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The myocutaneous platysma flap for the reconstruction of intraoral defects after radical tumour resection
j. Cranio-Max.-Fac. Surg. 17 (1989) J. Cranio-Max.-Fac.Surg. 17 (1989) 237-240 © GeorgThiemeVerlagStuttgart • New York
The Myocutaneous Platysma Flap for the Reconstruction of Intraoral Defects after Radical Tumour Resection
237
Summary After performing 54 myocutaneous platysma flaps for reconstruction of intraoral defects following tumour surgery, the results, with reference to the postoperative outcome, are presented. Interest is focused on the anatomical basis of the flap's pedicle and its relevance for the indication of this method.
Key words Myocutaneous platysma flap - Intraoral defects - Tumour resection
Hans-Peter Howaldt, Klaus Bitter Dept. of Maxillo-FacialSurgery(Head:Prof. K. Bitter, M.D., D.M.D.), Johann-Wolfgang-Goethe-University,Frankfurt/Main,West Germany) Submitted 22.9.88; accepted 8. 11.88
Introduction When planning an intraoral reconstruction following tumour resection, the surgeon can choose from a variety of techniques. The requirements of a flap vary with regard to the site and the size of the defect. In addition, the patient's general condition will influence the choice. For instance, time-consuming procedures such as microsurgical flaps cannot be used in patients otherwise burdened with risk factors. Bearing this in mind we originally performed the myocutaneous platysma flap presented here as a procedure for those patients who could not be stressed with a long operation resulting from complicated reconstruction measures. In showing the results of 54 flaps we present the pros and cons of this method. A hundred years ago Gersuny (1887) was the first to publish an operation, which he performed to cover an intraoral defect with a skin flap from the neck. It was cranially based on the platysma muscle and according to his description it healed primarily. The reason for the survival of the flap has to be sought in the anatomy of its pedicle, which was intensively examined by Hurwitz et al. (1983). By means of catherization of nutrient vessels of the platysma muscle they identified four arterial inputs. These are branches of the a. thyreodea cranialis, the a. transversus colli, the a. occipitalis and a. submentalis. Using fresh cadavers, the arteries were filled with ink to stain areas of the platysma and the overlying skin. In general, overlapping skin areas could be seen and the submental artery proved to be the main supply to the platysma muscle and its overlying skin (Cannon et al., 1982). The a. submentalis is the last branch of the facial artery prior to its passing round the lower border of the mandible. From this artery small vessels branch caudally to enter the platysma muscle and later the skin. It is controversial whether an island flap, based on the platysma muscle, can survive after the facial artery has been ligated as it is the normal procedure during radical neckdissection.
Material and Methods The platysma flap can be widely used for covering defects on the outer surface of the neck and lower part of the face (Coleman et al., 1983; Habel, 1984) as well as for intraoral and pharyngeal surfaces (Nieto et al., 1983). The use of the flap as an intraoral reconstruction method is presented here. Fixed nodes in the neck and extensive local disease have to be regarded as contraindications for the flap. The access to the neck is made by a horizontal submandibular skin incision for an upper neck dissection. If a radical neck dissection is planned a second incision is placed along and just above the clavicle. These incision lines, as described by McFee (1960), do not have to be modified to raise the flap, but the submandibular skin incision must not injure the platysma muscle. The flap is outlined in the middle of the neck at a level, that provides adequate length of the pedicle to enable it to be folded around the mandible into the oral cavity. The elliptical skin area required to cover the intraoral defect should not be smaller than 4 × 2 cm in diameter in order to include enough perforating vessels from the platysma muscle to the skin surface (Coleman et al. 1982)(Fig. 1). The skin between the submandibular incision and the cranial margin of the flap is raised superficial to the platysma while the inferior incision includes platysma and the superficial fascia colli. In this layer the preparation is performed up to the submandibular gland. During the following neck dissection the gland is removed and the facial artery and vein are ligated. After completing the resection the flap is folded around the mandible as the lining of the intraoral defect as shown in Fig. 2 and 3.
