on the inferior border of the rib with the specimen. This leaves the latissimus dorsi muscle-skin island and underlying rib attached by the muscle insertion and the thoracodorsal artery in the axilla. To complete preparation of the recipient site, a suitable artery and vein must be found. This depends on the extent of the original resection. We have been able to use either the facial (ipsilateral or contralateral) or the temporal ar-
The American Journal of Surgery
One-Stage Composite Reconstruction
Figure 1. Vascular perforators from the latisslmus dorsi muscle
to the underiying chest wall.
tery and accompanying vein. Previous radiation therapy has only been a problem during the suturing of the anastomosis. A previously radiated artery is thickened and very tough, and a large needle must sometimes be used with 9-O or LO-Onylon sutures. When the recipient site is ready, the muscle and va~cuh pedicle are transected in the axilla. The vascular pedicle of the latissimus dorsi muscle is large and can be dissected far enough into the axilla that we have found vein grafts unnecessary and anastomosis easy. The flap is initially sutured intraorally and then the rib is fixed to the mandible with interosseous wires. If the defect includes the symphysis, it may be necessary to make several parallel cuts in the cortex on either surface of the rib to allow it to bend. The flap is then revascularized and hemostasis achieved. The external wound is then closed over a suction drain.
Figure 2. Operative appearance of a composite reconstructlon using the trapezfus myocutaneous and free latfssfmus dorsl myoosteocutaneous fiap (Patlent 2).
The third patient was cosmetically deformed due to failure of reconstruction after resection of a massive adamantinoma of his mandible. His mandibular defect, extending from mid-ramus to mid-ramus, had been reconstructed with a Vita&urn@ tray filled with cancellous bone. He subsequently underwent seven procedures in an attempt to keep the anterior portion of the tray covered. He presented with a severe tissue shortage and with the anterior portion of the tray exposed. The middle third of the tray and the overlying soft tissue were resected leaving a portion of the tray posteriorly bilaterally. The defect was repaired with a latissimus dorsi myoosteocutaneous free flap. The rib was secured to the tray remnant bilaterally. The skin island was cut transversely and folded on itself, passing one portion under the lower lip for
Results The first patient was defective in his ability to ingest food, and he had a cosmetic deformity due to failure to reconstruct his mandible at the time of the resection of the floor of his mouth, a portion of his tongue, and his anterior mandible. He had been treated with 5,000 rads of external beam radiation postoperatively. He was unable to swallow or talk because of prolapse of his tongue into his throat. The second patient presented with a large tumor, recurring for the second time, of the anterior floor of the mouth that was eroding through his chin. He also had received a full curative dose of external beam radiation therapy. His resection included his entire tongue, the mandible from angle to angle, the floor of the mouth, and the chin. The defect was immediately reconstructed with a trapezius myocutaneous flap for lining and free latissimus dorsi myoosteocutaneous free flap for mandibular continuity and external coverage of this massive defect (Figure 2).
Volume 144, October 1992
Figure 3. Late appearance struct/on.
