Original Article
163
The Pedicled Latissimus Dorsi Flap in Head and Neck Reconstruction: An Old Method Revisited Sinikka Suominen, MD, PhD1
1 Department of Plastic Surgery, Helsinki University Central Hospital,
Helsinki University, Helsinki, Finland 2 Department of Otorhinolaryngology—Head and Neck Surgery, Helsinki University Central Hospital, Helsinki University, Helsinki, Finland
Leif Back, MD, PhD2
Jyrki Vuola, MD, PhD1
Address for correspondence Tommy Wilkman, MD, DDS, Department of Plastic Surgery, Helsinki University Hospital, PO 266, 00029 HUS, Helsinki, Finland (e-mail: tommy.wilkman@hus.fi).
J Reconstr Microsurg 2014;30:163–170.
Abstract
Keywords
► head and neck surgery ► reconstruction ► latissimus dorsi musculocutaneous flap
In head and neck cancer patients with significant comorbidities, the reconstructive options are limited, and there is a need for a safe alternative for microvascular flaps without compromising flap size. During the study period, 331 head and neck cancer patients were reconstructed with microvascular tissue flaps. Ten patients requiring large resections were considered to have high risks for long surgery and to be poor candidates for free tissue transfer and thus were reconstructed with a subpectorally tunneled pedicled latissimus dorsi (SP-LD) flap. The flap was raised simultaneously with the tumor resection and tunneled to the head and neck region. The flap was used for reconstruction of oral, mandibular, pharyngeal, or neck defects. Median follow-up was 3.6 years. Median duration of surgery was 7 hours and 17 minutes, and total hospital stay was 20 days. During the follow-up, four patients died of their disease and one from another cause (median of 329 days). We were able to perform large tumor resections with a curative intent and reconstruct major defects in high-risk head and neck cancer patients with a SP-LD flap. It possesses many of the characteristics of a free flap with the benefits of a shorter operation time and less perioperative risk.
In complex three-dimensional reconstructions, different tissues and organs should be restored by the principle of replacing like with like. Optimally, this includes both functional and structural reconstructions using composite tissues such as skin, fat, bone, muscle, and even mucosal lining with adequate blood supply and sensory abilities, as well as having the ability to withstand the mechanical and motional stress developed in the area.1–5 Reconstruction with microvascular free tissue transfer is considered as the primary method in large or complex defects.6–11 Secondary options may be needed in cases of cancer recurrence, following complications of the primary microvascular reconstruction12,13 or oncological treatment, such as osteoradionecrosis and in patients lacking usable ves-
sels.14–16 In addition, patients with poor general health should be assessed for minimally invasive reconstructive procedures. The most popular pedicled flaps in the head and neck area are the pectoral flap, the trapezius flap, and the latissimus dorsi flap. Today, their perforator variations are becoming increasingly popular as these flaps can be thinner and the pedicle longer. Other useful options are the submental and supraclavicular flaps,17,18 as well as the internal mammary artery perforator flap19; however, these are smaller in flap size.20–26 Although microvascular free tissue reconstruction is the primary method in our unit, we have looked for a safer alternative in high-risk patients. We have used the
received June 6, 2013 accepted after revision August 12, 2013 published online December 9, 2013
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1357497. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Tommy Wilkman, MD, DDS1 Patrik Lassus, MD, PhD1
SP-LD in Head and Neck Reconstruction
Wilkman et al.
subpectorally tunneled pedicled latissimus dorsi (SP-LD) musculocutaneous flap in those head and neck cancer patients in whom large resections and reconstructions are necessary but present with poor health and high operative risk. The purpose of this study was to evaluate the use of the flap, analyze the complications and patient outcome, as well as its suitability in this high-risk patient group.
Patients and Methods This study was approved by the Research Ethical Board of Helsinki University Central Hospital, Helsinki, Finland, May 11, 2011. During the years 2008 to 2011, 2,170 patients were assessed pre- and postoperatively in a weekly multidisciplinary head and neck cancer board. During this period, 341 patients had defects requiring microvascular flaps, but 10 of them were reconstructed with the SP-LD flap. These 10 patients had large tumors but were evaluated to be too high risk for microvascular tissue transfer. Data were collected from the patients’ hospital records. The median age of these 10 patients was 65 years (range, 47– 82 years), 6 were male and 4 were female. Of these patients, five suffered from oral cancer with mandibular invasion, two presented with laryngeal carcinoma requiring laryngophar-
yngectomy, and one patient had a tongue cancer requiring total glossectomy. In addition, two patients had large metastases in the cheek and neck region. In the patients who underwent mandibulectomy, the mandible was reconstructed with a reconstructive plate (Synthes Matrix Mandible Reconstruction plate 2.5 mm; Synthes GmbH, Zuchwil, Switzerland). All patients had severe comorbidities such as universal atherosclerosis, chronic obstructive pulmonary disease, and malnutrition. In three patients, the severity of alcoholism and the problems with compliance were considered a contraindication for microvascular surgery. In these patients, chemoirradiation therapy was also precluded leaving surgery to be the only treatment modality. Of the authors, P.L. participated in all operations (►Table 1).