Results Since 1983 we have performed 54 platysma flaps, all of them for the purpose of covering an intraoral defect, following turnout surgery. In every case, a radical or upper neck dissection was done and consequently the facial artery was ligated. The tumour site was located between the anterior floor of the mouth and the pharyngeal wall in its lower part. Some flaps had been brought up to the buccal mucous membrane and the soft palate as presented in Fig. 4. Table 1 shows the cause of the intraoral defect. The defect
238
J. Cranio-Max.-Fac. Surg. 17 (1989)
H.-P. Howaldt, K. Bitter Table1 Indication for the platysma flap referring to the tumour size expressed in T (of TNM) category T (TNM)
Incidence
Per cent
1 2 3 4 others
9 32 5 6 2
16.7 59,3 9,2 11.1 3.7
Table2 Outcome of 52 platysma flaps one week postoperatively (2 missing)
Fig.1
Healing
Incidence
Per cent
primarily epithelial breakdown partial loss
28 16 8
53.8 30.8 15.4
Platysma flap after preparation.
resulted predominantly from small- and medium-sized squamous cell carcinomas of the T1 and T2 category. The success of wound healing was examined one week postoperatively and a second time at least six months later, in order to estimate the final result. In Table 2 one can recognize that 28 flaps (53.8 %) healed primarily, 16 (30.8 %) cases showed superficial epithelial breakdown and 8 (15.4%) flaps were partially or completely lost. None of the patients required secondary surgery because despite partial or complete flap loss no tongue or other soft tissue adhesion occurred. Table 3 shows the final results. Seventy-five per cent of all cases healed completely without any loss of tissue, in other words the defect did not shrink due to scarring. The donor
site healed primarily in 94.5 % of the cases. Superficial wound dehiscence was observed in 5.5 %. In one patient we performed two platysma flaps from both sides of the neck, the right one healed primarily, while on the other side superficial epithelial breakdown without loss of tissue occurred. The two flaps covered a defect of the whole anterior floor of the mouth on both sides. It proved to be easier to perform a platysma flap if a partial resection of the mandible was done, as the radius of folding gets smaller thereafter. Despite of this experience, no different final results of the flaps could be observed. After radical tumour resection we followed up the patients, with a mean period of observation of 38.5 months
pla muscle skin
Fig.2
Diagram of the platysma flap before preparation.
Fig. 3 fect.
Diagram of the platysma flap after lining in an intraoral de-
The Myocutaneous Platysma Flap for the Reconstruction of Intraoral Defects
J. Cranio-Max.-Fac. Surg. 17 (1989)
2 39
Fig.4 Myocutaneous platysma flap healed in a defect extending to the basis of the velum.
Fig.5 Postoperative result of an extraoral scar after neck dissection including the donor site of the platysma flap as a horizontal scar.
"l'able3 Final results of 52 intraoral defects measured at least 6 months postoperatively (2 missing)
In the author's opinion, a vertical skin incision in the neck has to be considered disadvantageous in comparison with horizontal incisions because worse scarring will be produced. Freeland and Rogers (1975) saw many advantages of a horizontal skin incision line in the neck as introduced by McFee (1960), although they showed a more vertical trend of the neck skin vessels in fresh cadaver investigations. More recently Rabson et al. (1985) confirmed this experience. In their opinion the blood supply to the neck skin is a random one. They found the McFee incision to be the most reliable access to the neck as it is bipedicled rather than dependant on axial vessels. As we normally approach the neck dissection according to McFee, we found it quite easy to raise the platysma flap between the two horizontal incision lines. The aesthetic result at the donor site was in most cases as good as shown in Fig. 5. What we wanted to know was whether it is feasible to use the myocutaneous platysma flap when performing a radical or upper neck dissection. The anatomical basis for the platysma flap was discussed by Hurwitz et al. (1983). As mentioned above, the fresh cadaver investigations showed that four arterial systems supply the platysma muscle. The facial and subsequently the submental arteries proved to be the most important ones for the platysma. Therefore Coleman et al. (1983) concluded that the platysma flap must not be used in combination with radical neck-dissection because under such circumstances the facial artery is ligated. In contradistinction, Futrell et al. (1978) as well as Hurwitz et al. (1983) stated that the flap can be used even when performing a neck-dissection. They explained that the blood supply to the dissected flap was through various anastomoses from collaterals to the submental artery and from the cheek area.