of a composite mandibular recon-
471
Schmidt and Robson
lining and using the remaining portion for external coverage (Figure 3). The rib, muscle, and skin of the flaps have survived in their entirety in all three patients. However, a wound hematoma had to be drained in the immediate postoperative period in one patient. Comments Free tissue transfer by microvascular anastomosis provides the opportunity to achieve a one-step reconstruction of lining, structural support, bulk, and external coverage in head and neck defects. Rosen et al [5] and O’Brien et al [4] reported composite reconstruction using the dorsalis pedis with underlying metatarsal. This leaves a severe functional deformity of the donor site and often results in prolonged healing of the site. Also, in the average age group of head and neck cancer patients (sixth to eighth decade), severe arthrosclerosis is often present in the lower extremities. Taylor et al [3,fO] and recently Bitter [II], describe a groin flap carrying the iliac crest based on the deep circumflex iliac vessels. In our experience, this flap does not have a constant vascular anatomy. The pedicle is often short and vessel diameter is smaller than the thoracodorsal vessels. Also, this flap provides very little bulk in the cachectic cancer patient. Baker [12] reported carrying the iliac crest on the tensor facia lata musculocutaneous flap. We often find the pedicle to be short, requiring vein grafts, and again there is frequently insufficient bulk. Because of the aforementioned drawbacks, the latissimus dorsi myoosteocutaneous flap was deveIoped in our laboratory by Schlenker et al [9]. After working out the details in experiments with dogs, it was successfully performed in a 60 year old man who underwent secondary composite reconstruction after an initial healing resection of the tongue, floor of the mouth, and mandible, followed by 5pOO rads of external beam radiation therapy. We now have additional clinical experience and believe the procedure is easy to perform, and provides excellent lining, structural support, bulk, and an extensive amount of external skin. The long vascular pedicle allows the anastomosis to be performed low in the neck or in the contralateral neck if necessary. A single arterial and venous anastomosis is sufficient because of the size of the vessels. This rib has been shown to be viable [13] by tetracycline labeling and, to date, no tissue loss has occurred. We believe this flap is reliable and versatile and expect it to be a significant resource in head and neck reconstruction.
472
Summary Head and neck reconstruction using a free flap composed of latissimus dorsi muscle and overlying skin and attached to vascularized posterior rib based on the thoracodorsal vessel was recently developed in our laboratory. Further clinical experience in the use of this flap is presented, along with a detailed explanation of the surgical technique. This flap provides internal lining, structural support, bulk, and external coverage for head and neck defects in one stage. Herein alternative composite free flaps have been compared with this flap. References 1. Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap. Plast Reconstr Surg 1980;65:477-83. 2. Green MF, Gilson JR, Bryson JA, Thompson E. A one-stage connection of mandibular defects using a split sternum pectoralis major osteomusculocutaneous transfer. Br J Plast Surg 1981;34:11-6. 3. Taylor GI, Watson N. One-stage repair of compound leg defects with free revascularized flaps o! groin skin and iliac bone. Plast Reconstr Surg 1978;61:494-506. 4. O’Brien B. McMorrison WA, MacLeon AM. Dollev BJ. Microvascular osteocutaneous transfer using-the groin flap and iliac crest and the dorsalis pedis flap and second metatarsal. Br J Plast Surg 1979;32:188-206. 5. Rosen IB, Bell MSG, Barron PT, Zucker RM, Manktelow RT. Use of microvascular flaps including free osteocutaneous flaps in reconstruction after composite resection for radiationrecurrent oral cancer. Am J Surg 1979;138:544-9. 6. Zuken RM, Manktelow RT, Palmer JA, Rosen IB. Head and neck reconstruction following resection of carcinoma, using microvascular free flaps. Surgery 1980;88:461-6. 7. Serafin D. Riefkohl R. Thomas I, Georgiade NG. Vascularized rib-periosteal and osteocutaneous reconstruction of the maxilla and mandible: an assessment. Plast Reconstr Surg 1980;66:718-827. 8. Schlenker JD, Robson MC, Parsons RW. Methods and results of reconstruction with free flaps following resection of squamous cell carcinoma of the head and neck. Ann Plast S&g 1981;6:363-73. 9. Schlenker JD, lndresano AT, Raine T, Meredith SC, Robson MC. A new flap in the dog containing a vascularized rib graft and the latissimus dorsi myoosteocutaneous flap. J Surg Res 1980;29: 172-83. 10. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plast Reconstr Surg 1979;64:745-59. 11. Bitter K. Bone transplants from the iliac crest to the maxillofacial region by the microsurgical technique. J Maxillofacial Surg 1980;8:210-16. 12. Baker SR. Reconstruction of mandibular defects with the revascularized free tensor fascia lata osteomyocutaneous flap. Arch Dtolaryngol 1981;107:414-8. 13. Ariyan S. The viability of rib grafts transplanted with the periosteal blood supply. Plast Reconstr Surg 1980;65:14051.
