- Email: [email protected]
Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects
ARTICLE IN PRESS
YBJOM-4476; No. of Pages 3
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Short communication
Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects R.J. Shaw a,b,∗ , M.W. Ho c , J.S. Brown a a b c
Regional Maxillofacial Unit, Aintree University Hospital, Liverpool, UK Department of Molecular and Clinical Cancer Medicine, University of Liverpool, UK Head and Neck Centre, University College Hospital, London, UKd
Accepted 17 October 2014
Abstract The reconstruction of oromandibular defects associated with extensive loss of external skin is surgically challenging. We describe 2 cases where such defects were reconstructed with a chimeric thoracodorsal artery perforator and scapular (TDAP-Scap) free flap based on the subscapular system. The flap is a reliable option in the reconstruction of through-and-through oromandibular defects. © 2015 Published by Elsevier Ltd. on behalf of The British Association of Oral and Maxillofacial Surgeons.
Keywords: Mandibular reconstruction; Chimeric flap; Perforator free flap; Scapular flap; Thoracodorsal flap
Introduction We have previously published a series of 46 oral and maxillofacial reconstructions using scapular and parascapular composite flaps based on the circumflex scapular artery.1 This versatile flap allows 2 independent skin paddles to be raised, and enables intraoral and extraoral soft tissue defects to be reconstructed with one flap. Occasionally, when a large oromandibular defect is associated with extensive loss of facial skin, the versatility of the subscapular vascular pedicle can be exploited by combining the circumflex scapular and thoracodorsal arteries to raise a combined scapular and latissimus dorsi flap. This was first described by Granick et al. in 19862
∗ Corresponding author at: Department of Molecular and Clinical Cancer Medicine, University of Liverpool, UK. E-mail address: [email protected] (R.J. Shaw). d Formerly of Regional Maxillofacial Unit, Aintree University Hospital, Liverpool, UK.
and subsequently by Aviv et al. in 1991.3 In 1995, Angrigiani et al. described the thoracodorsal artery perforator (TDAP) flap,4 which largely avoids morbidity to the latissimus dorsi muscle and enables a much thinner flap to be raised when bulk is not required. It has been reported as a soft tissue flap in various reconstructions in the head and neck,5,6 and is particularly suited to defects in the forehead and scalp that need modest bulk and a long pedicle. We describe a logical evolution of chimeric flaps using the subscapular vessels. We combine the reliable composite scapular flap (circumflex scapular artery) with the TDAP flap, and suggest the name TDAP-Scap. We do not highlight the anatomical basis or details of the surgical method as they are well described elsewhere.2–4,6 Case 1 A 61-year-old manual worker presented with a T4aN0M0 squamous cell carcinoma (SCC) in the anterior floor of the
http://dx.doi.org/10.1016/j.bjoms.2014.10.018 0266-4356/© 2015 Published by Elsevier Ltd. on behalf of The British Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Shaw RJ, et al. Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2014.10.018
YBJOM-4476; No. of Pages 3
2
ARTICLE IN PRESS R.J. Shaw et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Fig. 1. Preoperative photograph of case 2 showing extent of cutaneous involvement by the right mandibular squamous cell carcinoma.
mouth that involved the anterior tongue, anterior mandible, lower lip, and chin. After resection, the moderately sized intraoral defect was reconstructed effectively with a 5 × 7 cm skin paddle and the mandible with a 10 cm scapula bone flap, but this left a large (10 × 12 cm) extraoral defect at the limits of what might be achieved with a parascapular flap. The raising of a TDAP-Scap flap enabled the defect to be reconstructed with a combined perforator and unilateral Karapandzic rotation flap. Ipsilateral recipient vessels provided a single pair of anastomoses and healing progressed uneventfully. The patient remains well after 4 years’ followup.
Case 2 A 63-year-old doctor presented with a large T4aN0M0 SCC that involved an extensive component of facial skin (Fig. 1). It had arisen from a previously treated keratocystic odontogenic tumour in the right body of the mandible. As in case 1, the moderate intraoral defect was reconstructed with the soft tissue component of the scapular flap, but the 8 × 12 cm extraoral defect was reconstructed with the TDAP flap. There were no complications (Figs. 2 and 3).
