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The versatility of the free lateral arm flap in head and neck soft tissue reconstruction: clinical experience of 210 cases
Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, 172e179
The versatility of the free lateral arm flap in head and neck soft tissue reconstruction: clinical experience of 210 cases ˆnica Lucia Rodrigues a, Jose Carlos Marques Faria a,c,d,*, Mo Gean Paulo Scopel c, Luiz Paulo Kowalski b, Marcus Castro Ferreira c a
Microsurgery Surgery Division, Hospital do Cancer A C Camargo, Sao Paulo, Brazil Head and Neck Surgery and Otorhinolaryngology Department, Hospital do Cancer A C Camargo, Sao Paulo, Brazil c Plastic Surgery Division, Hospital das Clinicas, Sao Paulo, Brazil d Plastic Surgery Division, Hospital PUC Campinas, Brazil b
Received 9 November 2006; accepted 16 October 2007
KEYWORDS Lateral arm; Free flap; Head and neck; Reconstruction
Summary A study of the authors’ experience with 210 free lateral arm flaps used to repair head and neck oncological defects over an 8-year period. Patients’ ages ranged from 4 to 83 years (average: 49.7 years). One hundred and forty-one were male and 66 female. Three patients received two consecutive flaps each. They were used to reconstruct: the tongue, 53 cases; retromolar trigone, 42 cases; soft/hard palate, 34 cases; skin/facial contour, 19 cases; hypopharynx, 17 cases; buccal mucosa, 12 cases; lips, five cases. Flap cutaneous dimensions ranged from 4 2 cm to 17 8 cm. Flap was composed of: skin and fascia, 18 cases; sensate (neurovascular) skin, six cases; subcutaneous fat tissue, five cases; skin and vascularised nerve graft, three cases, skin and partial triceps muscle, three cases. Nerve coaptations were performed for all lip reconstructions. All flaps survived except for nine (success rate: 95.2%). Severe postoperative clinical complications preceded flap failure and death in two cases. All but six donor sites were closed primarily. Complications related to the donor site were: paresthesia of the forearm, 210 cases; dog ear, 16 cases; hypertropic scar, 14 cases; weakness, nine cases; haematoma, five cases; seroma, three cases; dehiscence, one case. Radial nerve injury was not observed in this series. The lateral arm flap can be considered safe and versatile for most soft tissue head and neck microsurgical reconstructions. The possibility of sensory recovery through neural anastomoses and low donor site morbidity enhances its efficiency. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Rua Maestro Cardim, 377 Cjs 85/86 01323-000 Sao Paulo, Brazil. E-mail address: [email protected] (J.C. Marques Faria).
Selection of a free flap to repair tissue loss resulting from head and neck surgery is based on factors related to the flap, the defect, the patient and the surgeon’s experience.1e4
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.10.035
Free lateral arm flap in head and neck soft tissue reconstruction Because of the many aspects to be considered, strict rules that always define one type of flap for a specific defect cannot be established. In 1982, Song5 introduced the lateral arm flap (LAF). Since then, its use in head and neck surgical repairs has been the specific subject of publications generally restricted to a small number of cases.6e12 Factors such as a smaller skin paddle and shorter vascular pedicle with smaller calibre may explain why this flap is less popular than the free radial forearm flap (RFF).13 There are, however, favourable reasons for using the free LAF.14 The purpose of this study is to report the experience of 210 consecutive free LAFs used to repair head and neck defects resulting from oncological surgical treatments over an 8-year period.
Patients and methods From 1999 to 2006, our team performed a total of 661 microsurgical flaps to repair soft tissue defects after head and neck tumour resection in patients treated in three institutions: Hospital do Cancer, A.C. Camargo, Hospital das Clinicas, University of Sao Paulo and University Hospital, PUC Campinas, Brazil. Of these, 210 were LAFs. The main indications for using the LAF in this clinical series were: oncological defect and recipient vessels located on the same side of the medial line and the possibility of primary closure of the donor site. Three patients received two LAFs. Of the 207 patients, 141 were male and 66 were female. Their ages varied from 4 to 83 years (mean: 49.7 years). The tumour site, histological type and size are shown in Table 1. The majority of the flaps (90.9%) were used to reconstruct defects of the oral cavity. The flap dissection technique was basically the same in all cases with slight differences, depending on anatomical variations or the needs of the recipient site. A line was drawn from the insertion of the deltoid passing over the lateral epicondyle towards the forearm with the elbow flexed 45 . The flap was outlined centred on this line, which coincides with the course of the posterior radial collateral vessels. Elevation of the flap began with posterior incision which passed through the deep fascia. The ramifying branches to the triceps muscle were ligated and divided. The anterior border incision was made again in a subfascial plane dissecting over the surface of brachioradialis and brachialis muscles. Passing between theses muscles, the anterior radial collateral artery along the radial nerve was identified, ligated and divided. The posterior cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm accompanying the posterior radial collateral artery were also identified. The neurovascular pedicle was then dissected proximally by dividing the lateral head of the triceps muscle up to the profunda brachii artery. The vascular and nerve branches to the lateral head of the triceps muscle identified in the posterior region of the pedicle were preserved during dissection of the composite myocutaneous flap. One hundred and seventy-nine (85.2%) flaps were transplanted immediately after oncological surgery. In 31 cases (24.8%), microsurgical reconstruction was performed
Table 1
173 Site, histological type and tumour size (n Z 210)
Variable
n
%
Site Tongue Hemiglossectomy Near total glossectomy Extended glossectomy Total glossectomy Retromolar trigone/tonsil Hard/soft palate Floor of the mouth Skin/facial contour Hypopharynx Inner cheek Lower lip Upper lip Parotid
53 31 16 6 0 42 34 28 17 17 12 3 2 2
25.2 14.7 7.6 2.8 0 20.0 16.1 13.3 8.1 8.1 5.7 1.4 0.9 0.9
Histological type Squamous cell carcinoma Basal cell carcinoma Adenoid cystic carcinoma Sarcoma Other malignant tumours
166 16 14 5 9
79.0 7.6 6.6 2.3 4.2
7 55 90 58
3.3 26.2 42.8 27.6
Tumour size <1 cm 1e2 cm 2e4 cm >4 cm
between 2 days and 30 months (mean: 14.7 months) after tumour resection and indicated to treat sequelae or complications from prior treatments (Table 2).