Final result
Incidence
Per cent
no shrinkage shrinkage
39 13
75,0 25.0
(___15 months). We observed 11 tumour recurrences out of 52 patients suffering from squamous cell carcinoma. There was only one lymph node metastasis in the region of the flap's pedicle while three local recurrences occurred intraorally at the margin of the resection and seven tumour remanifestations arose contralaterally or at other distant sites. Discussion and Conclusions It was almost half a century until the ingenious method of
Gersuny (1887) for intraoral lining by a platysma-based flap was picked up again in the literature. A flap based on the platysma has many advantages. First of all, a flap consisting only of skin and platysma muscle is very thin and therefore suitable for intraoral lining (Manni and Bruaset, 1986). The flap can easily be raised in the neck and closing the donor site provides no difficulty (Persky et al., 1983). Edgerton (1951) described a two stage method of transporting skin into the oral cavity. Although he could show brilliant results in closing even large defects, especially of the cheek, this procedure seems to be too complicated. Farr et al. (1969) presented a platysma-based skin flap being raised by a vertical incision in the neck. A 3:1 length to width flap was outlined, with a maximum skin island measuring 6 x 6 cm, so it has to be regarded as a random flap.
240
J. Cranio-Max.-Fac. Surg. 17 (1989)
Cardoso de Castro (1980) found, in 75 % of these cadaver investigations, that muscle fibres of the platysma are interlaced with those of the opposite side of the neck. As these fibres are separated in the neck-dissection they cannot provide any blood supply to the platysma flap. Initially, our first objective in using the platysma flap was to have an easy and rapid method of closing intraoral defects in handicapped patients. The results presented above outline our success in that a stable result was achieved in almost 90 % of the cases. When this outcome was appreciated we extended this method to patients in better general condition. Our results, presenting 54 % primarily healed flaps and 31% with epithelial breakdown without shrinking defects, underline the feasibility of the reconstruction after radical neck surgery. Anyhow, the high incidence of secondary healing proved that the platysma flap is not a very safe method in this respect. Results like this have been reported previously. Coleman et al. (1983) observed 10 complicated results out of 24. Six out of 7 flaps suffering from skin loss were used for the intraoral lining. The rate of primary wound healing is dependent on meticulous dissection of the flap and the experience of the surgeon. The senior author who did the first platysma flaps produced from the beginning a higher rate of primary healing than the junior author who improved his results by perfoming almost the same number of flaps. During the follow up of the tumour patients we observed only one tumour to recur in the area of the platysma flap's pedicle and three local recurrences at the margin of the resection. Regarding this, one can assume that the platysma flap does not transgress the principles of radical tumour surgery because the results presented above are within the distribution of well known rates of turnout relapse after cancer of the oral cavity (Platz et al., 1986) Anyhow, the results did not prove to be sufficiently convincing to discard most of the other methods of closing intraoral defects. Large lesions caused by T3-tumours and defects of the upper part of the oral cavity cannot be dealt with using this flap. The blood supply to the skin of the flap is regarded as quite unsafe, as 46 % showed epithelial breakdown or more severe complications. Nevertheless, the underlying platysma muscle and fascia were not involved in this loss of tissue. In most cases secondary epithelialization occurred and only in 15 % of the flaps was an outcome with shrinking of the defect observed. In addition it is important to mention that none of the reconstructions required secondary surgery. Nobody will deny that preservation of the facial artery will diminish the risk to the flap. Conley et al. (1986) stated that ligating the facial artery converts the axial vascular pattern into a randomized one. In conclusion, any pressure, swelling, torsion or traction will reduce its tenuous blood supply below survival levels. According to our experience we would completely agree with this statement. As we always ligated the facial artery
H,-P. Howaldt, K. Bitter: The Myocutaneous Platysma Flap
during neck dissection it is imperative that the pedicle of the flap is long enough to avoid any traction or distortion. Moreover the size of the skin island raised has to be large enough to contain a sufficient number of perforating vessels.