Fig. 2. Harvested chimeric thoracodorsal artery perforator and scapular (TDAP-Scap) flap, the long perforator of the TDAP cutaneous paddle gives the flexibility to accommodate the needs of complex oromandibular defects.
as the TDAP, and only one skin paddle is generally available. The composite subscapular flap could provide 2 cutaneous paddles when both the scapular and parascapular vessels are included, but it does not provide as much flexibility in design and inset as the TDAP-Scap. Another alternative is to use 2 free flaps, but our audit showed that it was associated with a significantly higher rate of failure.9 The limitations of the TDAP-Scap are similar to any other combination of subscapular artery flaps; specifically, the additional time taken to turn the patient and the relatively short pedicle involved when the circumflex scapular vessel is used. Several authors have described raising scapular and TDAP flaps in the supine position to allow harvest at the same time as ablative surgery.6 To reliably reach neck vessels from the midface, a complex technique has been described for combined latissimus dorsi and scapular flaps. The circumflex scapular vessels are divided and re-anastomosed to the branch to the serratus anterior muscle, which effectively
Discussion These cases highlight the benefits of the TDAP-Scap chimeric flap. Although a number of other reconstructive options are available for such defects, it provides abundant tissue volume, flexibility of design, and large vessels, and also avoids excessive donor site morbidity. In these cases the fibular flap does not offer adequate soft tissue skin. Whilst the deep circumflex iliac artery (DCIA) perforator flap, has been described in the mandible7 and maxilla,8 and has an unparalleled combination of bony volume and a skin paddle, the anatomy of the perforator can be unpredictable; it does not permit as much mobility
Fig. 3. Clinical photographs of patient in case 2 after operation showing good restoration of facial contour and cutaneous thoracodorsal artery perforator (TDAP) component of the chimeric TDAP and scapular free flap (TDAPScap) (published with the patient’s consent).
Please cite this article in press as: Shaw RJ, et al. Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2014.10.018
ARTICLE IN PRESS
YBJOM-4476; No. of Pages 3
R.J. Shaw et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
lengthens the pedicle.10 Dissection of the perforators of the TDAP-Scap chimeric flap can be technically demanding (in comparison with perforators of the anterolateral thigh) but reliability has been excellent, particularly when at least 2 perforators have been dissected.11 The TDAP-Scap flap can be used to reconstruct large defects in the facial skin that are associated with oromandibular resections. Simultaneous use of the latissimus dorsi muscle and the TDAP flap,12 or additional independent bony islands including the tip of the scapula13 based on the angular branch, may further extend its range of applications.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient permission Patients’ consent obtained.
References 1. Brown J, Bekiroglu F, Shaw R. Indications for the scapular flap in reconstructions of the head and neck. Br J Oral Maxillofac Surg 2010;48:331–7. 2. Granick MS, Newton ED, Hanna DC. Scapular free flap for repair of massive lower facial composite defects. Head Neck Surg 1986;8:436–41.
3
3. Aviv JE, Urken ML, Vickery C, et al. The combined latissimus dorsiscapular free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1991;117:1242–50. 4. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995;96:1608–14. 5. Guerra AB, Lyons GD, Dupin CL, et al. Advantages of perforator flaps in reconstruction of complex defects of the head and neck. Ear Nose Throat J 2005;84:441–7. 6. Bach CA, Wagner I, Lachiver X, et al. The free thoracodorsal artery perforator flap in head and neck reconstruction. Eur Ann Otorhinolaryngol Head Neck Dis 2012;129:167–71. 7. Kimata Y, Uchiyama K, Sakuraba M, et al. Deep circumflex iliac perforator flap with iliac crest for mandibular reconstruction. Br J Plast Surg 2001;54:487–90. 8. Shaw RJ, Brown JS. Osteomyocutaneous deep circumflex iliac artery perforator flap in the reconstruction of midface defect with facial skin loss: a case report. Microsurgery 2009;29:299–302. 9. Ho MW, Brown JS, Magennis P, et al. Salvage outcomes of free tissue transfer in Liverpool: trends over 18 years (1992–2009). Br J Oral Maxillofac Surg 2012;50:13–8. 10. Watanabe K, Takahashi N, Morihisa Y, et al. Maxillary reconstruction using chimeric flaps of the subscapular artery system without vein grafts and the novel usage of chimeric flaps. J Reconstr Microsurg 2013;29:601–6. 11. Karaaltin MV, Erdem A, Kuvat S, et al. Comparison of clinical outcomes between single- and multiple-perforator-based free thoracodorsal artery perforator flaps: clinical experience in 87 patients. Plast Reconstr Surg 2011;128:158e–65e. 12. Mun GH, Lim SY, Hyon WS, et al. A novel reconstruction of 2 distinct defects: concomitant use of a thoracodorsal artery perforator flap and its corresponding muscle flap. Ann Plast Surg 2005;55: 676–8. 13. L’Heureux-Lebeau B, Odobescu A, Harris PG, et al. Chimaeric subscapular system free flap for complex oro-facial defects. J Plast Reconstr Aesthet Surg 2013;66:900–5.