Results The length and width of the flaps were between 4 2 and 17 8 cm. In 201 cases (95.7%), skin from the proximal third of the forearm was included, with the most distal portion taken 9 cm below the lateral epicondyle (Fig. 1). The majority of the flaps were taken from the left arm (185 cases, 88%), irrespective of which side the defect was
Table 2
Indications for delayed or late reconstruction
Site
No. of cases
Palate (oronasal fistula) Orbit (ocular exenteration) Partial necrosis of the local facial flap Oro or nasocutaneous fistula Contouring (facial depressions) Scar adherence of the tongue and floor of the mouth Microsurgical flap loss
13 5 4 3 3 2
Total
31
1
174
J.C. Marques Faria et al.
Figure 1
Outline of the extended lateral arm flap.
on, considering that the upper right limb is dominant in most individuals. The right arm was used in 25 cases (12%) due to the dominance of the upper left limb, operating room logistics or previous surgery on the left arm. Anatomical variations of the vascular and nerve pedicles were observed during flap dissection. Eight patients presented duplication of the posterior radial collateral artery. In 23 patients, the posterior cutaneous nerve of the arm ran intramuscularly through the lateral head of the triceps. Cutaneous flap dissection time varied from 25 to 40 min, which was prolonged by approximately 15 min when part of the triceps muscle was incorporated. In all cases, the skin flap was sutured to the defect before microvascular anastomoses were performed. Table 3 shows the recipient arteries used in the reconstructions. In 183 (87.1%) cases, only one venous anastomosis was performed, and two were performed in 27 (12.9%) cases. In two patients, the artery and vein of the flap were very similar in calibre and wall thickness. Because of the difficulty in differentiating the two, the artery of the flap was sutured to the recipient vein, which was quickly identified when the clamp was removed. The anastomoses were then redone without compromising the final result. Total ischaemia time never exceeded 2 h. Although, in the majority of the patients, the LAF was used to repair cutaneous (Fig. 2) and mucosal lining, other combinations were also used (Table 4). The final result of
Table 3
Recipient arteries
Recipient Artery
Number of Cases
Upper Tyroidea Facial Temporal External Carotid Lingual Common Carotid
107 89 7 4 2 1
Total
210
% 50.9 42.3 3.33 1.9 0.95 0.47 100
a patient who underwent two free LAFs, to reconstruct an oral cavity defect and to restore cheek volume, and the respective donor sites, are shown in Fig. 3. In the defects involving the tongue and floor of the mouth, the skin of the flap was positioned to repair tongue loss and its fascia was placed on the floor of the mouth and left to naturally develop oral mucosa epithelium within a few weeks. A composite flap, skin and a portion of the triceps muscle were used in three patients (Fig. 4). Two of these patients underwent extended hemiglossectomies. The resulting defect included the base of the tongue and other parts of the pharynx. In these cases, the muscle was inserted to elevate the larynx. The respective nerve branch was sutured to the hypoglossal nerve ipsilateral to the glossectomy. In another patient, the zygomatic major and minor muscles had to be sacrificed in the resection of a sarcoma of the cheek. The motor nerve of the triceps in this case was sutured to the buccal branch of the facial nerve and the skin of the same flap was used to repair the lining of the mouth. The long-term static and dynamic balances were considered satisfactory in this patient. None of the patients complained about the strength or range of movement of the respective limb. The posterior cutaneous nerve of the arm was sutured to the infraorbital nerve in the upper lip reconstructions (three cases), to the mental nerve in the lower lip reconstructions (two cases) and to the greater auricular nerve during inner cheek reconstruction (one case). Fig. 5 shows a case of innervated upper lip reconstruction. Hospitalisation varied from 2 to 95 days (mean: 6 days). The most significant clinical complications are shown in Table 5. No partial flap loss was observed. There were nine (4.2%) cases of total flap loss as a result of vascular thrombosis; five arterial and four venous. Of these patients, eight underwent secondary surgery to remove necrotic tissue and one presented clinical conditions so critical that secondary operation was not possible. In one of the eight patients, submitted to palate reconstruction, the defect was left open and, in the remaining seven, the defects were closed with: local flaps, five cases; pectoralis flap, one case; and a second free LAF, one case. Two patients died in the same hospital stay due to aggravation of the same clinical complications that precipitated flap loss. Nine patients presented with infections at the surgical site and three of the nine developed orocutaneous fistulae, all of which closed spontaneously. Antibiotic therapy, frequent bandage changes and nasoenteral tube feeding were the treatments used. All but six donor sites were closed primarily. All patients presented paresthesia in the proximal third of the forearm and in the upper arm. Nine patients temporarily presented slight weakness when bending the elbow and extending the wrist and fingers. Other early complications at the donor site were seroma, haematoma and dehiscence. The most frequent complaints relating to the donor site were of hypertrophic scars and ‘dog ears’ on the forearm (Table 6).