The American Journal of Surgery
Douglas R. Schmidt, MD, Chicago, Illinois Martin C. Robson,MD, Chicago, Illinois
Success or failure of treatment of malignant or benign neoplasms of the head and neck frequently depends on the adequacy of resection. Especially in cases of malignant disease, adequate composite resection will result in significant defects that, if inadequately reconstructed, are both cosmetically and functionally unacceptable. Fear of being unable to manage the reconstruction of these defects has probably influenced the physician to compromise resections and, as a result, has probably contributed to the high recurrence rate of head and neck tumors. Also, inadequate reconstruction that results in a cosmetically defective or functionally incapacitated patient has led patients and physicians alike to shy away from the surgical management of difficult lesions. Adequate reconstruction of the patient who has undergone composite resection of an oral-pharyngeal lesion must restore lining, internal structural support, soft tissue bulk, and external coverage. Historically, this was done in stages with viable soft tissue being provided first, followed by an avascular bone graft which would be replaced by creeping substitution from the vascularity of the soft tissue bed in which it was placed. Recently, attempts have been made to replace lining, bulk, external coverage, and structural support in a single procedure. Cuono and Ariyan [I] reported this with the pectoralis major musculocutaneous flap with an underlying attached anterior fifth rib, and Green et al [Z] reported using the pectoralis major musculocutaneous flap to carry a portion of the sternum. With the advent of successful free flap transfer by microvascular anastomosis, several investigators have reported free transfer of skin, muscle, and bone to the head and neck in one operation [3-71. From the Section of Plastic and Reconstructive Surgery, University of Chicago and Michael Reese Medical Center, Chicago, Illinois. Requests for reprints should be addressed to Martin C. Robson, MD, Section of Plastic and Reconstructive Surgery, University of Chicago, 950 East 59th Street, Chicago, Illinois. Presented at the 28th Annual Meeting of the Society of Head and Neck Surgeons, Marco Island, Florida, April 18-23. 1982.
470
Schlenker et al [8] described multiple animal experiments applying a free latissimus dorsi myoosteocutaneous flap transferred by the thoraco-dorsal vessels to the head and neck. An initial case was reported from our head and neck service in 1980 [9]. Here we report our further experience with the latissimus dorsi myoosteocutaneous free flap for reconstruction of head and neck defects. Material and Methods The operation is performed by two teams with the patient in the lateral position. We have found it possible to do the extirpative resection or the preparation of the recipient site in secondary reconstruction at the same time that the myoosteocutaneous flap is raised. Without concern for reconstruction, a standard radical resection is designed to provide adequate margins in tumor patients. In reconstructive cases, all the scar and unhealthy tissue that remain after the original procedure are excised. At the same time, a skin island of sufficient size to fill both the intraoral and external defects is designed over the latissimus dorsi muscle at the level of the seventh, eighth, and ninth ribs. The skin is incised down to the muscle and then the skin and subcutaneous tissue are elevated off the muscle in all directions away from the island. The muscle is cut free from its origin along the spine and transected well inferiorly. The anterior border is then freed up and the muscle is elevated off the chest wall starting superiorly, taking care to include the thoracodorsal artery with the muscle. As the elevation proceeds caudadly, large perforators from the chest wall to the muscle will be encountered (Figure 1). These must be preserved. The rib lying beneath the largest of the perforators is then selected. A portion of rib long enough to span the mandibular gap is marked and the rib is transected at both ends. The rib is then dissected free from the chest through the intercostal muscles, taking care to include the intercostal vessels on the inferior border of the rib with the specimen. This leaves the latissimus dorsi muscle-skin island and underlying rib attached by the muscle insertion and the thoracodorsal artery in the axilla. To complete preparation of the recipient site, a suitable artery and vein must be found. This depends on the extent of the original resection. We have been able to use either the facial (ipsilateral or contralateral) or the temporal ar-
The American Journal of Surgery
One-Stage Composite Reconstruction
Figure 1. Vascular perforators from the latisslmus dorsi muscle
to the underiying chest wall.