References Cannon, C. R., M. E. Johns, J.P. Atkins, W.M. Keane, R.W. Cantrell: Reconstruction of the oral cavity using the platysma myocutaneous flap. Arch. Otolaryngol. 108 (1982) 491 Cardoso de Castro, C.: The anatomy of the platysma muscle. Plast. Reconstr. Surg. 66 (1980) 680 Coleman III, J. J., F. Nahai, S. J. Mathes: Platysma musculocutaneous flap: clinical and anatomic considerations in head and neck reconstruction. Am J. Surg. 144 (1982) 477 Coleman III, J. J., M. J. Jurkiewicz, F. Nahai, S. J. Mathes: The platysma musculocutaneous flap: experience with 24 cases. Hast. Reconstr. Surg. 72 (1983) 315 Conley, J.J., D.M. Lanier, P. Tinsley Jr.: Platysma myocutaneous flap revisited. Arch. Otolaryngol. Head Neck Snrg. 112 (1986) 711 Edgerton, M. T.: Replacement of lining to oral cavity following surgery. Cancer 4 (1951) 110 Farr, H.W., B. Jean-Gilles, A. Die: Cervical island skin flap repair of oral and pharyngeal defects in composite operation for cancer. Am. J. Surg. 118 (1969) 759 Freeland, A. P., J. H. Rogers: The vascular supply of the cervical skin with reference to incision planning. Laryngoscope 85 (1975) 714 Futrell, J.W., M. E. Johns, M.T. Edgerton, R.W. Cantrell, G.S. FitzHugh: Platysma myocutaneous flap for intraoral reconstruction. Am. J. Surg. 136 (1978) 504 Gersuny, R.: Plastischer Ersatz der Wangenschleimhaut. Zentralblatt fiir Chirurgie 38 (1887) 706 Habel, G.: Der myokutane Platysma-Insellappen zur Defektdeckung nach Exzision ausgedehnter Tracbeotomienarben. Dtsch. Z. Mund Kiefer GesichtsCbir. 8 (1984) 149 Hurwitz, D. J., J. A. Rabson, J. W. Futrel[-The anatomic basis for the platysma skin flap. Hast. Reconstr. Surg. 72 (1983) 302 Manni, J.J., I. Bruaset: Reconstruction of the anterior oral cavity using the platysma myocutaneous island flap. Laryngoscope 96 (1986) 564 McFee, W.: Transverse incisions for neck dissection. Am. J. Surg. 151 (1960) 279 Nieto, C. S., L. L. Gallego, J. C. G. Cortes: Reconstruction of the posterior wall of the pharynx using a myocutaneous platysma flap. Br. J. Plastic Surg. 36 (1983) 36 Persky, M.S., D. Kaufman, N.L. Cohen: Platysma myocutaneous flap for intraoral defects. Arch. Otolaryngol. 109 (1983) 463 Platz, H., R. Fries, M. Hudec: Prognoses of oral cavity carcinomas. Results of a multicentric retrospective observational study. Hanser Miinchen - Wien (1986) Rabson, J. A., D. J. Hurwitz, J. W. Futrell: The cutaneous blood supply of the neck: relevance to incision planning and surgical reconstruction. Br. J. Hast. Surg. 38 (1985) 208
Dr. Dr. H.-P. Howaldt, M.D., D.M.D. Dept. of Maxillo-Facial Surgery Johann-Wolfgang-Goetbe-University Theodor-Stern-Kai7 D-6000 Frankfurt 70 West-Germany
The Myocutaneous Platysma Flap for the Reconstruction of Intraoral Defects after Radical Tumour Resection
237
Summary After performing 54 myocutaneous platysma flaps for reconstruction of intraoral defects following tumour surgery, the results, with reference to the postoperative outcome, are presented. Interest is focused on the anatomical basis of the flap's pedicle and its relevance for the indication of this method.
