Regional Advancement and Rotation Flaps for Large Defects of the Head and Neck

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Regional Advancement and Rotation Flaps for Large Defects of the Head and Neck

Head and Neck Surgery
Author Credentials 

Tanya Fancy, MD
Assistant Professor
West Virginia University
1 Medical Center Drive
Morgantown, WV

Rusha Patel, MD
Assistant Professor
West Virginia University
1 Medical Center Drive
Morgantown, WV

Module Summary

Loco-regional flaps are an invaluable alternative to free tissue transfer in the reconstruction of large head and neck defects, and offer the advantage of reduced operative time and possibly shorter postoperative hospitalization. A thorough knowledge of the advantages and limitations of the various donor sites (specifically maximal size and arc of rotation) is crucial in choosing the appropriate flap for the anticipated defect.

Module Learning Objectives 
  • Discuss the different local and loco-regional reconstruction options for head and neck defects.
  • Identify patients who would be candidates for reconstruction.
  • Describe angiosome anatomy.
  • Describe the vascular supply to regional and rotation flaps for the head and neck.
  • Be able to identify limitations to regional and rotation flaps.
  • Be familiar with the type and extent of defect that is amenable to loco-regional reconstruction.
  • Discuss methods of surgical salvage for failed reconstructions.

Anatomy

Learning Objectives 

Be able to discuss the anatomic basis of reconstruction.

  1. Describe the difference between random and axial blood supply (including the five types of axial patterns of muscular flaps).
  2. Be able to identify zones of blood supply for each flap based on the angiosome concept.
    1. Primary angiosome
    2. Secondary angiosome
    3. Tertiary angiosome
    4. Choke vessel connections between angiosomes
  3. Be familiar with the vascular supply of regional flaps for head and neck reconstruction.
    1. External carotid system
    2. Subscapularis system
    3. Axillary artery system
  4. Be able to recognize defect subtypes necessitating reconstruction
    1. Oral Cavity
    2. Oropharynx
    3. Glossectomy
    4. Cutaneous
    5. Combination defect
References 
  1. Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck: anatomic study and clinical applications. Plast Reconstr Surg. 2000 Jun; 105(7):2287-313.

Pathogenesis

Learning Objectives 

Be familiar with head and neck defects

  1. Aerodigestive tract malignancies.
  2. Cutaneous malignancies
    1. Primary cutaneous malignancy
    2. Metastatic cutaneous malignancy
  3. Salivary neoplasms.
  4. Trauma.
  5. Fistulae.

Basic Science

Learning Objectives 

Understand patient physiology and factors that affect reconstructive outcome

  1. Age and general health status of the patient.
  2. Coagulopathy risks
    1. Genetic factors
    2. Physiologic factors
      1. Sepsis
      2. Infection

Incidence

Learning Objectives 

Understand the prevalence of head and neck cancer and need for reconstruction.

  1. Incidence in the United States is 3%
    • Advanced stage disease more frequently requires reconstruction.
References 
  1. Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017. CA Cancer J Clin. 2017; 67(1):7.

Genetics

Learning Objectives 

Be familiar with genetic conditions that can affect reconstruction.

  1. Anticoagulant deficiencies
  2. Procoagulant deficiencies
  3. Autoimmune conditions
References 
  1. Kendra G. Bowman, MD, PhD and Matthew J. Carty, MD. Flap Complications and Thrombophilia: An Evidence-Based Model and Cost Analysis for Preoperative Screening. Eplasty. 2011;11:e32.

Patient Evaluation

Learning Objectives 

Be able to identify patient factors that contribute to successful regional reconstruction.

  1. General health.
    1. Complete medical history including comorbidities.
    2. Diabetes, immunocompromise, cardiovascular disease, coagulopathy, previous surgery, and history of poor wound healing should be specifically addressed and optimized.
    3. Additional factors that would direct optimal flap selection e.g. prior axillary dissection, prior neck dissection, type of previous reconstruction, prior irradiation, patient preference etc.
  2. Assessment of the potential soft tissue defect.
    1. Soft tissue volume and surface area
    2. Need for composite reconstruction
  3. Patient body habitus
    1. Cachexia
    2. Obesity
  4. Understand the potential limitations of regional reconstruction
    1. Through-and-through mucosal defects
    2. Composite defects involving bone
References 
  1. Marciano B. Ferrier, MD; Emiel B. Spuesens; Saskia Le Cessie, PhD; et al. Comorbidity as a Major Risk Factor for Mortality and Complications in Head and Neck Surgery. Arch Otolaryngol Head Neck Surg. 2005;131(1):27-32.
  2. Harvey Chim, MD,1 Christopher J. Salgado, MD,2 Rimante Seselgyte, MD, et al. Principles of Head and Neck Reconstruction: An Algorithm to Guide Flap Selection. Semin Plast Surg. 2010 May;24(2):148–154.