Discussion In the head and neck area, functional loss may not be proportional to the size of the defect. Since the brain, the
Free lateral arm flap in head and neck soft tissue reconstruction
175
Figure 2 Four-year-old patient presenting with a nasal-ethmoidal defect. (A) Preoperative view; (B) intraoperative view; (C) dissected LAF; (D) postoperative view.
sensory organs, the face and mimic muscles, upper airways and the beginning of the digestive tract are topographically close, sharing common anatomical structures, small defects can cause severe aesthetic and functional losses or even life-threatening complications. Thus, the skin paddle of the LAF, whose potential dimensions are considered small when compared to other free flaps, may be appropriate for reconstruction of a great
Table 4
Tissue composition of the flap
Flap composition
n
(%)
Skin Skin þ fascia Neurovascular skin Subcutaneous fat tissue Skin þ nerve graft Skin þ triceps muscle
174 18 7 5 3 3
82.8 8.5 3.3 2.3 1.4 1.3
Total
210
100.0
number of small to moderate size head and neck defects.15 The dimensions of the flap may vary significantly16 by including the skin of the proximal third or the subcutaneous tissue and fascia around it. The donor site can often be sutured primarily and the resulting scar may be hidden under a short-sleeve shirt. Individual differences in body fat distribution may change the characteristics of the LAF. Female patients tend to present thicker subcutaneous cellular tissue in the lateral portion of the arm,17,18 which sometimes makes it less advantageous when compared to male patients. In both sexes, meanwhile, as we move from the humeral insertion of the deltoid muscle towards the lateral epicondyle, the subcutaneous tissue becomes progressively thinner. This makes it possible to adjust or gauge the thickness of the flap, modifying its outlining according to the needs of the recipient site. For example, since losses in hemiglossectomies are generally more superficial, we use thinner flaps, outlined on the proximal third of the forearm. In near total glossectomies, tongue volume
176
J.C. Marques Faria et al.
Figure 3
Cheek reconstruction. (A) Preoperative view; (B) subcutaneous LAF; (C) postoperative view; (D) donor sites.
must be restored. In these cases, the flap is outlined more proximally to include more fascia and subcutaneous tissue. The combination of fascia and skin gives the LAF flexibility in the reconstruction of three-dimensional defects of the oral cavity. It allows the flap to be folded to form an acute angle similar to the angle between the tongue and the floor of the mouth. In our procedures the fascia was positioned on the floor of the mouth and the skin of the flap was used to recreate the shape and volume of the tongue. When the fascia was
used, we left an overlying layer of subcutaneous tissue in order to make suturing easier, reducing the possibility of fistulae. The anatomical differences of the course and branching of the posterior radial collateral pedicle already described by other authors19,20 did not compromise its safe dissection. Distinguishing artery and vein, however, is sometimes difficult as we discovered during this study. As a result, we began routinely performing arterial anastomosis with removal of the clamp to confirm the correct selection of the artery and vein.
Free lateral arm flap in head and neck soft tissue reconstruction
Figure 4 tongue.
177
(A) Extended hemiglossectomy; (B) composite myocutaneous LAF; (C) flap being sutured; (D, E) movement of the
The thyroid artery was the preferred choice because it is manipulated less than the facial artery during neck dissection and its calibre is most compatible with the flap artery. The facial artery was generally used for more cranial defects. Sensory loss on the lateral and posterior proximal third of the forearm due to systematic sacrifice of the posterior cutaneous nerve did not lead to severe functional deficits of the respective limb. Although infrequent, clinical complaints related to radial nerve function were temporary and of low intensity. One particularly difficult aspect of using neurovascular skin flaps in the head and neck is choosing the recipient nerve.21e23 Use of the greater auricular nerve may not give the type of sensibility desired, especially for the oral
cavity. The choice of recipient nerves in lip reconstruction is more obvious. In patients submitted to parotidectomy, the posterior cutaneous nerve of the arm may also be used as a vascularised graft to repair the facial nerve, while portions of fascia and subcutaneous tissue are used to fill the preauricular area. A segment of this nerve may also be used to repair the accessory nerve during radical neck dissection. Specific movements can be achieved with the inclusion of the triceps muscle and its respective nerve. Extended hemiglossectomies which include the base of the tongue and other parts of the pharynx may affect the anterosuperior displacement of the larynx and epiglottal closure, resulting in aspiration during swallowing. The fixation of the triceps muscle between the internal face of the
178
J.C. Marques Faria et al.