tery and accompanying vein. Previous radiation therapy has only been a problem during the suturing of the anastomosis. A previously radiated artery is thickened and very tough, and a large needle must sometimes be used with 9-O or LO-Onylon sutures. When the recipient site is ready, the muscle and va~cuh pedicle are transected in the axilla. The vascular pedicle of the latissimus dorsi muscle is large and can be dissected far enough into the axilla that we have found vein grafts unnecessary and anastomosis easy. The flap is initially sutured intraorally and then the rib is fixed to the mandible with interosseous wires. If the defect includes the symphysis, it may be necessary to make several parallel cuts in the cortex on either surface of the rib to allow it to bend. The flap is then revascularized and hemostasis achieved. The external wound is then closed over a suction drain.
Figure 2. Operative appearance of a composite reconstructlon using the trapezfus myocutaneous and free latfssfmus dorsl myoosteocutaneous fiap (Patlent 2).
The third patient was cosmetically deformed due to failure of reconstruction after resection of a massive adamantinoma of his mandible. His mandibular defect, extending from mid-ramus to mid-ramus, had been reconstructed with a Vita&urn@ tray filled with cancellous bone. He subsequently underwent seven procedures in an attempt to keep the anterior portion of the tray covered. He presented with a severe tissue shortage and with the anterior portion of the tray exposed. The middle third of the tray and the overlying soft tissue were resected leaving a portion of the tray posteriorly bilaterally. The defect was repaired with a latissimus dorsi myoosteocutaneous free flap. The rib was secured to the tray remnant bilaterally. The skin island was cut transversely and folded on itself, passing one portion under the lower lip for
Results The first patient was defective in his ability to ingest food, and he had a cosmetic deformity due to failure to reconstruct his mandible at the time of the resection of the floor of his mouth, a portion of his tongue, and his anterior mandible. He had been treated with 5,000 rads of external beam radiation postoperatively. He was unable to swallow or talk because of prolapse of his tongue into his throat. The second patient presented with a large tumor, recurring for the second time, of the anterior floor of the mouth that was eroding through his chin. He also had received a full curative dose of external beam radiation therapy. His resection included his entire tongue, the mandible from angle to angle, the floor of the mouth, and the chin. The defect was immediately reconstructed with a trapezius myocutaneous flap for lining and free latissimus dorsi myoosteocutaneous free flap for mandibular continuity and external coverage of this massive defect (Figure 2).
Volume 144, October 1992
Figure 3. Late appearance struct/on.
of a composite mandibular recon-
471
Schmidt and Robson
lining and using the remaining portion for external coverage (Figure 3). The rib, muscle, and skin of the flaps have survived in their entirety in all three patients. However, a wound hematoma had to be drained in the immediate postoperative period in one patient. Comments Free tissue transfer by microvascular anastomosis provides the opportunity to achieve a one-step reconstruction of lining, structural support, bulk, and external coverage in head and neck defects. Rosen et al [5] and O’Brien et al [4] reported composite reconstruction using the dorsalis pedis with underlying metatarsal. This leaves a severe functional deformity of the donor site and often results in prolonged healing of the site. Also, in the average age group of head and neck cancer patients (sixth to eighth decade), severe arthrosclerosis is often present in the lower extremities. Taylor et al [3,fO] and recently Bitter [II], describe a groin flap carrying the iliac crest based on the deep circumflex iliac vessels. In our experience, this flap does not have a constant vascular anatomy. The pedicle is often short and vessel diameter is smaller than the thoracodorsal vessels. Also, this flap provides very little bulk in the cachectic cancer patient. Baker [12] reported carrying the iliac crest on the tensor facia lata musculocutaneous flap. We often find the pedicle to be short, requiring vein grafts, and again there is frequently insufficient bulk. Because of the aforementioned drawbacks, the latissimus dorsi myoosteocutaneous flap was deveIoped in our laboratory by Schlenker et al [9]. After working out the details in experiments with dogs, it was successfully performed in a 60 year old man who underwent secondary composite reconstruction after an initial healing resection of the tongue, floor of the mouth, and mandible, followed by 5pOO rads of external beam radiation therapy. We now have additional clinical experience and believe the procedure is easy to perform, and provides excellent lining, structural support, bulk, and an extensive amount of external skin. The long vascular pedicle allows the anastomosis to be performed low in the neck or in the contralateral neck if necessary. A single arterial and venous anastomosis is sufficient because of the size of the vessels. This rib has been shown to be viable [13] by tetracycline labeling and, to date, no tissue loss has occurred. We believe this flap is reliable and versatile and expect it to be a significant resource in head and neck reconstruction.