Surgical Technique The operation began with tracheostomy and extraction of any infected teeth. The patient was placed in a semidecubital position, and the flap dissection and tumor resection were performed simultaneously by two teams. The latissimus dorsi skin island was designed longitudinally overlying the anterior border of the muscle and reaching as distally as possible. The flap was raised in the standard fashion. All branches of the thoracodorsal pedicle up to the axillary vessels were ligated to
Table 1 Patient data Patient age/sex
General health
Cancer region
Resection and osseous reconstruction
Previous treatments
82/F
Cerebral infarction, severe malnutrition
Base of mouth
Subtotal glossectomy, mandible (reconstruction plate)
None
64/M
COPD, smoker 100 pack years
Base of mouth
Hemiglossectomy, mandible (reconstruction plate)
None
66/M
Cerebral infarction, hypertension, atrial fibrillation
Tongue
Total glossectomy, mandible (reconstruction plate)
None
79/M
Hypertension, multiple venous thromboses, permanent anticoagulation, smoker 50 pack years
Subglottal
Laryngopharyngectomy
None
64/F
COPD, aortic valve stenosis, smoker 40 pack years
Unknown primary, neck metastases
Extended radical neck dissection
None
73/M
COPD, hypertension, atherosclerotic disease, chronic kidney failure
Submandibular gland metastases
Full-thickness cheek resection, mandible (reconstruction plate)
2006 submandibular gland cancer, neck dissection, 2008 skin metastases operated, radiation therapy
47/M
Alcoholism, smoker 25 pack years
Hypopharynx
Laryngopharyngectomy
2009 chemo- and radiation therapy
51/F
Alcoholism, brain contusion, epilepsy, malnutrition
Tongue
Full-thickness cheek resection, mandible (reconstruction plate)
2010 resection of tongue, neck dissection, radiation therapy, 2010 resection relapse
58/M
Alcoholism, smoker, hypertension
Tongue
Total glossectomy, soft palate/ tonsils
Anterolateral thigh flap, second ALT, pectoralis major flap for fistula 2011
70/F
SLE, several prior malignancies
Squamous cell cancer metastases
Cheek and neck skin
2007 submental flap, 2010 bilateral neck dissection
Abbreviations: ALT, Anterolateral thigh flap; COPD, chronic obstructive pulmonary disease; F/M, female/male; SLE, systematic lupus erythematosus. Journal of Reconstructive Microsurgery
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Wilkman et al.
Fig. 3 Semidecubital position with two-team approach. SP-LD skin island is situated longitudinally in the anterior border of the latissimus dorsi. Size of the skin island is 18 9 cm. SP-LD, subpectorally tunneled pedicled latissimus dorsi.
Fig. 1 A 51-year-old woman with alcoholism, brain contusion, epilepsia, and malnutrition. Previous resection of Stage IVA tongue cancer with bilateral neck dissection and radiation therapy. The patient presented large neck metastases invading mandible.
prevent kinking of the pedicle that was rotated 180 degrees when the flap was brought to the neck. To prevent muscular contractions, 2 cm of the thoracodorsal nerve was resected and to avoid bulk in the neck, the proximal part of the muscle cephalic to the vessels was resected. A tunnel was created from the axilla to the clavicle between the pectoralis major and minor muscles. A 5-cm segment of the insertion of the pectoralis major muscle was divided, and the tunnel was continued into the neck. The flap was then delivered to the neck or oral region. A short transverse supraclavicular incision was made for access and control of
Fig. 2 Full-thickness resection of the skin, floor of the mouth, and mandible. The mandible was fixed with external fixator before the resection and reconstructed with an AO 2.4-mm reconstruction plate.
the pedicle. The donor site was closed primarily. Postoperatively, we had no limitations of head movements. Shoulder motion was limited to 90 degrees of abduction and extension for 2 weeks (►Figs. 1–6).
Statistics The data were analyzed using Microsoft Excel 2011 and we report the values as median and ranges for descriptive purposes.
Results Surgery The median duration of the whole procedure was 7 hours and 17 minutes (range, 3 hours and 20 minutes to 9 hours), which included all events performed in the operation theater (e.g., tracheostomy, anesthesia, extraction of teeth, prepping and redraping of the patient, and the actual surgical procedure). The median blood loss was 1,035 mL (range, 600–4,400 mL).
Fig. 4 The flap is mobilized to the axillary vessels, tunneled between the pectoralis muscles, releasing the lateral clavicular insertion of the pectoralis major, and brought to the defect via a supraclavicular secondary incision to secure the pedicle. Journal of Reconstructive Microsurgery
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SP-LD in Head and Neck Reconstruction
SP-LD in Head and Neck Reconstruction
Wilkman et al. resected with a minimum of 3 mm margins in all patients verified by histology.
Early Complications During the primary hospital stay, three patients had major early complications. Patient 1 died 10 days postoperatively of multiorgan failure. Patient 5 had a rupture of the internal carotid artery during tumor resection and developed a skin fistula early in the postoperative period. The carotid artery was successfully repaired but the fistula required a revision and a skin graft during the hospital stay. Patient 6 developed an early paralytic ileus, which was treated conservatively.
Late Complications
Fig. 5 Inset of the flap. The muscle covers the reconstruction plate 360 degrees, and the skin is used to reconstruct both the intra-oral as well as the external defect.
The median size of the skin island of the SP-LD flap was 8.5 16.5 cm (range, 8 10 cm–8 30 cm). There were no total flap losses. In patient 5, a major part of the skin island was lost requiring secondary operation. The cancer was
Two patients had major late complications. Patient 5 had a persistent chronic wound in the neck region and required several reconstructions (free skin graft, local transposition flap, trapezius flap, and pectoral flap). This patient had had previous radiation therapy to the neck region and consequently poor recipient vessels for a microvascular flap. In patient 8, the mandibular reconstruction plate became exposed 2 years after surgery.