Figure 5 Innervated cutaneous LAF for partial lip reconstruction. (A) Ulcerated squamous cell carcinoma of the upper lip; (B) surgical defect; (C, D) Late postoperative result.
anterior arch of the mandible and the thyroid cartilage, and its motor nerve sutured to the ipsilateral hypoglossal nerve seems to facilitate the swallowing mechanism. This muscle may also be used to replace mimic muscles while using the skin paddle to re-establish mucosa lining. The results observed in our patients support further clinical studies on the myocutaneous composition of the LAF. Head and neck reconstruction can always bring some degree of functional benefit regardless of the type of flap used, but the clinical rationale must also include the relative morbidity of the donor site. That, in addition to
Table 5
Clinical complications (n Z 210)
Clinical complications
n
(%)
Hypotension e shock Acute pulmonary oedema Acute myocardial infarction Pneumonia Secondary operations Deaths
11 5 2 6 14 2
5.2 2.3 0.9 2.8 6.6 0.9
constant anatomy, quick dissection, versatility in composition and geometrical flexibility, has made the LAF our first choice for immediate microvascular reconstruction of head and neck soft tissue defects, especially those located in the oral cavity.
Table 6
Local complications (n Z 210)
Local complications Recipient site Bleeding Infection Fistula Donor site Dog ear Hypertrophic scar Wrist/elbow weakness Haematoma Seroma Dehiscence Radial nerve lesion
n
(%)
4 9 3
1.90 4.2 1.4
16 14 9 5 3 1 0
7.6 6.6 4.2 2.3 1.4 0.4 0
Free lateral arm flap in head and neck soft tissue reconstruction
References 1. Blackwell KE, Brown MT, Gonzalez D. Overcoming the learning curve in microvascular head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1997;123:1332e5. 2. Hidalgo DA, Disa JJ, Cordeiro PG, et al. A review of 716 consecutive free flaps for oncologic surgical defects: refinement in donor-site selection and technique. Plast Reconstr Surg 1998; 102:722e32. 3. Haughey BH, Wilson E, Kluwe L, et al. Free flap reconstruction of the head and neck: analysis of 241 cases. Otolaryngol Head Neck Surg 2001;125:10e7. 4. Eckardt A, Fokas K. Microsurgical reconstruction in the head and neck region: an 18-year experience with 500 consecutive cases. J Craniomaxillofac Surg 2003;31:197e201. 5. Song R, Song Y, Yu Y, et al. The upper arm free flap. Clin Plast Surg 1982;9:27e35. 6. Wenig BL. The lateral arm free flap for head and neck reconstruction. Otolaryngol Head Neck Surg 1993;109:116e9. 7. Ross DA, Thomson G, Restifo R, et al. The extended lateral arm free flap for head and neck reconstruction: the Yale experience. Laryngoscope 1996;106:14e8. 8. Civantos Jr FJ, Burkey B, Lu FL, et al. Lateral arm microvascular flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1997;123:830e6. 9. Gellrich NC, Kwon TG, Lauer G, et al. The lateral upper arm free flap for intraoral reconstruction. Int J Oral Maxillofac Surg 2000;29:104e11. 10. Reinert S. The free revascularized lateral upper arm flap in maxillofacial reconstruction following ablative tumour surgery. J Craniomaxillofac Surg 2000;28:69e73. 11. Nahabedian MY, Deune EG, Manson PN. Utility of the lateral arm flap in head and neck reconstruction. Ann Plast Surg 2001;46:501e5.
179
12. Chen IC, Lin CY, Yen RS, et al. The extended lateral arm flap in head and neck reconstruction. J Chin Med Assoc 2003;66: 544e50. 13. Rosenthal E, Carrol W, Dobbs M, et al. Simplifying head and neck microvascular reconstruction. Head Neck 2004;26:930e6. 14. Hage JJ, Woerdeman LA, Smeulders MJ. The truly distal lateral arm flap: rationale and risk factors of a microsurgical workhorse in 30 patients. Ann Plast Surg 2005;54:153e9. 15. Karamursel S, Bagdatly D, Markal N, et al. Versatility of the lateral arm free flap in various anatomic defect reconstructions. J Reconstr Microsurg 2005;21:107e12. 16. Kuek LB, Chuan TL. The extended lateral arm flap: a new modification. J Reconstr Microsurg 1991;7:167e73. 17. Graham B, Adkins P, Sheker LR. Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps. J Hand Surg [Br] 1992;17B:189e92. 18. Sieg P, Hakim SG, Bierwolf S, et al. Subcutaneous fat layer in different donor regions used for harvesting microvascular soft tissue flaps in slender and adipose patients. Int J Oral Maxillofac Surg 2003;32:544e7. 19. Fogdestam I, Tarnow P, Kalaaji A. Extended free lateral arm flap with preservation of the posterior cutaneous nerve of the forearm. Scand J Plast Reconstr Hand Surg 1996;30:49e55. 20. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 1984;12:489e500. 21. Boyd B, Mulholland S, Gullane P, et al. Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense? Plast Reconstr Surg 1994;93:1350e9. 22. Urken ML. Advances in head and neck reconstruction. Laryngoscope 2003;113:1473e6. 23. Aviv JE, Mohr JP, Blitzer A, et al. Restoration of laryngopharyngeal sensation by neural anastomosis. Arch Otolaryngol Head Neck Surg 1997;123:154e60.
