Eur Arch Otorhinolaryngol (1990) 247 : 379-381
European Archives of
Oto-RhinoLaryngology © Spnnger-Verlag 1990
Sternocleidomastoid myocutaneous flap for intraoral reconstruction* W. G o ~ b e k t and J. Kondratowicz 2 1Department of Otolaryngology, Medical Academy of Lublin and 2Department of Surgery, Oncologm Hospital, Lublin, Poland Received December 1, 1989 / Accepted December 20, 1989
Summary. T h e results of healing of the sternocleidomastoid m y o c u t a n e o u s flap in 22 patients o p e r a t e d u p o n because of cancer of the t o n g u e and floor of the m o u t h are presented. A n inferiorly based island flap was used in 5 patients. A l t h o u g h total or partial cutaneous necrosis occurred in 4 of the patients, the w o u n d healed without fistula formation in all cases. A superiorly based c o m p o u n d flap was used in 17 patients and in 5 of t h e m the oral part of the skin u n d e r w e n t total or partial necrosis. Key words: Sternocleidomastoid m y o c u t a n e o u s flap Oral reconstruction
In all patients the SCM muscle could be preserved ipsilateral to the lesion excised. In 10 patients neck dissection included the internal jugular vein, in 5 patients the jugular vein was saved, and in 7 patients suprahyoid neck dissection was performed. The facial artery and vein were tied and cut in all patients, while the lingual artery was also tied in 6 patients. Four patients required temporary tracheostomy. Two variations of the SCM myocutaneous flap were used to close the postoperative defect in the oral cavity. In 5 patients an inferiorly based island flap was used with a skin paddle of about 3 x 4 cm attached to the superior pole of the muscle. The wound in the neck was closed primarily in these patients. In 17 patients a compound SCM flap was used that was based superiorly and contained the platysma and skin along the whole length of the SCM muscle (Fig. 1). The latter muscle flap required a two-stage reconstruction with a temporary orostoma, which was closed within 3-4 weeks after the primary operation.
Introduction T h e clinical application of m y o c u t a n e o u s flaps has presented significant progress in h e a d and neck reconstruction. T h e pectoralis m a j o r m y o c u t a n e o u s flap is the m o s t p o p u l a r flap n o w used, but the latissimus dorsi, sternocleidomastoid, trapezius and platysma flaps have also b e e n used [3, 6, 8, 9]. R e c e n t modifications o f the classical neck dissection during cancer surgery allow the stern o c l e i d o m a s t o i d (SCM) muscle to be preserved [2]. The aim o f the present study was to assess critically the S C M m y o c u t a n e o u s flap used for reconstruction of the oral cavity.
Results W h e n using the island S C M flap, the whole skin necrotized in 2 patients within 10 days after surgery. In 2 o t h e r patients a part of the skin paddle u n d e r w e n t necrosis. Nevertheless, the muscle survived in all 5 patients and p r e v e n t e d fistulization. D e l a y e d epithelial coverage was accomplished w h e n n e e d e d f r o m the adjacent oral mucosa. Following healing, all patients d e m o n s t r a t e d g o o d
Patients and methods Twenty-two patients, aged 38-80 years, were operated on because of cancer of the oral cavity. There were 17 men and 5 women in the group and the majority (13 patients) were in their fifth decade of life. Four patients were arradiated before and 11 patients after surgery. The defect after excision of tumor in 13 patients included the floor of the mouth and a part of the tongue. In 5 patients the defect involved the floor of the mouth and a part of the mandible and in the remaining 4 patients the defect extended to a part of the tongue, the floor of the mouth and a part of the mandible. * Presented at the Fourth Symposium of Oncology in Otorhinolaryngology, Poznafi, 26 June 1988 Offprint requests: W. Golgbek, ul. Kleniewskich 6/28, 20-093 Lublin, Poland
t
Fig.1. The sternocleidomastoid (SCM) myocutaneous island (A) and compound (B) flaps
w. Goigbek and J. Kondratowicz:Sternocleidomastoidmyocutaneousflap
380
patients had distinct deterioration of speech and 9 patients developed slight speech defects. In 1 of 15 irradiated patients, the SCM flap underwent late cicatrical deformation.