Follow-Up Of the nine surviving patients, four were decannulated during the hospital stay and five remained permanently tracheostomied. Of the latter five patients, one laryngopharyngectomy patient was rehabilitated with a speech prosthesis (Provox Atos Medical Ab, Hörby, Sweden). The nine surviving patients were treated in the intensive care unit for 4 days (range, 0–18 days), and the total hospital stay was 20 days
Fig. 6 A 73-year-old man with cancer of submandibular gland, earlier local resection, neck dissection, and radiation therapy. Relapse of the disease with full-thickness cheek resection including mandible. Reconstruction with reconstruction plate and SP-LD, 18 months postoperative. Atrophy of the denervated latissimus muscle and resected proximal muscle resulting in minimal bulk and acceptable esthetics in the neck. (A) Frontal view and (B) lateral view. Journal of Reconstructive Microsurgery
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Patient
Duration of operation (h)
Hospital stay (d)
Size of skin flap (cm)
Need of tracheostomy (d)
Early major complications
Late major complications
Survival (d)
1
5.25
–
15 10
–
Early multiorgan failure
0
10
2
9.00
20
15 8
Permanent
0
0
779, unrelated cause
3
7.72
21
10 8
Permanent
0
0
166
4
7.92
14
20 9
Permanent
0
0
144
5
8.17
23
18 10
8
Cutaneous fistula, partial flap necrosis
Persistent neck fistula
Alive
6
6.93
36
15 8
18
Paralytic ileus
0
226
7
7.93
17
18 11
Speech prosthesis
0
0
Alive
8
7.17
16
18 9
4
0
Late plate exposure
Alive
9
4.75
58
15 5
Permanent
0
0
Alive
10
3.33
19
20 15
0
0
0
Alive
Note: Duration of operation includes all procedures in the operation theater.
(range, 14–58 days). All surviving patients were discharged from hospital and could return to their homes. Four patients died during follow-up, all due to progression of the cancer. One patient died 2 years later of an unrelated cause (►Table 2).
Discussion In this series of SP-LD flaps, we were able to perform cancer resections with curative intention in morbid patients with advanced locoregional head and neck tumors. Despite the dorsal location of the muscle, the skin paddle was designed longitudinal in the anterior border of the latissimus muscle and as distal as possible including the distal muscle. The flap could be harvested in all cases simultaneously with the resection, thus shortening surgical time. We have not observed any problems with the vascularity of the flap in this design. Although one can argue that an operation with microvascular reconstruction is not necessarily longer, these patients were evaluated to have an elevated risk for thromboembolic complications and would not have tolerated possible reoperations. Moreover, the defects after tumor resection were estimated to be very difficult to reconstruct with other local or pedicled flaps. The pedicled latissimus dorsi flap has been proven to be a useful flap in head and neck reconstructions with reliable results.22,27,28 However, the popularity of this flap has diminished due to the availability of various free flap options. The flap in our series is the same, but the patient selection has changed. With advances in perioperative and intensive care, patients previously considered nonoperable can now be treated. In some patients, the method of reconstruction may be limited by general health factors precluding general anesthesia, and even a microvas-
cular reconstruction with a latissimus dorsi free flap has been preformed under locoregional anesthesia.29 In spite of this, not all patients will survive complex surgical treatments and more simple reconstructive options will always be needed. The SP-LD offers many qualities required in these situations. The SP-LD flap enables a two-team approach with simultaneous resection and reconstruction without the need for repositioning the patient. The operation time for the SP-LD is shorter and the postoperative requirements are less complex than in microvascular surgery. In addition, the pedicle of the SP-LD is situated outside the field of resection and previous irradiation.28 The anatomy of the latissimus dorsi flap is constant and reliable with a long pedicle of good caliber.28 The muscle part is large, pliable, and often thin. The subcutaneous tissue in this patient group is usually very thin and the skin island can nearly always be positioned as needed in the reconstruction. In our experience, the flap can be reached to the temporal area with this anterior tunneling. In some patients, it could be possible to reach the vertex of the scull as cited, though we have not tried it.27 In avoiding compression of the pedicle meticulous ligation of all branches of the thoracodorsal vein up, the axillary vein is important to avoid kinking of the pedicle. The most proximal part of the latissimus muscle, cephalic to the entrance of the vessels can be resected. The tightest area of the tunnel for the pedicle is at the region where pectoralis major muscle is attached to the clavicle. The pectoralis muscle is separated for three fingers to give space for the pedicle to continue above the clavicle and to the neck. Care was taken postoperatively to avoid external compression to the area of the pedicle. In this design, no compression of the pedicle was observed in our patients. The cutaneous perforators enable two separate skin islands for Journal of Reconstructive Microsurgery
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Table 2 Results and complications of the patients with SP-LD reconstruction
SP-LD in Head and Neck Reconstruction
Wilkman et al.