The versatility of the free lateral arm flap in head and neck soft tissue reconstruction: clinical experience of 210 cases ˆnica Lucia Rodrigues a, Jose Carlos Marques Faria a,c,d,*, Mo Gean Paulo Scopel c, Luiz Paulo Kowalski b, Marcus Castro Ferreira c a
Microsurgery Surgery Division, Hospital do Cancer A C Camargo, Sao Paulo, Brazil Head and Neck Surgery and Otorhinolaryngology Department, Hospital do Cancer A C Camargo, Sao Paulo, Brazil c Plastic Surgery Division, Hospital das Clinicas, Sao Paulo, Brazil d Plastic Surgery Division, Hospital PUC Campinas, Brazil b
Received 9 November 2006; accepted 16 October 2007
KEYWORDS Lateral arm; Free flap; Head and neck; Reconstruction
Summary A study of the authors’ experience with 210 free lateral arm flaps used to repair head and neck oncological defects over an 8-year period. Patients’ ages ranged from 4 to 83 years (average: 49.7 years). One hundred and forty-one were male and 66 female. Three patients received two consecutive flaps each. They were used to reconstruct: the tongue, 53 cases; retromolar trigone, 42 cases; soft/hard palate, 34 cases; skin/facial contour, 19 cases; hypopharynx, 17 cases; buccal mucosa, 12 cases; lips, five cases. Flap cutaneous dimensions ranged from 4 2 cm to 17 8 cm. Flap was composed of: skin and fascia, 18 cases; sensate (neurovascular) skin, six cases; subcutaneous fat tissue, five cases; skin and vascularised nerve graft, three cases, skin and partial triceps muscle, three cases. Nerve coaptations were performed for all lip reconstructions. All flaps survived except for nine (success rate: 95.2%). Severe postoperative clinical complications preceded flap failure and death in two cases. All but six donor sites were closed primarily. Complications related to the donor site were: paresthesia of the forearm, 210 cases; dog ear, 16 cases; hypertropic scar, 14 cases; weakness, nine cases; haematoma, five cases; seroma, three cases; dehiscence, one case. Radial nerve injury was not observed in this series. The lateral arm flap can be considered safe and versatile for most soft tissue head and neck microsurgical reconstructions. The possibility of sensory recovery through neural anastomoses and low donor site morbidity enhances its efficiency. ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Rua Maestro Cardim, 377 Cjs 85/86 01323-000 Sao Paulo, Brazil. E-mail address: [email protected] (J.C. Marques Faria).
Selection of a free flap to repair tissue loss resulting from head and neck surgery is based on factors related to the flap, the defect, the patient and the surgeon’s experience.1e4
1748-6815/$ - see front matter ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.10.035
Free lateral arm flap in head and neck soft tissue reconstruction Because of the many aspects to be considered, strict rules that always define one type of flap for a specific defect cannot be established. In 1982, Song5 introduced the lateral arm flap (LAF). Since then, its use in head and neck surgical repairs has been the specific subject of publications generally restricted to a small number of cases.6e12 Factors such as a smaller skin paddle and shorter vascular pedicle with smaller calibre may explain why this flap is less popular than the free radial forearm flap (RFF).13 There are, however, favourable reasons for using the free LAF.14 The purpose of this study is to report the experience of 210 consecutive free LAFs used to repair head and neck defects resulting from oncological surgical treatments over an 8-year period.