Key words Myocutaneous platysma flap - Intraoral defects - Tumour resection
Hans-Peter Howaldt, Klaus Bitter Dept. of Maxillo-FacialSurgery(Head:Prof. K. Bitter, M.D., D.M.D.), Johann-Wolfgang-Goethe-University,Frankfurt/Main,West Germany) Submitted 22.9.88; accepted 8. 11.88
Introduction When planning an intraoral reconstruction following tumour resection, the surgeon can choose from a variety of techniques. The requirements of a flap vary with regard to the site and the size of the defect. In addition, the patient's general condition will influence the choice. For instance, time-consuming procedures such as microsurgical flaps cannot be used in patients otherwise burdened with risk factors. Bearing this in mind we originally performed the myocutaneous platysma flap presented here as a procedure for those patients who could not be stressed with a long operation resulting from complicated reconstruction measures. In showing the results of 54 flaps we present the pros and cons of this method. A hundred years ago Gersuny (1887) was the first to publish an operation, which he performed to cover an intraoral defect with a skin flap from the neck. It was cranially based on the platysma muscle and according to his description it healed primarily. The reason for the survival of the flap has to be sought in the anatomy of its pedicle, which was intensively examined by Hurwitz et al. (1983). By means of catherization of nutrient vessels of the platysma muscle they identified four arterial inputs. These are branches of the a. thyreodea cranialis, the a. transversus colli, the a. occipitalis and a. submentalis. Using fresh cadavers, the arteries were filled with ink to stain areas of the platysma and the overlying skin. In general, overlapping skin areas could be seen and the submental artery proved to be the main supply to the platysma muscle and its overlying skin (Cannon et al., 1982). The a. submentalis is the last branch of the facial artery prior to its passing round the lower border of the mandible. From this artery small vessels branch caudally to enter the platysma muscle and later the skin. It is controversial whether an island flap, based on the platysma muscle, can survive after the facial artery has been ligated as it is the normal procedure during radical neckdissection.
Material and Methods The platysma flap can be widely used for covering defects on the outer surface of the neck and lower part of the face (Coleman et al., 1983; Habel, 1984) as well as for intraoral and pharyngeal surfaces (Nieto et al., 1983). The use of the flap as an intraoral reconstruction method is presented here. Fixed nodes in the neck and extensive local disease have to be regarded as contraindications for the flap. The access to the neck is made by a horizontal submandibular skin incision for an upper neck dissection. If a radical neck dissection is planned a second incision is placed along and just above the clavicle. These incision lines, as described by McFee (1960), do not have to be modified to raise the flap, but the submandibular skin incision must not injure the platysma muscle. The flap is outlined in the middle of the neck at a level, that provides adequate length of the pedicle to enable it to be folded around the mandible into the oral cavity. The elliptical skin area required to cover the intraoral defect should not be smaller than 4 × 2 cm in diameter in order to include enough perforating vessels from the platysma muscle to the skin surface (Coleman et al. 1982)(Fig. 1). The skin between the submandibular incision and the cranial margin of the flap is raised superficial to the platysma while the inferior incision includes platysma and the superficial fascia colli. In this layer the preparation is performed up to the submandibular gland. During the following neck dissection the gland is removed and the facial artery and vein are ligated. After completing the resection the flap is folded around the mandible as the lining of the intraoral defect as shown in Fig. 2 and 3.