intra- and extraoral reconstructions if needed, and reconstruction plates or exposed bone can be covered with the well vascularized muscular part. The flap is also possible to design as a skin-only perforator flap to achieve an even longer pedicle. The thoracodorsal vessels are seldom affected by atherosclerotic disease, and the pedicle vessels are thus reliable also in older patients with serious comorbidity.22,25 Donor-site morbidity of the latissimus dorsi musculocutaneous flap harvest is well tolerated and aesthetically acceptable as the donor site can be closed primarily. Esthetics of a posterior longitudinal scar for the donor site is unsightly but considering the major surgery performed, it can be tolerated and acceptable. Studies on shoulder function have also shown that the recovery of strength and motion is acceptable after the use of the latissimus dorsi muscle.30–33 It is difficult to estimate the isolated effect of the flap for the neck and shoulder function because these patients have had primarily a modified neck dissection as well as postoperative radiotherapy for the neck, both having a major impact on the neck and shoulder function. In addition, in contrast with a free flap, the three-dimensional positioning of the flap is limited by the orientation of the pedicle. The muscle part of SP-LD is larger and thinner and more pliable compared with the pectoralis major flap or trapezius flap. The skin island of SP-LD is reliable and can be designed much larger than in the pectoralis major or trapezius flaps. By using the SP-LD flap, the bulk of the tunneled pedicle is less comparing to the pectoralis major because the proximal muscle can be trimmed without compromising the vascularity of the distal flap. In addition, the SP-LD has a longer pedicle and thus reaches further than either the pectoralis major flap or trapezius flap.34–36 In this study, the SP-LD flap was used in mandible reconstructions, but it also demonstrated its usefulness in laryngopharyngectomies, where double layers consisting of muscular and cutaneous parts could be sutured and anastomosed separately reducing the risk of leakage and fistulas. No other pedicled flap in the head and neck region can provide similar versatility in our opinion. In this high-risk group of 10 patients, 4 patients had major early or late complications. However, 9 out of 10 patients could be discharged from the hospital and were able to return to independent daily living. It can be postulated that the shorter operation time and less demanding postoperative needs in comparison with microvascular surgery was a smaller burden to our patients. However, comparing pedicled and microvascular reconstructions in this setting is not possible because the patient selection was different. Four of our patients died of the cancer during the follow-up period. Although our patients had an aggressive cancer and poor general health resulting in a limited life expectancy, they were still in need of operative treatment to enable an acceptable quality of life.
reliable and useful method for those cancer patients who are not candidates for microvascular surgery but who still require a complex reconstruction. The rediscovered SP-LD flap has become a useful tool in the treatment of difficult head and neck tumors in our unit.
Funding No external financial funding was used in this study.
References 1 Deschler DG, Hayden RE. Head and neck reconstruction. Neuro-
imaging Clin N Am 1996;6(2):505–514 2 Disa JJ, Cordeiro PG. Mandible reconstruction with microvascular
surgery. Semin Surg Oncol 2000;19(3):226–234 3 Hurvitz KA, Kobayashi M, Evans GR. Current options in head and
neck reconstruction. Plast Reconstr Surg 2006;118(5):122e–133e 4 Leonard AG. Musculocutaneous flaps in head and neck reconstruc-
tion. Ann R Coll Surg Engl 1989;71(3):159–168 5 Urken ML, Buchbinder D, Costantino PD, et al. Oromandibular
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Conclusions The SP-LD flap is a versatile flap that can be used in various types of head and neck reconstructions. It seems to be a Journal of Reconstructive Microsurgery
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reconstruction using microvascular composite flaps: report of 210 cases. Arch Otolaryngol Head Neck Surg 1998;124(1):46–55 Disa JJ, Cordeiro PG. Mandible reconstruction with microvascular surgery. Semin Surg Oncol 2000;19(3):226–234 Fairbanks GA, Hallock GG. Facial reconstruction using a combined flap of the subscapular axis simultaneously including separate medial and lateral scapular vascularized bone grafts. Ann Plast Surg 2002;49(1):104–108, discussion 108 Guo L, Ferraro NF, Padwa BL, Kaban LB, Upton J. Vascularized fibular graft for pediatric mandibular reconstruction. Plast Reconstr Surg 2008;121(6):2095–2105 Wells MD. Part I. Mandibular reconstruction using vascularized bone grafts. J Oral Maxillofac Surg 1996;54(7):883–888 Takushima A, Harii K, Asato H, Momosawa A, Okazaki M, Nakatsuka T. Choice of osseous and osteocutaneous flaps for mandibular reconstruction. Int J Clin Oncol 2005;10(4):234–242 Fischer JP, Sieber B, Nelson JA, et al. A 15-year experience of complex scalp reconstruction using free tissue transfer-analysis of risk factors for complications. J Reconstr Microsurg 2013;29(2): 89–97 al Qattan MM, Boyd JB. Complications in head and neck microsurgery. Microsurgery 1993;14(3):187–195 Genden EM, Rinaldo A, Suárez C, Wei WI, Bradley PJ, Ferlito A. Complications of free flap transfers for head and neck reconstruction following cancer resection. Oral Oncol 2004;40(10):979–984 Jereczek-Fossa BA, Orecchia R. Radiotherapy-induced mandibular bone complications. Cancer Treat Rev 2002;28(1):65–74 Alam DS, Nuara M, Christian J. Analysis of outcomes of vascularized flap reconstruction in patients with advanced mandibular osteoradionecrosis. Otolaryngol Head Neck Surg 2009;141(2): 196–201 Chia HL, Wong CH, Tan BK, Tan KC, Ong YS. An algorithm for recipient vessel selection in microsurgical head and neck reconstruction. J Reconstr Microsurg 2011;27(1):47–56 Amin AA, Sakkary MA, Khalil AA, Rifaat MA, Zayed SB. The submental flap for oral cavity reconstruction: extended indications and technical refinements. Head Neck Oncol 2011;3:51 Berenholz L, Kessler A, Segal S. Platysma myocutaneous flap for intraoral reconstruction: an option in the compromised patient. Int J Oral Maxillofac Surg 1999;28(4):285–287 Yu BT, Hsieh CH, Feng GM, Jeng SF. Clinical application of the internal mammary artery perforator flap in head and neck reconstruction. Plast Reconstr Surg 2013;131(4):520e–526e