Discussion
Fig. 2. A 53-year-oldwoman with the island SCM flap 1 week (a) and 2 months (b) after surgery Table
1. Healingof the sternocleidomastoidmyocutaneousflap
Type of flap
Island Compound
Num- Skin ber of paNecrosis tients total partial
Muscle Good Partial Good healing necro- healing sis
5
2
2
1
0
5
17
2
3
12
2
15
mobility of the reconstructed tongue, as illustrated in Fig. 2. Of the 17 patients with the compound SCM flaps, 2 developed complete necrosis of the oral portion of the flap, while marginal parts of the skin necrotized in 3 other patients. A temporary orostoma was closed in 13 patients 3-4 weeks after primary surgery and in 4 patients later on (Table 1). Functional results of the SCM flap in the oral cavity were good. No patient had any swallowing problems. Six
Although a part or all of the skin of the SCM island flap necrotized in 4 of 5 patients, the wound produced in the neck healed without fistula in all patients. The advantage of the island flap is a one-stage reconstruction of the oral cavity, whereas the compound SCM flap requires a temporary orostoma and a two-stage procedure. To date, only small clinical series of SCM island flaps have been reported. In a group of 10 patients with the flap, Cho et al. [5] reported 6 failures, including 4 fistulas with skin necrosis. Arian [1] had 7 failures in 14 cases and Sasaki [10] 3 tissue breakdowns in 5 cases. However, no salivary fistula was observed despite necrosis of the skin paddle. In our series of patients the failure rate of the compound SCM flap was smaller than that of the island flap. The reason for this is presumably the better blood supply. Whereas the skin paddle in the island flaps is supplied only by the small perforating vessels originating from the SCM muscle, the skin in the compound flap also receives an accessory nutrition from the skin pedicle and from the platysma muscle [4]. The main reasons for flap failure involve vascular insufficiency and inflammation. In order to survive, a flap must have vascular channels supplying and draining all of its parts. Veins are more prone than arteries to faulty techniques of flap transfer, such as excessive tension, shearing the skin from the underlying muscle or strangulation of the underlying pedicle [3, 5, 7]. Postoperative irradiation does not seem to affect the "take" rate of the SCM flap, and both Arian [1] and Mann [8] reported good healing of myocutaneous flaps in irradiated patients. The blood supply to the SCM muscle is derived from three sources: a branch of the occipital artery superiorly, a branch of the superior thyroid artery to the middle portion, and the thyrocervical trunk inferiorly [1]. Sasaki [10] suggested that preserving at least two of the three nutrient arteries improves the flap's skin viability. Charles et al. [4] described a modified SCM flap for the reconstruction of intraoral defects. This is a compound flap containing skin and the platysma and SCM muscles. However, the tunneled portion of the flap is completely de-epithelialized. This flap allows a one-stage reconstruction without sacrificing the additional blood supply from the platysma muscle and the overlying dermis. In the study of Charles et al. [4], 3 of 27 such flaps had cutaneous sloughs and 2 patients developed inclusion cysts. We should emphasize that the SCM myocutaneous flap cannot be used at the expense of oncologic safety nor for defects greater than 6 cm in diameter [8, 10]. In our experience, the SCM myocutaneous flap is useful for the reconstruction of intraoral defects, especially in
w . Gotgbek and J. Kondratowicz: Sternocleidomastold myocutaneous flap some circumstances when harvesting of the pectoralis m a j o r flap is n o t p o s s i b l e (for e x a m p l e , in o b e s e p a t i e n t s o r p a t i e n t s with small m u s c l e mass).
References 1. Arian S (1980) The sternomastoid myocutaneous flap. Laryngoscope 90 : 676-679 2. Bocca E, Piguataro O (1967) A conservation technique in radical neck dissection. Ann Otol Rhinol Laryngol 76 : 975-988 3. Cantrell RW (1983) Myocutaneous flaps. Otolaryngol Clin North Am 16 : 353-371 4. Charles GA, Hamaker RC, Singer MI (1987) Sternocleidomastoid myocutaneous flap. Laryngoscope 97 : 970-974
381
5. Cho HT, Mignogna F, Garay K, Blitzer A (1983) Delayed failure of myocutaneous flaps in head and neck reconstruction. Laryngoscope 93 : 17-19 6. Gehanno P, Astier P, Rodriguez J, Chauffete JP, Janot F (1983) Pelviglossectomies totales avec reconstruction par lainbeau musculocutane. J Fr Oto-Rhino-Laryngol 32 : 605-612 7. Jethon J (1986) Complications after the use of pectoralis major myocutaneous flap (in Polish). Otolaryngol Pol 40:427-431 8. Mann W (1983) Grenzen und Anwendungsbereiche myocutaner Insellappen in der rekonstruktiven Kopf-Hals-Chirurgie. Laryngol Rhinol Otol 62:29-32 9. Pa~nikowski T, Andrzejewski K (1985) Pectoralis major myocutaneous flap for reconstructon of defects in head and neck (in Polish). Otolaryngol Pol 39 : 226-233 10. Sasaki CT (1980) The sternocleidomastoid myocutaneous flap. Arch Otolaryngol 106 : 72-76