Patients and methods From 1999 to 2006, our team performed a total of 661 microsurgical flaps to repair soft tissue defects after head and neck tumour resection in patients treated in three institutions: Hospital do Cancer, A.C. Camargo, Hospital das Clinicas, University of Sao Paulo and University Hospital, PUC Campinas, Brazil. Of these, 210 were LAFs. The main indications for using the LAF in this clinical series were: oncological defect and recipient vessels located on the same side of the medial line and the possibility of primary closure of the donor site. Three patients received two LAFs. Of the 207 patients, 141 were male and 66 were female. Their ages varied from 4 to 83 years (mean: 49.7 years). The tumour site, histological type and size are shown in Table 1. The majority of the flaps (90.9%) were used to reconstruct defects of the oral cavity. The flap dissection technique was basically the same in all cases with slight differences, depending on anatomical variations or the needs of the recipient site. A line was drawn from the insertion of the deltoid passing over the lateral epicondyle towards the forearm with the elbow flexed 45 . The flap was outlined centred on this line, which coincides with the course of the posterior radial collateral vessels. Elevation of the flap began with posterior incision which passed through the deep fascia. The ramifying branches to the triceps muscle were ligated and divided. The anterior border incision was made again in a subfascial plane dissecting over the surface of brachioradialis and brachialis muscles. Passing between theses muscles, the anterior radial collateral artery along the radial nerve was identified, ligated and divided. The posterior cutaneous nerve of the arm and the posterior cutaneous nerve of the forearm accompanying the posterior radial collateral artery were also identified. The neurovascular pedicle was then dissected proximally by dividing the lateral head of the triceps muscle up to the profunda brachii artery. The vascular and nerve branches to the lateral head of the triceps muscle identified in the posterior region of the pedicle were preserved during dissection of the composite myocutaneous flap. One hundred and seventy-nine (85.2%) flaps were transplanted immediately after oncological surgery. In 31 cases (24.8%), microsurgical reconstruction was performed
Table 1
173 Site, histological type and tumour size (n Z 210)
Variable
n
%
Site Tongue Hemiglossectomy Near total glossectomy Extended glossectomy Total glossectomy Retromolar trigone/tonsil Hard/soft palate Floor of the mouth Skin/facial contour Hypopharynx Inner cheek Lower lip Upper lip Parotid
53 31 16 6 0 42 34 28 17 17 12 3 2 2
25.2 14.7 7.6 2.8 0 20.0 16.1 13.3 8.1 8.1 5.7 1.4 0.9 0.9
Histological type Squamous cell carcinoma Basal cell carcinoma Adenoid cystic carcinoma Sarcoma Other malignant tumours
166 16 14 5 9
79.0 7.6 6.6 2.3 4.2
7 55 90 58
3.3 26.2 42.8 27.6
Tumour size <1 cm 1e2 cm 2e4 cm >4 cm
between 2 days and 30 months (mean: 14.7 months) after tumour resection and indicated to treat sequelae or complications from prior treatments (Table 2).
Results The length and width of the flaps were between 4 2 and 17 8 cm. In 201 cases (95.7%), skin from the proximal third of the forearm was included, with the most distal portion taken 9 cm below the lateral epicondyle (Fig. 1). The majority of the flaps were taken from the left arm (185 cases, 88%), irrespective of which side the defect was
Table 2
Indications for delayed or late reconstruction
Site
No. of cases
Palate (oronasal fistula) Orbit (ocular exenteration) Partial necrosis of the local facial flap Oro or nasocutaneous fistula Contouring (facial depressions) Scar adherence of the tongue and floor of the mouth Microsurgical flap loss
13 5 4 3 3 2
Total
31
1
174
J.C. Marques Faria et al.
Figure 1
Outline of the extended lateral arm flap.
on, considering that the upper right limb is dominant in most individuals. The right arm was used in 25 cases (12%) due to the dominance of the upper left limb, operating room logistics or previous surgery on the left arm. Anatomical variations of the vascular and nerve pedicles were observed during flap dissection. Eight patients presented duplication of the posterior radial collateral artery. In 23 patients, the posterior cutaneous nerve of the arm ran intramuscularly through the lateral head of the triceps. Cutaneous flap dissection time varied from 25 to 40 min, which was prolonged by approximately 15 min when part of the triceps muscle was incorporated. In all cases, the skin flap was sutured to the defect before microvascular anastomoses were performed. Table 3 shows the recipient arteries used in the reconstructions. In 183 (87.1%) cases, only one venous anastomosis was performed, and two were performed in 27 (12.9%) cases. In two patients, the artery and vein of the flap were very similar in calibre and wall thickness. Because of the difficulty in differentiating the two, the artery of the flap was sutured to the recipient vein, which was quickly identified when the clamp was removed. The anastomoses were then redone without compromising the final result. Total ischaemia time never exceeded 2 h. Although, in the majority of the patients, the LAF was used to repair cutaneous (Fig. 2) and mucosal lining, other combinations were also used (Table 4). The final result of
Table 3
Recipient arteries
Recipient Artery
Number of Cases
Upper Tyroidea Facial Temporal External Carotid Lingual Common Carotid
107 89 7 4 2 1
Total
210
% 50.9 42.3 3.33 1.9 0.95 0.47 100