Please cite this article in press as: Shaw RJ, et al. Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2014.10.018
YBJOM-4476; No. of Pages 3
Available online at www.sciencedirect.com
British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Short communication
Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects R.J. Shaw a,b,∗ , M.W. Ho c , J.S. Brown a a b c
Regional Maxillofacial Unit, Aintree University Hospital, Liverpool, UK Department of Molecular and Clinical Cancer Medicine, University of Liverpool, UK Head and Neck Centre, University College Hospital, London, UKd
Accepted 17 October 2014
Abstract The reconstruction of oromandibular defects associated with extensive loss of external skin is surgically challenging. We describe 2 cases where such defects were reconstructed with a chimeric thoracodorsal artery perforator and scapular (TDAP-Scap) free flap based on the subscapular system. The flap is a reliable option in the reconstruction of through-and-through oromandibular defects. © 2015 Published by Elsevier Ltd. on behalf of The British Association of Oral and Maxillofacial Surgeons.
Keywords: Mandibular reconstruction; Chimeric flap; Perforator free flap; Scapular flap; Thoracodorsal flap
Introduction We have previously published a series of 46 oral and maxillofacial reconstructions using scapular and parascapular composite flaps based on the circumflex scapular artery.1 This versatile flap allows 2 independent skin paddles to be raised, and enables intraoral and extraoral soft tissue defects to be reconstructed with one flap. Occasionally, when a large oromandibular defect is associated with extensive loss of facial skin, the versatility of the subscapular vascular pedicle can be exploited by combining the circumflex scapular and thoracodorsal arteries to raise a combined scapular and latissimus dorsi flap. This was first described by Granick et al. in 19862
∗ Corresponding author at: Department of Molecular and Clinical Cancer Medicine, University of Liverpool, UK. E-mail address: [email protected] (R.J. Shaw). d Formerly of Regional Maxillofacial Unit, Aintree University Hospital, Liverpool, UK.
and subsequently by Aviv et al. in 1991.3 In 1995, Angrigiani et al. described the thoracodorsal artery perforator (TDAP) flap,4 which largely avoids morbidity to the latissimus dorsi muscle and enables a much thinner flap to be raised when bulk is not required. It has been reported as a soft tissue flap in various reconstructions in the head and neck,5,6 and is particularly suited to defects in the forehead and scalp that need modest bulk and a long pedicle. We describe a logical evolution of chimeric flaps using the subscapular vessels. We combine the reliable composite scapular flap (circumflex scapular artery) with the TDAP flap, and suggest the name TDAP-Scap. We do not highlight the anatomical basis or details of the surgical method as they are well described elsewhere.2–4,6 Case 1 A 61-year-old manual worker presented with a T4aN0M0 squamous cell carcinoma (SCC) in the anterior floor of the
http://dx.doi.org/10.1016/j.bjoms.2014.10.018 0266-4356/© 2015 Published by Elsevier Ltd. on behalf of The British Association of Oral and Maxillofacial Surgeons.
Please cite this article in press as: Shaw RJ, et al. Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2014.10.018
YBJOM-4476; No. of Pages 3
2
ARTICLE IN PRESS R.J. Shaw et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
Fig. 1. Preoperative photograph of case 2 showing extent of cutaneous involvement by the right mandibular squamous cell carcinoma.
mouth that involved the anterior tongue, anterior mandible, lower lip, and chin. After resection, the moderately sized intraoral defect was reconstructed effectively with a 5 × 7 cm skin paddle and the mandible with a 10 cm scapula bone flap, but this left a large (10 × 12 cm) extraoral defect at the limits of what might be achieved with a parascapular flap. The raising of a TDAP-Scap flap enabled the defect to be reconstructed with a combined perforator and unilateral Karapandzic rotation flap. Ipsilateral recipient vessels provided a single pair of anastomoses and healing progressed uneventfully. The patient remains well after 4 years’ followup.
Case 2 A 63-year-old doctor presented with a large T4aN0M0 SCC that involved an extensive component of facial skin (Fig. 1). It had arisen from a previously treated keratocystic odontogenic tumour in the right body of the mandible. As in case 1, the moderate intraoral defect was reconstructed with the soft tissue component of the scapular flap, but the 8 × 12 cm extraoral defect was reconstructed with the TDAP flap. There were no complications (Figs. 2 and 3).
Fig. 2. Harvested chimeric thoracodorsal artery perforator and scapular (TDAP-Scap) flap, the long perforator of the TDAP cutaneous paddle gives the flexibility to accommodate the needs of complex oromandibular defects.