Measurement of Functional Status

Learning Objectives 

Recognize patient functional status and relationship to reconstruction

  1. Swallowing function
  2. Dentition status
  3. Medical co-morbidities

Imaging

Learning Objectives 

Although no specific imaging is warranted prior to advancement or rotational flap placement, imaging to assess extent of disease (and therefore defect size) is generally necessary.

Identify the imaging tests of choice and their usefulness in determining defect extent

  1. Computed tomography (CT) scan with contrast.
  2. Magnetic resonance imaging (MRI).
  3. PET/CT
  4. Vascular studies

- CT angiogram can be used to assess flap pedicle

References 
  1. Adams, AS, Wright, MJ, Johnston, S. The use of multislice CT angiography preoperative study for supraclavicular artery island flap harvesting. Ann Plast Surg. 2012;69:312-315.

Pathology

Learning Objectives 

Know the primary pathology in the head and neck is squamous cell carcinoma.

Be able to discuss different malignancies that may require reconstruction.

  1. Primary or metastatic cutaneous carcinoma
    • Cutaneous squamous cell carcinoma
    • Cutaneous basal cell carcinoma
    • Melanoma
  2. Primary salivary malignancy
  3. Sarcoma

Medical Therapies

Learning Objectives 

Identify some options available in cases of flap compromise such as hirudotherapy, nitropaste etc.

Pharmacology

Learning Objectives 

Be able to discuss the role of vasoactive medication for regional reconstruction.

  1. Nitroglycerine
  2. Aspirin
  3. Heparin
References 
  1. Nguyen MQ et al. Outcomes of flap salvage with medicinal leech therapy. Microsurgery. Jul 2012; 32(5): 351-357.

Surgical Therapies

Learning Objectives 

Know the common reconstructive sites and applications for head and neck defects.

  1. Pectoralis major myocutaneous flap
  2. Supraclavicular island flap
  3. Submental artery island flap
  4. Pedicled latissimus dorsi flap
  5. Trapezius flap
  6. Cervicofacial flap
  7. Platysma myocutaneous flap
  8. Combination flaps
  • Larger defects may require several regional reconstructions to close the defect.
  • Defects and commonly used flaps:
    1. Oral cavity/Oropharynx: Submental artery island, supraclavicular artery island, pectoralis major, platysma flap
    2. Larynx: Pectoralis major, supraclavicular artery island
    3. Tongue: Submental artery island, supraclavicular artery island, pectoralis major, platysma flap
    4. Lateral skull base: Supraclavicular artery island flap, submental artery island flap, cervicofacial flap, pectoralis major, trapezius, pedicled latissimus dorsi
    5. Scalp: Trapezius, pedicled latissimus, cervicofacial advancement
    6. Neck and face: cervicofacial advancement, pectoralis major, supraclavicular artery island flap, pedicled trapezius
References 
  1. Pink R, Dvorak Z, Michl P, Heinz P, Tvrdy P (2017) Regional Flap in Head and Neck Reconstruction- Part I: Philosophy, Submental and Supraclavicular Flaps. Dentistry 7:433.
  2. Urken, Mark L. Atlas of Regional and Free Flaps for Head and Neck Reconstruction: Flap Harvest and Insetting. Wolters Kluwer Health/Lippincott Williams & Wilkins, 2012.
  3. Patel UA, Hartig GK, Hanasono MM et al. Locoregional Flaps for Oral Cavity Reconstruction: A Review of Modern Options. Otolaryngol Head Neck Surg. 2017 Aug;157(2):201-209.
  4. Jangpreet Singh Multani, Gurinderjit Singh Nagi, Baljit Singh Bajwa. Local and Locoregional Flaps in Head and Neck Defects Journal of Evolution of Medical and Dental Sciences. 2015;4(1):12-16.
  5. Fang Z, He J, Jin S, Zhang Y, He Y. Pedicled latissimus dorsi myocutaneous flap for large neck defect reconstruction. Annals of Oral & Maxillofacial Surgery 2013 Oct 13;1(3):29.

Rehabilitation

Learning Objectives 

Explain the particular rehabilitative challenges associated defect reconstruction.

  1. Preoperative evaluation by a speech pathologist.
  2. Use of dynamic modified barium swallows to guide rehabilitation.

Staging

Learning Objectives 

Recognize that a universal AJCC staging system is utilized to describe size of the primary tumor.

Complications

Learning Objectives 

Be familiar with potential complications of regional reconstruction.

  1. Regional flap failure due to pedicle injury or random blood supply.
  2. Poor functional outcome.
  3. Donor site morbidity.

Review

Review Questions 

Discuss what you would consider the appropriate local or regional flap for a large defect involving

  1. Vertex and occipital scalp
  2. Radical parotidectomy with auriculectomy and right facial skin resection
  3. Total laryngopharyngectomy
  4. Partial glossectomy with FOM resection and marginal mandibulectomy
Resources 

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  1. Annual Meeting Webcast (AMW):