British Journal of Oral and Maxillofacial Surgery (1990) 28,2 0

1990 The British

Association

of Oral and Maxillofscial

Su

Is skin necessary for intraoral reconstruction

with myocutaneous

flaps?

M. A. Johnson, J. D. Langdon Department of Oral and Maxillofacial Surgery, King’s College School of Medicine and Dentistry, London

Intraoral defects may be reconstructed in many ways following cancer resection. Following the SUMMARY. advent of the myocutaneous flap, this has been very much the mainstay in intraoral reconstructive surgery. Although it has proved to be a reliable flap it has certain innate disadvantages which can often be attributed to the skin component of the flap. This paper attempts to make a case for using muscle-only pedicle flaps such as pectoralis major, masseter transfer and latissmus dorsi flaps.

INTRODUCTION

Case 1

Muscle-only flaps were first described for intraoral reconstruction using the temporalis muscle flap (Bradley & Brockbank, 1986). From this method it was seen that rapid epithelialisation of the raw muscle surface takes place. Consequently is skin really necessary for reconstructive purposes when using pedicle flaps? It was therefore decided to reconstruct intraoral defects, where possible, using muscle-only flaps for a 12-month period, and to compare the results and complications with cases reconstructed with the more orthodox myocutaneous flap.

A 59-year-old woman presented with a T3N1M0 carcinoma of the anterior floor of mouth extending onto the alveolus in 2% region. This was treated with a right-sided radical neck dissection via McPhee incisions with incontinuity resection of the right side of mandible, right side of floor of mouth and right ventral aspect of tongue. Reconstruction of the defect was with a pectoralis major muscle flap. The patient made an uneventful recovery. Although the intraoral flap appeared dusky during the first week postsurgery; it had epithelialised after 4 weeks. Postoperative radiotherapy was commenced 4 weeks postsurgery65 Gy in 30 fractions. Speech and swallowing were very good, with very little cosmetic deformity to the chest wall.

METHOD

Case 2

The pectoralis major muscle flap is raised in identical fashion to the myocutaneous flap except that the skin, superficial fascia and fat are left on the chest wall. The muscle is then tunnelled through the neck and sutured in place in the oral cavity in the normal manner. In raising the masseter transfer flap the muscle is freed from it’s wide insertion into the lateral aspect of the ramus and angle regions of the mandible. This must be performed with care to ensure that the whole of the masseter muscle is freed from it’s insertion to ensure adequate mobility thereby minimising any tension on the flap during wound closure (Tiwari, 1978; Langdon, 1989). Care must also be taken to preserve the blood supply to the muscle via the masseteric artery, a branch of the transverse facial artery.

A 54-year-old man presented with T2NoMo alveolar carcinoma of the right side of the mandible in the fl region. Surgery involved a right-sided radical neck dissection, with incontinuity resection of the right side of the mandible and right floor of mouth, the defect being reconstructed with a pectoralis major muscle flap. Postoperative recovery was uneventful with the flap epithelialising by the fourth week postsurgery. Case 3 A 73-year-old woman presented with TZNIMO squamous cell carcinoma of the right edentulous alveolus and retromolar fossa. A right-sided radical neck dissection was carried out via a McPhee incision extending the upper incision to include a midline lip-split. The right masseter muscle was freed from the ramus and angle regions, and the right mandible was resected from the canine region to the condylar neck together with the overlying tumour. The defect was reclonstructed by mobilising the masseter muscle forwards and suturing it to the remaining mylohyoid muscle anteriorly and medial pterygoid posteriorly. The mucosa of the floor of the mouth was sutured to the lingual aspect

Case reports Four case reports are presented to illustrate the use of masseter transfer and pectoralis major muscle flaps. 299

300 British Journal of Oral and Maxillofacial Surgery of the masseter and buccal mucosa to its outer aspect leaving the bare masseter muscle to reconstitute the sulcus. The patient underwent a course of postoperative radiotherapy to 60 Gy commencing 2 weeks postsurgery. Healing was uneventful and epithelialisation had occurred by 3 weeks.

Case 4 A 67-year-old woman presented with a painful ulcerated TzNoMo adenoid cystic carcinoma of the left soft and posterior hard palate. Magnetic resonance imaging showed the tumour to be remarkably well localised. The approach to the area was via a submandibular incision, lip split and mandibulotomy. The tumour was resected to include three-quarters of the soft palate and the posterior maxilla including the pterygoid plates on the left side. The masseter muscle was detached from the left ramus and an L-shaped osteotomy cut was made downwards from the sigmoid notch and forwards at the crest of the alveolus. Following removal of the coronoid process and anterior ramus the masseter muscle was mobilised across the residual ramus and sutured to the remaining soft palate on the right side and residual mucosa of the hard palate. On the following day, speech and swallowing were excellent. Healing was delayed owing to a large buccal haematoma which required drainage. A small residual fistula at the junction of the flap and posterior hard palate required closure at 6 weeks. Again the bare muscle had epithelialised spontaneously 3 weeks following initial surgery. Six months after surgery the reconstructed soft palate remains excellent with minimal hypernasality of speech.