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pedicled flap in head and neck reconstruction: retrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital. J Otolaryngol 2001;30(1):34–40 Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg 2006;35(3):199–207 Barton FE Jr, Spicer TE, Byrd HS. Head and neck reconstruction with the latissimus dorsi myocutaneous flap: anatomic observations and report of 60 cases. Plast Reconstr Surg 1983;71(2): 199–204 Har-El G, Bhaya M, Sundaram K. Latissimus dorsi myocutaneous flap for secondary head and neck reconstruction. Am J Otolaryngol 1999;20(5):287–293 Quillen CG, Shearin JC Jr, Georgiade NG. Use of the latissimus dorsi myocutaneous island flap for reconstruction in the head and neck area: case report. Plast Reconstr Surg 1978;62(1):113–117 Quillen CG. Latissimus dorsi myocutaneous flaps in head and neck reconstruction. Plast Reconstr Surg 1979;63(5):664–670 Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction of the mandible with osseous free flaps: a 10-year experience with 150 consecutive patients. Plast Reconstr Surg 1999;104(5):1314–1320 Olivari N. The latissimus dorsi flap, experience with 51 operations. Acta Chir Belg 1980;79(2):111–114 Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg 1981;67(5):631–636 Carey JN, Watt AJ, Ho O, Zeidler K, Lee GK. Free flap scalp reconstruction in a 91-year-old patient under local-regional an-
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esthesia: case report and review of the literature. J Reconstr Microsurg 2012;28(3):189–193 30 Adams WP Jr, Lipschitz AH, Ansari M, Kenkel JM, Rohrich RJ.
Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg 2004;53(1):6–11 31 Clough KB, Louis-Sylvestre C, Fitoussi A, Couturaud B, Nos C. Donor
site sequelae after autologous breast reconstruction with an extended latissimus dorsi flap. Plast Reconstr Surg 2002;109(6): 1904–1911 32 Russell RC, Pribaz J, Zook EG, Leighton WD, Eriksson E, Smith CJ.
Functional evaluation of latissimus dorsi donor site. Plast Reconstr Surg 1986;78(3):336–344 33 Salmi A, Tuominen R, Tukiainen E, Asko-Seljavaara S. Morbidity of
donor and recipient sites after free flap surgery. A prospective study. Scand J Plast Reconstr Surg Hand Surg 1995;29(4):337–341 34 Dedivitis RA, Guimarães AV. Pectoralis major musculocutaneous
flap in head and neck cancer reconstruction. World J Surg 2002; 26(1):67–71 35 Schuller DE. Pectoralis myocutaneous flap in head and neck cancer
reconstruction. Arch Otolaryngol 1983;109(3):185–189 36 Chen WL, Yang ZH, Zhang DM, Huang ZQ, Fan S, Wang L. Recon-
struction of major full cheek defects with combined extensive pedicled supraclavicular fasciocutaneous island flaps and extended vertical lower trapezius island myocutaneous flaps after ablation of advanced oral cancer. J Oral Maxillofac Surg 2012;70(5): 1224–1231
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Wilkman et al.
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163
The Pedicled Latissimus Dorsi Flap in Head and Neck Reconstruction: An Old Method Revisited Sinikka Suominen, MD, PhD1
1 Department of Plastic Surgery, Helsinki University Central Hospital,
Helsinki University, Helsinki, Finland 2 Department of Otorhinolaryngology—Head and Neck Surgery, Helsinki University Central Hospital, Helsinki University, Helsinki, Finland
Leif Back, MD, PhD2
Jyrki Vuola, MD, PhD1
Address for correspondence Tommy Wilkman, MD, DDS, Department of Plastic Surgery, Helsinki University Hospital, PO 266, 00029 HUS, Helsinki, Finland (e-mail: tommy.wilkman@hus.fi).
J Reconstr Microsurg 2014;30:163–170.
Abstract
Keywords
► head and neck surgery ► reconstruction ► latissimus dorsi musculocutaneous flap
In head and neck cancer patients with significant comorbidities, the reconstructive options are limited, and there is a need for a safe alternative for microvascular flaps without compromising flap size. During the study period, 331 head and neck cancer patients were reconstructed with microvascular tissue flaps. Ten patients requiring large resections were considered to have high risks for long surgery and to be poor candidates for free tissue transfer and thus were reconstructed with a subpectorally tunneled pedicled latissimus dorsi (SP-LD) flap. The flap was raised simultaneously with the tumor resection and tunneled to the head and neck region. The flap was used for reconstruction of oral, mandibular, pharyngeal, or neck defects. Median follow-up was 3.6 years. Median duration of surgery was 7 hours and 17 minutes, and total hospital stay was 20 days. During the follow-up, four patients died of their disease and one from another cause (median of 329 days). We were able to perform large tumor resections with a curative intent and reconstruct major defects in high-risk head and neck cancer patients with a SP-LD flap. It possesses many of the characteristics of a free flap with the benefits of a shorter operation time and less perioperative risk.