a patient who underwent two free LAFs, to reconstruct an oral cavity defect and to restore cheek volume, and the respective donor sites, are shown in Fig. 3. In the defects involving the tongue and floor of the mouth, the skin of the flap was positioned to repair tongue loss and its fascia was placed on the floor of the mouth and left to naturally develop oral mucosa epithelium within a few weeks. A composite flap, skin and a portion of the triceps muscle were used in three patients (Fig. 4). Two of these patients underwent extended hemiglossectomies. The resulting defect included the base of the tongue and other parts of the pharynx. In these cases, the muscle was inserted to elevate the larynx. The respective nerve branch was sutured to the hypoglossal nerve ipsilateral to the glossectomy. In another patient, the zygomatic major and minor muscles had to be sacrificed in the resection of a sarcoma of the cheek. The motor nerve of the triceps in this case was sutured to the buccal branch of the facial nerve and the skin of the same flap was used to repair the lining of the mouth. The long-term static and dynamic balances were considered satisfactory in this patient. None of the patients complained about the strength or range of movement of the respective limb. The posterior cutaneous nerve of the arm was sutured to the infraorbital nerve in the upper lip reconstructions (three cases), to the mental nerve in the lower lip reconstructions (two cases) and to the greater auricular nerve during inner cheek reconstruction (one case). Fig. 5 shows a case of innervated upper lip reconstruction. Hospitalisation varied from 2 to 95 days (mean: 6 days). The most significant clinical complications are shown in Table 5. No partial flap loss was observed. There were nine (4.2%) cases of total flap loss as a result of vascular thrombosis; five arterial and four venous. Of these patients, eight underwent secondary surgery to remove necrotic tissue and one presented clinical conditions so critical that secondary operation was not possible. In one of the eight patients, submitted to palate reconstruction, the defect was left open and, in the remaining seven, the defects were closed with: local flaps, five cases; pectoralis flap, one case; and a second free LAF, one case. Two patients died in the same hospital stay due to aggravation of the same clinical complications that precipitated flap loss. Nine patients presented with infections at the surgical site and three of the nine developed orocutaneous fistulae, all of which closed spontaneously. Antibiotic therapy, frequent bandage changes and nasoenteral tube feeding were the treatments used. All but six donor sites were closed primarily. All patients presented paresthesia in the proximal third of the forearm and in the upper arm. Nine patients temporarily presented slight weakness when bending the elbow and extending the wrist and fingers. Other early complications at the donor site were seroma, haematoma and dehiscence. The most frequent complaints relating to the donor site were of hypertrophic scars and ‘dog ears’ on the forearm (Table 6).
Discussion In the head and neck area, functional loss may not be proportional to the size of the defect. Since the brain, the
Free lateral arm flap in head and neck soft tissue reconstruction
175
Figure 2 Four-year-old patient presenting with a nasal-ethmoidal defect. (A) Preoperative view; (B) intraoperative view; (C) dissected LAF; (D) postoperative view.
sensory organs, the face and mimic muscles, upper airways and the beginning of the digestive tract are topographically close, sharing common anatomical structures, small defects can cause severe aesthetic and functional losses or even life-threatening complications. Thus, the skin paddle of the LAF, whose potential dimensions are considered small when compared to other free flaps, may be appropriate for reconstruction of a great
Table 4
Tissue composition of the flap
Flap composition
n
(%)
Skin Skin þ fascia Neurovascular skin Subcutaneous fat tissue Skin þ nerve graft Skin þ triceps muscle
174 18 7 5 3 3
82.8 8.5 3.3 2.3 1.4 1.3
Total
210
100.0
number of small to moderate size head and neck defects.15 The dimensions of the flap may vary significantly16 by including the skin of the proximal third or the subcutaneous tissue and fascia around it. The donor site can often be sutured primarily and the resulting scar may be hidden under a short-sleeve shirt. Individual differences in body fat distribution may change the characteristics of the LAF. Female patients tend to present thicker subcutaneous cellular tissue in the lateral portion of the arm,17,18 which sometimes makes it less advantageous when compared to male patients. In both sexes, meanwhile, as we move from the humeral insertion of the deltoid muscle towards the lateral epicondyle, the subcutaneous tissue becomes progressively thinner. This makes it possible to adjust or gauge the thickness of the flap, modifying its outlining according to the needs of the recipient site. For example, since losses in hemiglossectomies are generally more superficial, we use thinner flaps, outlined on the proximal third of the forearm. In near total glossectomies, tongue volume
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Figure 3
Cheek reconstruction. (A) Preoperative view; (B) subcutaneous LAF; (C) postoperative view; (D) donor sites.
must be restored. In these cases, the flap is outlined more proximally to include more fascia and subcutaneous tissue. The combination of fascia and skin gives the LAF flexibility in the reconstruction of three-dimensional defects of the oral cavity. It allows the flap to be folded to form an acute angle similar to the angle between the tongue and the floor of the mouth. In our procedures the fascia was positioned on the floor of the mouth and the skin of the flap was used to recreate the shape and volume of the tongue. When the fascia was
used, we left an overlying layer of subcutaneous tissue in order to make suturing easier, reducing the possibility of fistulae. The anatomical differences of the course and branching of the posterior radial collateral pedicle already described by other authors19,20 did not compromise its safe dissection. Distinguishing artery and vein, however, is sometimes difficult as we discovered during this study. As a result, we began routinely performing arterial anastomosis with removal of the clamp to confirm the correct selection of the artery and vein.
Free lateral arm flap in head and neck soft tissue reconstruction
Figure 4 tongue.