Results Since 1983 we have performed 54 platysma flaps, all of them for the purpose of covering an intraoral defect, following turnout surgery. In every case, a radical or upper neck dissection was done and consequently the facial artery was ligated. The tumour site was located between the anterior floor of the mouth and the pharyngeal wall in its lower part. Some flaps had been brought up to the buccal mucous membrane and the soft palate as presented in Fig. 4. Table 1 shows the cause of the intraoral defect. The defect
238
J. Cranio-Max.-Fac. Surg. 17 (1989)
H.-P. Howaldt, K. Bitter Table1 Indication for the platysma flap referring to the tumour size expressed in T (of TNM) category T (TNM)
Incidence
Per cent
1 2 3 4 others
9 32 5 6 2
16.7 59,3 9,2 11.1 3.7
Table2 Outcome of 52 platysma flaps one week postoperatively (2 missing)
Fig.1
Healing
Incidence
Per cent
primarily epithelial breakdown partial loss
28 16 8
53.8 30.8 15.4
Platysma flap after preparation.
resulted predominantly from small- and medium-sized squamous cell carcinomas of the T1 and T2 category. The success of wound healing was examined one week postoperatively and a second time at least six months later, in order to estimate the final result. In Table 2 one can recognize that 28 flaps (53.8 %) healed primarily, 16 (30.8 %) cases showed superficial epithelial breakdown and 8 (15.4%) flaps were partially or completely lost. None of the patients required secondary surgery because despite partial or complete flap loss no tongue or other soft tissue adhesion occurred. Table 3 shows the final results. Seventy-five per cent of all cases healed completely without any loss of tissue, in other words the defect did not shrink due to scarring. The donor
site healed primarily in 94.5 % of the cases. Superficial wound dehiscence was observed in 5.5 %. In one patient we performed two platysma flaps from both sides of the neck, the right one healed primarily, while on the other side superficial epithelial breakdown without loss of tissue occurred. The two flaps covered a defect of the whole anterior floor of the mouth on both sides. It proved to be easier to perform a platysma flap if a partial resection of the mandible was done, as the radius of folding gets smaller thereafter. Despite of this experience, no different final results of the flaps could be observed. After radical tumour resection we followed up the patients, with a mean period of observation of 38.5 months
pla muscle skin
Fig.2
Diagram of the platysma flap before preparation.
Fig. 3 fect.
Diagram of the platysma flap after lining in an intraoral de-
The Myocutaneous Platysma Flap for the Reconstruction of Intraoral Defects
J. Cranio-Max.-Fac. Surg. 17 (1989)
2 39
Fig.4 Myocutaneous platysma flap healed in a defect extending to the basis of the velum.
Fig.5 Postoperative result of an extraoral scar after neck dissection including the donor site of the platysma flap as a horizontal scar.
"l'able3 Final results of 52 intraoral defects measured at least 6 months postoperatively (2 missing)
In the author's opinion, a vertical skin incision in the neck has to be considered disadvantageous in comparison with horizontal incisions because worse scarring will be produced. Freeland and Rogers (1975) saw many advantages of a horizontal skin incision line in the neck as introduced by McFee (1960), although they showed a more vertical trend of the neck skin vessels in fresh cadaver investigations. More recently Rabson et al. (1985) confirmed this experience. In their opinion the blood supply to the neck skin is a random one. They found the McFee incision to be the most reliable access to the neck as it is bipedicled rather than dependant on axial vessels. As we normally approach the neck dissection according to McFee, we found it quite easy to raise the platysma flap between the two horizontal incision lines. The aesthetic result at the donor site was in most cases as good as shown in Fig. 5. What we wanted to know was whether it is feasible to use the myocutaneous platysma flap when performing a radical or upper neck dissection. The anatomical basis for the platysma flap was discussed by Hurwitz et al. (1983). As mentioned above, the fresh cadaver investigations showed that four arterial systems supply the platysma muscle. The facial and subsequently the submental arteries proved to be the most important ones for the platysma. Therefore Coleman et al. (1983) concluded that the platysma flap must not be used in combination with radical neck-dissection because under such circumstances the facial artery is ligated. In contradistinction, Futrell et al. (1978) as well as Hurwitz et al. (1983) stated that the flap can be used even when performing a neck-dissection. They explained that the blood supply to the dissected flap was through various anastomoses from collaterals to the submental artery and from the cheek area.