RESULTS

(Table)

Eighteen cases were included in the study; seven pectoralis major myocutaneous flaps, seven pectoralis major muscle flaps and four masseter transfer flaps. Table - Complications seen in 18 flaps investigated

Pectoralis major myocutaneous flaps Pectoralis major muscle flaps Masseter transfer flaps

Complications

No complications

3

4

0 1

7 3

Of the three complications involving pectoralis major myocutaneous flaps, two had dehiscence at the suture line and one the skin paddle necrosed. The one complication involving the masseter transfer flap was the development of a large buccal haematoma 1 day postoperatively and a minimal residual fistula at the junction of the hard and soft palate.

DISCUSSION

The use of myocutaneous flaps in general, and the pectoralis major myocutaneous flaps in particular

(Ariyan, 1979), continue to be the most commonly used technique for reconstruction of major intraoral defects. In the cases included in our study it would appear that the postsurgery complication rate is higher when reconstructing intraoral defects with myocutaneous flaps than the muscle-only variety. Wilson et aE. (1984) in their paper quote overall complication rate of 7%. Specifically our paper deals with a prospective rate is study and, although the complication somewhat higher, 7 years previous experience in this unit of reconstruction of intraoral defects utilising pectoralis major myocutaneous flaps gives a similar complication rate to that found in Wilson’s series. Of the cases reconstructed with myocutaneous flaps, two had dehiscence at the suture line. This problem could be attributed to the increased weight of the flap when both muscle and skin are used, and the relative unstretchability of the myocutaneous flap due to its skin component. It may be argued that both these problems are avoided if a muscle-only flap is utilised. One of the criticisms of the pectoralis major muscle flap in the past has been it’s relatively poor dimensional stability. In our own study the dimensional stability of all the muscle-only flaps was found to be good and contraction was not a problem encountered. Our own feeling is that this may be explained by careful suturing of the flap into the tissues of the neck, thereby taking the weight off the flap, and by not skeletonising the pedicle, but using a wider-based pedicle so as to ensure a more widespread distribution of nerve fibres to the muscle, thereby minimising atrophy. One of the myocutaneous flaps lost its skin paddle, although the underlying muscle component of the flap survived. The skin relies for survival upon perforators from the underlying muscle, and the smaller the skin paddle the greater the risk of missing a sufficient number of these perforators. Thus, when reconstructing smaller defects in the oral cavity, a larger flap must be used than one might want, in order to preserve the vitality of the skin component. If a loss of vitality of the skin component is a possibility then why use skin at all when raw muscle will epithelialise within 3 to 4 weeks? This will leave the reconstructed area similar in colour and texture to normal oral mucosa, rather than an area of skin different in colour and texture and which may be hair-bearing in the male patient if postoperative radiotherapy is not part of the treatment regime. (Fig. 1A & B.) Myocutaneous flaps also increase the morbidity of the donor site because of the need often to use a skin graft and possible distortion of the breast. (Fig. 2A&B.) It is our experience that when using flaps for intraoral reconstruction that some of the complications (Mehrof et al., 1983) may be avoided if the skin component is not incorporated in the flap. Since completing this investigation the authors have used a further nine pectoralis major flaps and’ seven masseter transfer flaps without skin with no compli-

Intraoral reconstruction with myocutaneous flaps

301

Fig. 1 - (A) Intraoral reconstruction

reconstruction

using skin. Note the macerated appearance of keratinised epithelium in the mouth. (B) Intraoral with muscle flap showing spontaneous epithelialisation.

Fig. 2 - (A) Typical appearance of a male chest following the elevation of a conventional myocutaneous flap. In females primary closure can usually be obtained but with distortion of the breast. (B) Improved appearance of the chest when skin is not raised with the muscle flap.

cations attributable to the flaps. We no longer use skin for routine intraoral reconstruction when using pedicle flaps.

The Authors M. A. Johnson BDS, FDSRCS

Registrar

References

J. D. Langdon FDSRCS,

Ariyan, S. (1979). The pectoralis major myocutaneou.s flap. Plastic and Reconstructive Surgery, 63, 73.

Bradley, P. & Brockbank, J. (1981). The temporalis muscle flap in oral reconstruction. Journal of Maxillofacial Surgery, 9, 139.

Langdon, J. D. (1989). The masseter muscle cross-over flap-a versatile flap for reconstruction in the oral cavity. British

FRCS

Senior Lecturer and Honorary Consultant Department of Oral and Maxillofacial Surgery King’s College School of Medicine and Dentistry Denmark Hill London SE5 8RX

Journal of Oral and Maxillofacial Surgery, 27,124.

Mehrof, A. I., Rosenstock, A. & Nelfeld, J. P., (1983). The pectoralis major myocutaneous flap in head and neck reconstruction: An analysis of complications. American Journal of Surgery, 146,478.

Correspondence

and requests for offprints to Mr M. A. Johnson

Tiwari, R. (1987). Masseter muscle cross-over flap in primary closure of oral-oropharyngeal defects. Journal of Laryngology

and Otology, 101, 172.

Wilson, J. S. P., Yiacoumettis, A. M. & O’Neill, T. (1984). Some observations on 112 pectoralis major myocutaneous flaps. American Journal of Surgery, 147,273.

Paper received 12 May 1989 Accepted 11 October 1989

Is skin necessary for intraoral reconstruction with myocutaneous flaps?

Intraoral defects may be reconstructed in many ways following cancer resection. Following the advent of the myocutaneous flap, this has been very much...
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