In complex three-dimensional reconstructions, different tissues and organs should be restored by the principle of replacing like with like. Optimally, this includes both functional and structural reconstructions using composite tissues such as skin, fat, bone, muscle, and even mucosal lining with adequate blood supply and sensory abilities, as well as having the ability to withstand the mechanical and motional stress developed in the area.1–5 Reconstruction with microvascular free tissue transfer is considered as the primary method in large or complex defects.6–11 Secondary options may be needed in cases of cancer recurrence, following complications of the primary microvascular reconstruction12,13 or oncological treatment, such as osteoradionecrosis and in patients lacking usable ves-
sels.14–16 In addition, patients with poor general health should be assessed for minimally invasive reconstructive procedures. The most popular pedicled flaps in the head and neck area are the pectoral flap, the trapezius flap, and the latissimus dorsi flap. Today, their perforator variations are becoming increasingly popular as these flaps can be thinner and the pedicle longer. Other useful options are the submental and supraclavicular flaps,17,18 as well as the internal mammary artery perforator flap19; however, these are smaller in flap size.20–26 Although microvascular free tissue reconstruction is the primary method in our unit, we have looked for a safer alternative in high-risk patients. We have used the
received June 6, 2013 accepted after revision August 12, 2013 published online December 9, 2013
Copyright © 2014 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0033-1357497. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Tommy Wilkman, MD, DDS1 Patrik Lassus, MD, PhD1
SP-LD in Head and Neck Reconstruction
Wilkman et al.
subpectorally tunneled pedicled latissimus dorsi (SP-LD) musculocutaneous flap in those head and neck cancer patients in whom large resections and reconstructions are necessary but present with poor health and high operative risk. The purpose of this study was to evaluate the use of the flap, analyze the complications and patient outcome, as well as its suitability in this high-risk patient group.
Patients and Methods This study was approved by the Research Ethical Board of Helsinki University Central Hospital, Helsinki, Finland, May 11, 2011. During the years 2008 to 2011, 2,170 patients were assessed pre- and postoperatively in a weekly multidisciplinary head and neck cancer board. During this period, 341 patients had defects requiring microvascular flaps, but 10 of them were reconstructed with the SP-LD flap. These 10 patients had large tumors but were evaluated to be too high risk for microvascular tissue transfer. Data were collected from the patients’ hospital records. The median age of these 10 patients was 65 years (range, 47– 82 years), 6 were male and 4 were female. Of these patients, five suffered from oral cancer with mandibular invasion, two presented with laryngeal carcinoma requiring laryngophar-
yngectomy, and one patient had a tongue cancer requiring total glossectomy. In addition, two patients had large metastases in the cheek and neck region. In the patients who underwent mandibulectomy, the mandible was reconstructed with a reconstructive plate (Synthes Matrix Mandible Reconstruction plate 2.5 mm; Synthes GmbH, Zuchwil, Switzerland). All patients had severe comorbidities such as universal atherosclerosis, chronic obstructive pulmonary disease, and malnutrition. In three patients, the severity of alcoholism and the problems with compliance were considered a contraindication for microvascular surgery. In these patients, chemoirradiation therapy was also precluded leaving surgery to be the only treatment modality. Of the authors, P.L. participated in all operations (►Table 1).
Surgical Technique The operation began with tracheostomy and extraction of any infected teeth. The patient was placed in a semidecubital position, and the flap dissection and tumor resection were performed simultaneously by two teams. The latissimus dorsi skin island was designed longitudinally overlying the anterior border of the muscle and reaching as distally as possible. The flap was raised in the standard fashion. All branches of the thoracodorsal pedicle up to the axillary vessels were ligated to
Table 1 Patient data Patient age/sex
General health
Cancer region
Resection and osseous reconstruction
Previous treatments
82/F
Cerebral infarction, severe malnutrition
Base of mouth
Subtotal glossectomy, mandible (reconstruction plate)
None
64/M
COPD, smoker 100 pack years
Base of mouth
Hemiglossectomy, mandible (reconstruction plate)
None
66/M
Cerebral infarction, hypertension, atrial fibrillation
Tongue
Total glossectomy, mandible (reconstruction plate)
None
79/M
Hypertension, multiple venous thromboses, permanent anticoagulation, smoker 50 pack years
Subglottal
Laryngopharyngectomy
None
64/F
COPD, aortic valve stenosis, smoker 40 pack years
Unknown primary, neck metastases
Extended radical neck dissection
None
73/M
COPD, hypertension, atherosclerotic disease, chronic kidney failure
Submandibular gland metastases
Full-thickness cheek resection, mandible (reconstruction plate)
2006 submandibular gland cancer, neck dissection, 2008 skin metastases operated, radiation therapy
47/M
Alcoholism, smoker 25 pack years
Hypopharynx
Laryngopharyngectomy
2009 chemo- and radiation therapy
51/F
Alcoholism, brain contusion, epilepsy, malnutrition
Tongue
Full-thickness cheek resection, mandible (reconstruction plate)
2010 resection of tongue, neck dissection, radiation therapy, 2010 resection relapse
58/M
Alcoholism, smoker, hypertension
Tongue
Total glossectomy, soft palate/ tonsils
Anterolateral thigh flap, second ALT, pectoralis major flap for fistula 2011
70/F
SLE, several prior malignancies
Squamous cell cancer metastases
Cheek and neck skin
2007 submental flap, 2010 bilateral neck dissection
Abbreviations: ALT, Anterolateral thigh flap; COPD, chronic obstructive pulmonary disease; F/M, female/male; SLE, systematic lupus erythematosus. Journal of Reconstructive Microsurgery
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Fig. 3 Semidecubital position with two-team approach. SP-LD skin island is situated longitudinally in the anterior border of the latissimus dorsi. Size of the skin island is 18 9 cm. SP-LD, subpectorally tunneled pedicled latissimus dorsi.