Final result
Incidence
Per cent
no shrinkage shrinkage
39 13
75,0 25.0
(___15 months). We observed 11 tumour recurrences out of 52 patients suffering from squamous cell carcinoma. There was only one lymph node metastasis in the region of the flap's pedicle while three local recurrences occurred intraorally at the margin of the resection and seven tumour remanifestations arose contralaterally or at other distant sites. Discussion and Conclusions It was almost half a century until the ingenious method of
Gersuny (1887) for intraoral lining by a platysma-based flap was picked up again in the literature. A flap based on the platysma has many advantages. First of all, a flap consisting only of skin and platysma muscle is very thin and therefore suitable for intraoral lining (Manni and Bruaset, 1986). The flap can easily be raised in the neck and closing the donor site provides no difficulty (Persky et al., 1983). Edgerton (1951) described a two stage method of transporting skin into the oral cavity. Although he could show brilliant results in closing even large defects, especially of the cheek, this procedure seems to be too complicated. Farr et al. (1969) presented a platysma-based skin flap being raised by a vertical incision in the neck. A 3:1 length to width flap was outlined, with a maximum skin island measuring 6 x 6 cm, so it has to be regarded as a random flap.
240
J. Cranio-Max.-Fac. Surg. 17 (1989)
Cardoso de Castro (1980) found, in 75 % of these cadaver investigations, that muscle fibres of the platysma are interlaced with those of the opposite side of the neck. As these fibres are separated in the neck-dissection they cannot provide any blood supply to the platysma flap. Initially, our first objective in using the platysma flap was to have an easy and rapid method of closing intraoral defects in handicapped patients. The results presented above outline our success in that a stable result was achieved in almost 90 % of the cases. When this outcome was appreciated we extended this method to patients in better general condition. Our results, presenting 54 % primarily healed flaps and 31% with epithelial breakdown without shrinking defects, underline the feasibility of the reconstruction after radical neck surgery. Anyhow, the high incidence of secondary healing proved that the platysma flap is not a very safe method in this respect. Results like this have been reported previously. Coleman et al. (1983) observed 10 complicated results out of 24. Six out of 7 flaps suffering from skin loss were used for the intraoral lining. The rate of primary wound healing is dependent on meticulous dissection of the flap and the experience of the surgeon. The senior author who did the first platysma flaps produced from the beginning a higher rate of primary healing than the junior author who improved his results by perfoming almost the same number of flaps. During the follow up of the tumour patients we observed only one tumour to recur in the area of the platysma flap's pedicle and three local recurrences at the margin of the resection. Regarding this, one can assume that the platysma flap does not transgress the principles of radical tumour surgery because the results presented above are within the distribution of well known rates of turnout relapse after cancer of the oral cavity (Platz et al., 1986) Anyhow, the results did not prove to be sufficiently convincing to discard most of the other methods of closing intraoral defects. Large lesions caused by T3-tumours and defects of the upper part of the oral cavity cannot be dealt with using this flap. The blood supply to the skin of the flap is regarded as quite unsafe, as 46 % showed epithelial breakdown or more severe complications. Nevertheless, the underlying platysma muscle and fascia were not involved in this loss of tissue. In most cases secondary epithelialization occurred and only in 15 % of the flaps was an outcome with shrinking of the defect observed. In addition it is important to mention that none of the reconstructions required secondary surgery. Nobody will deny that preservation of the facial artery will diminish the risk to the flap. Conley et al. (1986) stated that ligating the facial artery converts the axial vascular pattern into a randomized one. In conclusion, any pressure, swelling, torsion or traction will reduce its tenuous blood supply below survival levels. According to our experience we would completely agree with this statement. As we always ligated the facial artery
H,-P. Howaldt, K. Bitter: The Myocutaneous Platysma Flap
during neck dissection it is imperative that the pedicle of the flap is long enough to avoid any traction or distortion. Moreover the size of the skin island raised has to be large enough to contain a sufficient number of perforating vessels.