472
Summary Head and neck reconstruction using a free flap composed of latissimus dorsi muscle and overlying skin and attached to vascularized posterior rib based on the thoracodorsal vessel was recently developed in our laboratory. Further clinical experience in the use of this flap is presented, along with a detailed explanation of the surgical technique. This flap provides internal lining, structural support, bulk, and external coverage for head and neck defects in one stage. Herein alternative composite free flaps have been compared with this flap. References 1. Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap. Plast Reconstr Surg 1980;65:477-83. 2. Green MF, Gilson JR, Bryson JA, Thompson E. A one-stage connection of mandibular defects using a split sternum pectoralis major osteomusculocutaneous transfer. Br J Plast Surg 1981;34:11-6. 3. Taylor GI, Watson N. One-stage repair of compound leg defects with free revascularized flaps o! groin skin and iliac bone. Plast Reconstr Surg 1978;61:494-506. 4. O’Brien B. McMorrison WA, MacLeon AM. Dollev BJ. Microvascular osteocutaneous transfer using-the groin flap and iliac crest and the dorsalis pedis flap and second metatarsal. Br J Plast Surg 1979;32:188-206. 5. Rosen IB, Bell MSG, Barron PT, Zucker RM, Manktelow RT. Use of microvascular flaps including free osteocutaneous flaps in reconstruction after composite resection for radiationrecurrent oral cancer. Am J Surg 1979;138:544-9. 6. Zuken RM, Manktelow RT, Palmer JA, Rosen IB. Head and neck reconstruction following resection of carcinoma, using microvascular free flaps. Surgery 1980;88:461-6. 7. Serafin D. Riefkohl R. Thomas I, Georgiade NG. Vascularized rib-periosteal and osteocutaneous reconstruction of the maxilla and mandible: an assessment. Plast Reconstr Surg 1980;66:718-827. 8. Schlenker JD, Robson MC, Parsons RW. Methods and results of reconstruction with free flaps following resection of squamous cell carcinoma of the head and neck. Ann Plast S&g 1981;6:363-73. 9. Schlenker JD, lndresano AT, Raine T, Meredith SC, Robson MC. A new flap in the dog containing a vascularized rib graft and the latissimus dorsi myoosteocutaneous flap. J Surg Res 1980;29: 172-83. 10. Taylor GI, Townsend P, Corlett R. Superiority of the deep circumflex iliac vessels as the supply for free groin flaps. Plast Reconstr Surg 1979;64:745-59. 11. Bitter K. Bone transplants from the iliac crest to the maxillofacial region by the microsurgical technique. J Maxillofacial Surg 1980;8:210-16. 12. Baker SR. Reconstruction of mandibular defects with the revascularized free tensor fascia lata osteomyocutaneous flap. Arch Dtolaryngol 1981;107:414-8. 13. Ariyan S. The viability of rib grafts transplanted with the periosteal blood supply. Plast Reconstr Surg 1980;65:14051.
The American Journal of Surgery