Fig. 1 A 51-year-old woman with alcoholism, brain contusion, epilepsia, and malnutrition. Previous resection of Stage IVA tongue cancer with bilateral neck dissection and radiation therapy. The patient presented large neck metastases invading mandible.
prevent kinking of the pedicle that was rotated 180 degrees when the flap was brought to the neck. To prevent muscular contractions, 2 cm of the thoracodorsal nerve was resected and to avoid bulk in the neck, the proximal part of the muscle cephalic to the vessels was resected. A tunnel was created from the axilla to the clavicle between the pectoralis major and minor muscles. A 5-cm segment of the insertion of the pectoralis major muscle was divided, and the tunnel was continued into the neck. The flap was then delivered to the neck or oral region. A short transverse supraclavicular incision was made for access and control of
Fig. 2 Full-thickness resection of the skin, floor of the mouth, and mandible. The mandible was fixed with external fixator before the resection and reconstructed with an AO 2.4-mm reconstruction plate.
the pedicle. The donor site was closed primarily. Postoperatively, we had no limitations of head movements. Shoulder motion was limited to 90 degrees of abduction and extension for 2 weeks (►Figs. 1–6).
Statistics The data were analyzed using Microsoft Excel 2011 and we report the values as median and ranges for descriptive purposes.
Results Surgery The median duration of the whole procedure was 7 hours and 17 minutes (range, 3 hours and 20 minutes to 9 hours), which included all events performed in the operation theater (e.g., tracheostomy, anesthesia, extraction of teeth, prepping and redraping of the patient, and the actual surgical procedure). The median blood loss was 1,035 mL (range, 600–4,400 mL).
Fig. 4 The flap is mobilized to the axillary vessels, tunneled between the pectoralis muscles, releasing the lateral clavicular insertion of the pectoralis major, and brought to the defect via a supraclavicular secondary incision to secure the pedicle. Journal of Reconstructive Microsurgery
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SP-LD in Head and Neck Reconstruction
SP-LD in Head and Neck Reconstruction
Wilkman et al. resected with a minimum of 3 mm margins in all patients verified by histology.
Early Complications During the primary hospital stay, three patients had major early complications. Patient 1 died 10 days postoperatively of multiorgan failure. Patient 5 had a rupture of the internal carotid artery during tumor resection and developed a skin fistula early in the postoperative period. The carotid artery was successfully repaired but the fistula required a revision and a skin graft during the hospital stay. Patient 6 developed an early paralytic ileus, which was treated conservatively.
Late Complications
Fig. 5 Inset of the flap. The muscle covers the reconstruction plate 360 degrees, and the skin is used to reconstruct both the intra-oral as well as the external defect.
The median size of the skin island of the SP-LD flap was 8.5 16.5 cm (range, 8 10 cm–8 30 cm). There were no total flap losses. In patient 5, a major part of the skin island was lost requiring secondary operation. The cancer was
Two patients had major late complications. Patient 5 had a persistent chronic wound in the neck region and required several reconstructions (free skin graft, local transposition flap, trapezius flap, and pectoral flap). This patient had had previous radiation therapy to the neck region and consequently poor recipient vessels for a microvascular flap. In patient 8, the mandibular reconstruction plate became exposed 2 years after surgery.
Follow-Up Of the nine surviving patients, four were decannulated during the hospital stay and five remained permanently tracheostomied. Of the latter five patients, one laryngopharyngectomy patient was rehabilitated with a speech prosthesis (Provox Atos Medical Ab, Hörby, Sweden). The nine surviving patients were treated in the intensive care unit for 4 days (range, 0–18 days), and the total hospital stay was 20 days
Fig. 6 A 73-year-old man with cancer of submandibular gland, earlier local resection, neck dissection, and radiation therapy. Relapse of the disease with full-thickness cheek resection including mandible. Reconstruction with reconstruction plate and SP-LD, 18 months postoperative. Atrophy of the denervated latissimus muscle and resected proximal muscle resulting in minimal bulk and acceptable esthetics in the neck. (A) Frontal view and (B) lateral view. Journal of Reconstructive Microsurgery
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Patient
Duration of operation (h)
Hospital stay (d)
Size of skin flap (cm)
Need of tracheostomy (d)
Early major complications
Late major complications
Survival (d)
1
5.25
–
15 10
–
Early multiorgan failure
0
10
2
9.00
20
15 8
Permanent
0
0
779, unrelated cause
3
7.72
21
10 8
Permanent
0
0
166
4
7.92
14
20 9
Permanent
0
0
144
5
8.17
23
18 10
8
Cutaneous fistula, partial flap necrosis
Persistent neck fistula
Alive
6
6.93
36
15 8
18
Paralytic ileus
0
226
7
7.93
17
18 11
Speech prosthesis
0
0
Alive
8
7.17
16
18 9
4
0
Late plate exposure
Alive
9
4.75
58
15 5
Permanent
0
0
Alive
10
3.33
19
20 15
0
0
0
Alive
Note: Duration of operation includes all procedures in the operation theater.
(range, 14–58 days). All surviving patients were discharged from hospital and could return to their homes. Four patients died during follow-up, all due to progression of the cancer. One patient died 2 years later of an unrelated cause (►Table 2).