as the TDAP, and only one skin paddle is generally available. The composite subscapular flap could provide 2 cutaneous paddles when both the scapular and parascapular vessels are included, but it does not provide as much flexibility in design and inset as the TDAP-Scap. Another alternative is to use 2 free flaps, but our audit showed that it was associated with a significantly higher rate of failure.9 The limitations of the TDAP-Scap are similar to any other combination of subscapular artery flaps; specifically, the additional time taken to turn the patient and the relatively short pedicle involved when the circumflex scapular vessel is used. Several authors have described raising scapular and TDAP flaps in the supine position to allow harvest at the same time as ablative surgery.6 To reliably reach neck vessels from the midface, a complex technique has been described for combined latissimus dorsi and scapular flaps. The circumflex scapular vessels are divided and re-anastomosed to the branch to the serratus anterior muscle, which effectively
Discussion These cases highlight the benefits of the TDAP-Scap chimeric flap. Although a number of other reconstructive options are available for such defects, it provides abundant tissue volume, flexibility of design, and large vessels, and also avoids excessive donor site morbidity. In these cases the fibular flap does not offer adequate soft tissue skin. Whilst the deep circumflex iliac artery (DCIA) perforator flap, has been described in the mandible7 and maxilla,8 and has an unparalleled combination of bony volume and a skin paddle, the anatomy of the perforator can be unpredictable; it does not permit as much mobility
Fig. 3. Clinical photographs of patient in case 2 after operation showing good restoration of facial contour and cutaneous thoracodorsal artery perforator (TDAP) component of the chimeric TDAP and scapular free flap (TDAPScap) (published with the patient’s consent).
Please cite this article in press as: Shaw RJ, et al. Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2014.10.018
ARTICLE IN PRESS
YBJOM-4476; No. of Pages 3
R.J. Shaw et al. / British Journal of Oral and Maxillofacial Surgery xxx (2015) xxx–xxx
lengthens the pedicle.10 Dissection of the perforators of the TDAP-Scap chimeric flap can be technically demanding (in comparison with perforators of the anterolateral thigh) but reliability has been excellent, particularly when at least 2 perforators have been dissected.11 The TDAP-Scap flap can be used to reconstruct large defects in the facial skin that are associated with oromandibular resections. Simultaneous use of the latissimus dorsi muscle and the TDAP flap,12 or additional independent bony islands including the tip of the scapula13 based on the angular branch, may further extend its range of applications.
Conflict of interest We have no conflicts of interest.
Ethics statement/confirmation of patient permission Patients’ consent obtained.
References 1. Brown J, Bekiroglu F, Shaw R. Indications for the scapular flap in reconstructions of the head and neck. Br J Oral Maxillofac Surg 2010;48:331–7. 2. Granick MS, Newton ED, Hanna DC. Scapular free flap for repair of massive lower facial composite defects. Head Neck Surg 1986;8:436–41.
3
3. Aviv JE, Urken ML, Vickery C, et al. The combined latissimus dorsiscapular free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 1991;117:1242–50. 4. Angrigiani C, Grilli D, Siebert J. Latissimus dorsi musculocutaneous flap without muscle. Plast Reconstr Surg 1995;96:1608–14. 5. Guerra AB, Lyons GD, Dupin CL, et al. Advantages of perforator flaps in reconstruction of complex defects of the head and neck. Ear Nose Throat J 2005;84:441–7. 6. Bach CA, Wagner I, Lachiver X, et al. The free thoracodorsal artery perforator flap in head and neck reconstruction. Eur Ann Otorhinolaryngol Head Neck Dis 2012;129:167–71. 7. Kimata Y, Uchiyama K, Sakuraba M, et al. Deep circumflex iliac perforator flap with iliac crest for mandibular reconstruction. Br J Plast Surg 2001;54:487–90. 8. Shaw RJ, Brown JS. Osteomyocutaneous deep circumflex iliac artery perforator flap in the reconstruction of midface defect with facial skin loss: a case report. Microsurgery 2009;29:299–302. 9. Ho MW, Brown JS, Magennis P, et al. Salvage outcomes of free tissue transfer in Liverpool: trends over 18 years (1992–2009). Br J Oral Maxillofac Surg 2012;50:13–8. 10. Watanabe K, Takahashi N, Morihisa Y, et al. Maxillary reconstruction using chimeric flaps of the subscapular artery system without vein grafts and the novel usage of chimeric flaps. J Reconstr Microsurg 2013;29:601–6. 11. Karaaltin MV, Erdem A, Kuvat S, et al. Comparison of clinical outcomes between single- and multiple-perforator-based free thoracodorsal artery perforator flaps: clinical experience in 87 patients. Plast Reconstr Surg 2011;128:158e–65e. 12. Mun GH, Lim SY, Hyon WS, et al. A novel reconstruction of 2 distinct defects: concomitant use of a thoracodorsal artery perforator flap and its corresponding muscle flap. Ann Plast Surg 2005;55: 676–8. 13. L’Heureux-Lebeau B, Odobescu A, Harris PG, et al. Chimaeric subscapular system free flap for complex oro-facial defects. J Plast Reconstr Aesthet Surg 2013;66:900–5.
Please cite this article in press as: Shaw RJ, et al. Thoracodorsal artery perforator – scapular flap in oromandibular reconstruction with associated large facial skin defects. Br J Oral Maxillofac Surg (2015), http://dx.doi.org/10.1016/j.bjoms.2014.10.018