European Archives of
Oto-RhinoLaryngology © Spnnger-Verlag 1990
Sternocleidomastoid myocutaneous flap for intraoral reconstruction* W. G o ~ b e k t and J. Kondratowicz 2 1Department of Otolaryngology, Medical Academy of Lublin and 2Department of Surgery, Oncologm Hospital, Lublin, Poland Received December 1, 1989 / Accepted December 20, 1989
Summary. T h e results of healing of the sternocleidomastoid m y o c u t a n e o u s flap in 22 patients o p e r a t e d u p o n because of cancer of the t o n g u e and floor of the m o u t h are presented. A n inferiorly based island flap was used in 5 patients. A l t h o u g h total or partial cutaneous necrosis occurred in 4 of the patients, the w o u n d healed without fistula formation in all cases. A superiorly based c o m p o u n d flap was used in 17 patients and in 5 of t h e m the oral part of the skin u n d e r w e n t total or partial necrosis. Key words: Sternocleidomastoid m y o c u t a n e o u s flap Oral reconstruction
In all patients the SCM muscle could be preserved ipsilateral to the lesion excised. In 10 patients neck dissection included the internal jugular vein, in 5 patients the jugular vein was saved, and in 7 patients suprahyoid neck dissection was performed. The facial artery and vein were tied and cut in all patients, while the lingual artery was also tied in 6 patients. Four patients required temporary tracheostomy. Two variations of the SCM myocutaneous flap were used to close the postoperative defect in the oral cavity. In 5 patients an inferiorly based island flap was used with a skin paddle of about 3 x 4 cm attached to the superior pole of the muscle. The wound in the neck was closed primarily in these patients. In 17 patients a compound SCM flap was used that was based superiorly and contained the platysma and skin along the whole length of the SCM muscle (Fig. 1). The latter muscle flap required a two-stage reconstruction with a temporary orostoma, which was closed within 3-4 weeks after the primary operation.
Introduction T h e clinical application of m y o c u t a n e o u s flaps has presented significant progress in h e a d and neck reconstruction. T h e pectoralis m a j o r m y o c u t a n e o u s flap is the m o s t p o p u l a r flap n o w used, but the latissimus dorsi, sternocleidomastoid, trapezius and platysma flaps have also b e e n used [3, 6, 8, 9]. R e c e n t modifications o f the classical neck dissection during cancer surgery allow the stern o c l e i d o m a s t o i d (SCM) muscle to be preserved [2]. The aim o f the present study was to assess critically the S C M m y o c u t a n e o u s flap used for reconstruction of the oral cavity.
Results W h e n using the island S C M flap, the whole skin necrotized in 2 patients within 10 days after surgery. In 2 o t h e r patients a part of the skin paddle u n d e r w e n t necrosis. Nevertheless, the muscle survived in all 5 patients and p r e v e n t e d fistulization. D e l a y e d epithelial coverage was accomplished w h e n n e e d e d f r o m the adjacent oral mucosa. Following healing, all patients d e m o n s t r a t e d g o o d
Patients and methods Twenty-two patients, aged 38-80 years, were operated on because of cancer of the oral cavity. There were 17 men and 5 women in the group and the majority (13 patients) were in their fifth decade of life. Four patients were arradiated before and 11 patients after surgery. The defect after excision of tumor in 13 patients included the floor of the mouth and a part of the tongue. In 5 patients the defect involved the floor of the mouth and a part of the mandible and in the remaining 4 patients the defect extended to a part of the tongue, the floor of the mouth and a part of the mandible. * Presented at the Fourth Symposium of Oncology in Otorhinolaryngology, Poznafi, 26 June 1988 Offprint requests: W. Golgbek, ul. Kleniewskich 6/28, 20-093 Lublin, Poland
t
Fig.1. The sternocleidomastoid (SCM) myocutaneous island (A) and compound (B) flaps
w. Goigbek and J. Kondratowicz:Sternocleidomastoidmyocutaneousflap
380
patients had distinct deterioration of speech and 9 patients developed slight speech defects. In 1 of 15 irradiated patients, the SCM flap underwent late cicatrical deformation.