References Cannon, C. R., M. E. Johns, J.P. Atkins, W.M. Keane, R.W. Cantrell: Reconstruction of the oral cavity using the platysma myocutaneous flap. Arch. Otolaryngol. 108 (1982) 491 Cardoso de Castro, C.: The anatomy of the platysma muscle. Plast. Reconstr. Surg. 66 (1980) 680 Coleman III, J. J., F. Nahai, S. J. Mathes: Platysma musculocutaneous flap: clinical and anatomic considerations in head and neck reconstruction. Am J. Surg. 144 (1982) 477 Coleman III, J. J., M. J. Jurkiewicz, F. Nahai, S. J. Mathes: The platysma musculocutaneous flap: experience with 24 cases. Hast. Reconstr. Surg. 72 (1983) 315 Conley, J.J., D.M. Lanier, P. Tinsley Jr.: Platysma myocutaneous flap revisited. Arch. Otolaryngol. Head Neck Snrg. 112 (1986) 711 Edgerton, M. T.: Replacement of lining to oral cavity following surgery. Cancer 4 (1951) 110 Farr, H.W., B. Jean-Gilles, A. Die: Cervical island skin flap repair of oral and pharyngeal defects in composite operation for cancer. Am. J. Surg. 118 (1969) 759 Freeland, A. P., J. H. Rogers: The vascular supply of the cervical skin with reference to incision planning. Laryngoscope 85 (1975) 714 Futrell, J.W., M. E. Johns, M.T. Edgerton, R.W. Cantrell, G.S. FitzHugh: Platysma myocutaneous flap for intraoral reconstruction. Am. J. Surg. 136 (1978) 504 Gersuny, R.: Plastischer Ersatz der Wangenschleimhaut. Zentralblatt fiir Chirurgie 38 (1887) 706 Habel, G.: Der myokutane Platysma-Insellappen zur Defektdeckung nach Exzision ausgedehnter Tracbeotomienarben. Dtsch. Z. Mund Kiefer GesichtsCbir. 8 (1984) 149 Hurwitz, D. J., J. A. Rabson, J. W. Futrel[-The anatomic basis for the platysma skin flap. Hast. Reconstr. Surg. 72 (1983) 302 Manni, J.J., I. Bruaset: Reconstruction of the anterior oral cavity using the platysma myocutaneous island flap. Laryngoscope 96 (1986) 564 McFee, W.: Transverse incisions for neck dissection. Am. J. Surg. 151 (1960) 279 Nieto, C. S., L. L. Gallego, J. C. G. Cortes: Reconstruction of the posterior wall of the pharynx using a myocutaneous platysma flap. Br. J. Plastic Surg. 36 (1983) 36 Persky, M.S., D. Kaufman, N.L. Cohen: Platysma myocutaneous flap for intraoral defects. Arch. Otolaryngol. 109 (1983) 463 Platz, H., R. Fries, M. Hudec: Prognoses of oral cavity carcinomas. Results of a multicentric retrospective observational study. Hanser Miinchen - Wien (1986) Rabson, J. A., D. J. Hurwitz, J. W. Futrell: The cutaneous blood supply of the neck: relevance to incision planning and surgical reconstruction. Br. J. Hast. Surg. 38 (1985) 208
Dr. Dr. H.-P. Howaldt, M.D., D.M.D. Dept. of Maxillo-Facial Surgery Johann-Wolfgang-Goetbe-University Theodor-Stern-Kai7 D-6000 Frankfurt 70 West-Germany