Discussion In this series of SP-LD flaps, we were able to perform cancer resections with curative intention in morbid patients with advanced locoregional head and neck tumors. Despite the dorsal location of the muscle, the skin paddle was designed longitudinal in the anterior border of the latissimus muscle and as distal as possible including the distal muscle. The flap could be harvested in all cases simultaneously with the resection, thus shortening surgical time. We have not observed any problems with the vascularity of the flap in this design. Although one can argue that an operation with microvascular reconstruction is not necessarily longer, these patients were evaluated to have an elevated risk for thromboembolic complications and would not have tolerated possible reoperations. Moreover, the defects after tumor resection were estimated to be very difficult to reconstruct with other local or pedicled flaps. The pedicled latissimus dorsi flap has been proven to be a useful flap in head and neck reconstructions with reliable results.22,27,28 However, the popularity of this flap has diminished due to the availability of various free flap options. The flap in our series is the same, but the patient selection has changed. With advances in perioperative and intensive care, patients previously considered nonoperable can now be treated. In some patients, the method of reconstruction may be limited by general health factors precluding general anesthesia, and even a microvas-
cular reconstruction with a latissimus dorsi free flap has been preformed under locoregional anesthesia.29 In spite of this, not all patients will survive complex surgical treatments and more simple reconstructive options will always be needed. The SP-LD offers many qualities required in these situations. The SP-LD flap enables a two-team approach with simultaneous resection and reconstruction without the need for repositioning the patient. The operation time for the SP-LD is shorter and the postoperative requirements are less complex than in microvascular surgery. In addition, the pedicle of the SP-LD is situated outside the field of resection and previous irradiation.28 The anatomy of the latissimus dorsi flap is constant and reliable with a long pedicle of good caliber.28 The muscle part is large, pliable, and often thin. The subcutaneous tissue in this patient group is usually very thin and the skin island can nearly always be positioned as needed in the reconstruction. In our experience, the flap can be reached to the temporal area with this anterior tunneling. In some patients, it could be possible to reach the vertex of the scull as cited, though we have not tried it.27 In avoiding compression of the pedicle meticulous ligation of all branches of the thoracodorsal vein up, the axillary vein is important to avoid kinking of the pedicle. The most proximal part of the latissimus muscle, cephalic to the entrance of the vessels can be resected. The tightest area of the tunnel for the pedicle is at the region where pectoralis major muscle is attached to the clavicle. The pectoralis muscle is separated for three fingers to give space for the pedicle to continue above the clavicle and to the neck. Care was taken postoperatively to avoid external compression to the area of the pedicle. In this design, no compression of the pedicle was observed in our patients. The cutaneous perforators enable two separate skin islands for Journal of Reconstructive Microsurgery
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Table 2 Results and complications of the patients with SP-LD reconstruction
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Wilkman et al.
intra- and extraoral reconstructions if needed, and reconstruction plates or exposed bone can be covered with the well vascularized muscular part. The flap is also possible to design as a skin-only perforator flap to achieve an even longer pedicle. The thoracodorsal vessels are seldom affected by atherosclerotic disease, and the pedicle vessels are thus reliable also in older patients with serious comorbidity.22,25 Donor-site morbidity of the latissimus dorsi musculocutaneous flap harvest is well tolerated and aesthetically acceptable as the donor site can be closed primarily. Esthetics of a posterior longitudinal scar for the donor site is unsightly but considering the major surgery performed, it can be tolerated and acceptable. Studies on shoulder function have also shown that the recovery of strength and motion is acceptable after the use of the latissimus dorsi muscle.30–33 It is difficult to estimate the isolated effect of the flap for the neck and shoulder function because these patients have had primarily a modified neck dissection as well as postoperative radiotherapy for the neck, both having a major impact on the neck and shoulder function. In addition, in contrast with a free flap, the three-dimensional positioning of the flap is limited by the orientation of the pedicle. The muscle part of SP-LD is larger and thinner and more pliable compared with the pectoralis major flap or trapezius flap. The skin island of SP-LD is reliable and can be designed much larger than in the pectoralis major or trapezius flaps. By using the SP-LD flap, the bulk of the tunneled pedicle is less comparing to the pectoralis major because the proximal muscle can be trimmed without compromising the vascularity of the distal flap. In addition, the SP-LD has a longer pedicle and thus reaches further than either the pectoralis major flap or trapezius flap.34–36 In this study, the SP-LD flap was used in mandible reconstructions, but it also demonstrated its usefulness in laryngopharyngectomies, where double layers consisting of muscular and cutaneous parts could be sutured and anastomosed separately reducing the risk of leakage and fistulas. No other pedicled flap in the head and neck region can provide similar versatility in our opinion. In this high-risk group of 10 patients, 4 patients had major early or late complications. However, 9 out of 10 patients could be discharged from the hospital and were able to return to independent daily living. It can be postulated that the shorter operation time and less demanding postoperative needs in comparison with microvascular surgery was a smaller burden to our patients. However, comparing pedicled and microvascular reconstructions in this setting is not possible because the patient selection was different. Four of our patients died of the cancer during the follow-up period. Although our patients had an aggressive cancer and poor general health resulting in a limited life expectancy, they were still in need of operative treatment to enable an acceptable quality of life.
reliable and useful method for those cancer patients who are not candidates for microvascular surgery but who still require a complex reconstruction. The rediscovered SP-LD flap has become a useful tool in the treatment of difficult head and neck tumors in our unit.
Funding No external financial funding was used in this study.
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Conclusions The SP-LD flap is a versatile flap that can be used in various types of head and neck reconstructions. It seems to be a Journal of Reconstructive Microsurgery
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