Discussion
Fig. 2. A 53-year-oldwoman with the island SCM flap 1 week (a) and 2 months (b) after surgery Table
1. Healingof the sternocleidomastoidmyocutaneousflap
Type of flap
Island Compound
Num- Skin ber of paNecrosis tients total partial
Muscle Good Partial Good healing necro- healing sis
5
2
2
1
0
5
17
2
3
12
2
15
mobility of the reconstructed tongue, as illustrated in Fig. 2. Of the 17 patients with the compound SCM flaps, 2 developed complete necrosis of the oral portion of the flap, while marginal parts of the skin necrotized in 3 other patients. A temporary orostoma was closed in 13 patients 3-4 weeks after primary surgery and in 4 patients later on (Table 1). Functional results of the SCM flap in the oral cavity were good. No patient had any swallowing problems. Six
Although a part or all of the skin of the SCM island flap necrotized in 4 of 5 patients, the wound produced in the neck healed without fistula in all patients. The advantage of the island flap is a one-stage reconstruction of the oral cavity, whereas the compound SCM flap requires a temporary orostoma and a two-stage procedure. To date, only small clinical series of SCM island flaps have been reported. In a group of 10 patients with the flap, Cho et al. [5] reported 6 failures, including 4 fistulas with skin necrosis. Arian [1] had 7 failures in 14 cases and Sasaki [10] 3 tissue breakdowns in 5 cases. However, no salivary fistula was observed despite necrosis of the skin paddle. In our series of patients the failure rate of the compound SCM flap was smaller than that of the island flap. The reason for this is presumably the better blood supply. Whereas the skin paddle in the island flaps is supplied only by the small perforating vessels originating from the SCM muscle, the skin in the compound flap also receives an accessory nutrition from the skin pedicle and from the platysma muscle [4]. The main reasons for flap failure involve vascular insufficiency and inflammation. In order to survive, a flap must have vascular channels supplying and draining all of its parts. Veins are more prone than arteries to faulty techniques of flap transfer, such as excessive tension, shearing the skin from the underlying muscle or strangulation of the underlying pedicle [3, 5, 7]. Postoperative irradiation does not seem to affect the "take" rate of the SCM flap, and both Arian [1] and Mann [8] reported good healing of myocutaneous flaps in irradiated patients. The blood supply to the SCM muscle is derived from three sources: a branch of the occipital artery superiorly, a branch of the superior thyroid artery to the middle portion, and the thyrocervical trunk inferiorly [1]. Sasaki [10] suggested that preserving at least two of the three nutrient arteries improves the flap's skin viability. Charles et al. [4] described a modified SCM flap for the reconstruction of intraoral defects. This is a compound flap containing skin and the platysma and SCM muscles. However, the tunneled portion of the flap is completely de-epithelialized. This flap allows a one-stage reconstruction without sacrificing the additional blood supply from the platysma muscle and the overlying dermis. In the study of Charles et al. [4], 3 of 27 such flaps had cutaneous sloughs and 2 patients developed inclusion cysts. We should emphasize that the SCM myocutaneous flap cannot be used at the expense of oncologic safety nor for defects greater than 6 cm in diameter [8, 10]. In our experience, the SCM myocutaneous flap is useful for the reconstruction of intraoral defects, especially in
w . Gotgbek and J. Kondratowicz: Sternocleidomastold myocutaneous flap some circumstances when harvesting of the pectoralis m a j o r flap is n o t p o s s i b l e (for e x a m p l e , in o b e s e p a t i e n t s o r p a t i e n t s with small m u s c l e mass).
References 1. Arian S (1980) The sternomastoid myocutaneous flap. Laryngoscope 90 : 676-679 2. Bocca E, Piguataro O (1967) A conservation technique in radical neck dissection. Ann Otol Rhinol Laryngol 76 : 975-988 3. Cantrell RW (1983) Myocutaneous flaps. Otolaryngol Clin North Am 16 : 353-371 4. Charles GA, Hamaker RC, Singer MI (1987) Sternocleidomastoid myocutaneous flap. Laryngoscope 97 : 970-974
381
5. Cho HT, Mignogna F, Garay K, Blitzer A (1983) Delayed failure of myocutaneous flaps in head and neck reconstruction. Laryngoscope 93 : 17-19 6. Gehanno P, Astier P, Rodriguez J, Chauffete JP, Janot F (1983) Pelviglossectomies totales avec reconstruction par lainbeau musculocutane. J Fr Oto-Rhino-Laryngol 32 : 605-612 7. Jethon J (1986) Complications after the use of pectoralis major myocutaneous flap (in Polish). Otolaryngol Pol 40:427-431 8. Mann W (1983) Grenzen und Anwendungsbereiche myocutaner Insellappen in der rekonstruktiven Kopf-Hals-Chirurgie. Laryngol Rhinol Otol 62:29-32 9. Pa~nikowski T, Andrzejewski K (1985) Pectoralis major myocutaneous flap for reconstructon of defects in head and neck (in Polish). Otolaryngol Pol 39 : 226-233 10. Sasaki CT (1980) The sternocleidomastoid myocutaneous flap. Arch Otolaryngol 106 : 72-76