177
(A) Extended hemiglossectomy; (B) composite myocutaneous LAF; (C) flap being sutured; (D, E) movement of the
The thyroid artery was the preferred choice because it is manipulated less than the facial artery during neck dissection and its calibre is most compatible with the flap artery. The facial artery was generally used for more cranial defects. Sensory loss on the lateral and posterior proximal third of the forearm due to systematic sacrifice of the posterior cutaneous nerve did not lead to severe functional deficits of the respective limb. Although infrequent, clinical complaints related to radial nerve function were temporary and of low intensity. One particularly difficult aspect of using neurovascular skin flaps in the head and neck is choosing the recipient nerve.21e23 Use of the greater auricular nerve may not give the type of sensibility desired, especially for the oral
cavity. The choice of recipient nerves in lip reconstruction is more obvious. In patients submitted to parotidectomy, the posterior cutaneous nerve of the arm may also be used as a vascularised graft to repair the facial nerve, while portions of fascia and subcutaneous tissue are used to fill the preauricular area. A segment of this nerve may also be used to repair the accessory nerve during radical neck dissection. Specific movements can be achieved with the inclusion of the triceps muscle and its respective nerve. Extended hemiglossectomies which include the base of the tongue and other parts of the pharynx may affect the anterosuperior displacement of the larynx and epiglottal closure, resulting in aspiration during swallowing. The fixation of the triceps muscle between the internal face of the
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Figure 5 Innervated cutaneous LAF for partial lip reconstruction. (A) Ulcerated squamous cell carcinoma of the upper lip; (B) surgical defect; (C, D) Late postoperative result.
anterior arch of the mandible and the thyroid cartilage, and its motor nerve sutured to the ipsilateral hypoglossal nerve seems to facilitate the swallowing mechanism. This muscle may also be used to replace mimic muscles while using the skin paddle to re-establish mucosa lining. The results observed in our patients support further clinical studies on the myocutaneous composition of the LAF. Head and neck reconstruction can always bring some degree of functional benefit regardless of the type of flap used, but the clinical rationale must also include the relative morbidity of the donor site. That, in addition to
Table 5
Clinical complications (n Z 210)
Clinical complications
n
(%)
Hypotension e shock Acute pulmonary oedema Acute myocardial infarction Pneumonia Secondary operations Deaths
11 5 2 6 14 2
5.2 2.3 0.9 2.8 6.6 0.9
constant anatomy, quick dissection, versatility in composition and geometrical flexibility, has made the LAF our first choice for immediate microvascular reconstruction of head and neck soft tissue defects, especially those located in the oral cavity.
Table 6
Local complications (n Z 210)
Local complications Recipient site Bleeding Infection Fistula Donor site Dog ear Hypertrophic scar Wrist/elbow weakness Haematoma Seroma Dehiscence Radial nerve lesion
n
(%)
4 9 3
1.90 4.2 1.4
16 14 9 5 3 1 0
7.6 6.6 4.2 2.3 1.4 0.4 0
Free lateral arm flap in head and neck soft tissue reconstruction
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12. Chen IC, Lin CY, Yen RS, et al. The extended lateral arm flap in head and neck reconstruction. J Chin Med Assoc 2003;66: 544e50. 13. Rosenthal E, Carrol W, Dobbs M, et al. Simplifying head and neck microvascular reconstruction. Head Neck 2004;26:930e6. 14. Hage JJ, Woerdeman LA, Smeulders MJ. The truly distal lateral arm flap: rationale and risk factors of a microsurgical workhorse in 30 patients. Ann Plast Surg 2005;54:153e9. 15. Karamursel S, Bagdatly D, Markal N, et al. Versatility of the lateral arm free flap in various anatomic defect reconstructions. J Reconstr Microsurg 2005;21:107e12. 16. Kuek LB, Chuan TL. The extended lateral arm flap: a new modification. J Reconstr Microsurg 1991;7:167e73. 17. Graham B, Adkins P, Sheker LR. Complications and morbidity of the donor and recipient sites in 123 lateral arm flaps. J Hand Surg [Br] 1992;17B:189e92. 18. Sieg P, Hakim SG, Bierwolf S, et al. Subcutaneous fat layer in different donor regions used for harvesting microvascular soft tissue flaps in slender and adipose patients. Int J Oral Maxillofac Surg 2003;32:544e7. 19. Fogdestam I, Tarnow P, Kalaaji A. Extended free lateral arm flap with preservation of the posterior cutaneous nerve of the forearm. Scand J Plast Reconstr Hand Surg 1996;30:49e55. 20. Katsaros J, Schusterman M, Beppu M, et al. The lateral upper arm flap: anatomy and clinical applications. Ann Plast Surg 1984;12:489e500. 21. Boyd B, Mulholland S, Gullane P, et al. Reinnervated lateral antebrachial cutaneous neurosome flaps in oral reconstruction: are we making sense? Plast Reconstr Surg 1994;93:1350e9. 22. Urken ML. Advances in head and neck reconstruction. Laryngoscope 2003;113:1473e6. 23. Aviv JE, Mohr JP, Blitzer A, et al. Restoration of laryngopharyngeal sensation by neural anastomosis. Arch Otolaryngol Head Neck Surg 1997;123:154e60.