HEAD AND NECK SURGERY
A Comparative Study of Lateral Extension Versus Conventional Deltopectoral Flap in Head and Neck Reconstruction After Surgical Extirpation of Tumor Mohd Altaf Mir, MCH, Mohd Yaseen, MCh, and Mohd Fahud Khurram, MCh
(Ann Plast Surg 2018;80: 130–136)
T
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he reliable reconstruction of postsurgical defects is always challenging in head and neck cancer patient that has been made possible by the development and application of different flap techniques. It is possible to reconstruct most defects immediately, which leads to better restoration of form and function.1 Free microvascular and regional flaps are the main reconstructive options for reconstruction of head and neck defects after surgical extirpation of head and neck cancer. The free microvascular flap allows more reliable designs but donor site morbidity, such as reduced strength and sensation, is still unavoidable when harvesting these flaps.2 The donor sites of CDP/LEDP flaps are often concealed, which is the advantage over the radial forearm free microvascular flap donor site. The potential use of CDP/LEDP flaps in head and neck reconstruction in this era where microsurgery really has revolutionized head and neck reconstruction is still felt necessary in certain situations where the need for a free microvascular flap can be eliminated such as after chemotherapy/ radiotherapy, when 2 flaps are needed; one free microvascular flap and other pedicled locoregional flap for lining and coverage, and when the expertise or the facilities of microvascular surgery are unavailable. Bakamjian,3 in 1965, first described a 2-stage deltopectoral (DP) flap based on perforators of the internal mammary artery for pharyngoesophageal reconstruction. In that era, the DP flap was a major breakthrough in reconstructing the head and neck defects after large ablative resections, which made it quite popular in head and neck reconstructions. The Received June 15, 2017, and accepted for publication, after revision June 29, 2017. From the Department of Plastic and Reconstructive Surgery, Aligarh Muslim University, Aligarh, Uttar Pradesh, India. Conflicts of interest and sources of funding: none declared. Reprints: Mohd Altaf Mir, MS, Department of Plastic and Reconstructive Surgery, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Uttar Pradesh, India 202002. E-mail:
[email protected]. Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/18/8002–0130 DOI: 10.1097/SAP.0000000000001206
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MATERIAL AND METHODS
This study was conducted in the Postdoctoral Department of Burns, Plastic and Reconstructive Surgery of our institution from November 2014 to January 2017. It has been approved by the institutional ethical committee. Formal informed consent for the procedure, clinical photography, and publication for academic purposes has been taken from all the cases. The patients with previous surgery on internal mammary artery, traumatic/surgical scar in the territory of DP flap, nonconsenting patients, and patients unfit for anaesthesia were excluded from the study. Fifteen CDP flaps and 17 LEDP flaps were raised in 32 patients after ablation of head and neck cancers. Data on the age, sex, tumor site, and preoperative chemotherapy and radiotherapy were analyzed. Harvesting of both flaps followed the method of Bakamjian,3 using a broad base that routinely incorporates the first 3 to 4 intercostal perforating branches of the internal mammary artery. However, the distal end of the LEDP flap was extended laterally beyond the DP groove with or without L-shaped extension around the upper arm, and all the flaps were nondelayed immediately. The lateral extension random part of LEDP flaps were raised with the breadth to length ratio of 1:1.5 or less. The blood supply of the flap was examined 3 weeks later by surgical delay and dividing of pedicle base at the second stage. The proximal portion of the flap pedicle was returned to the chest wall during the second stage. The flaps were folded only in the LEDP flap group. Six of 17 LEDP flaps were folded to become bilayered flaps to repair full thickness defects. A loss of more than 2 cm of the entire flap was defined as a flap loss, and a loss of less than 2 cm was defined as marginal necrosis. A loss of more than one fourth of the entire flap was defined as complete flap loss, and a loss of less than one fourth of the entire flap was defined as partial flap loss. Partial and complete flap loss were defined as major complications. A dehiscence, marginal necrosis, seroma, or hematoma leading to impairment of wound healing was defined as a minor complication. Risk factors (chemotherapy and radiotherapy), size of the harvested flap, harvesting time, flap success rates, and complication rates were analyzed and compared between the CDP flap and LEDP flap groups. The data was tabulated in excel spread sheet and was followed by statistical analysis with Pearson χ2 test and Student t test using SPSS version 23 statistical tool. A P < 0.05 was considered statistically significant difference of observation.
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Key Words: deltopectoral flap, lateral extension, nondelayed flap, head and neck reconstruction
advantages of DP flap transfer are its ease of use, a vascular supply that is easy to forecast, an acceptable success rate, and minimal morbidity at donor sites. Bakamjian et al4 also suggested a modified lateral extension deltopectoral (LEDP) flap approach, but he advised delay procedure approximately 2 weeks before the main operation. The following report describes our experience with conventional DP (CDP) and immediate nondelayed LEDP flaps in head and neck reconstructions after surgical extirpation of tumor, which may enhance and renew the application of the DP flaps.
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Background: We investigated outcomes for nondelayed conventional deltopectoral (CDP) flaps and lateral extension deltopectoral (LEDP) flaps. Material and Methods: Fifteen CDP flaps and 17 LEDP flaps were raised in 32 patients. All flaps were nondelayed. The flaps were folded only in the LEDP flap group. Six of 17 LEDP flaps were folded to become bilayered flaps to repair full thickness defects. Flap success rates and complication rates were compared between the CDP flap and LEDP flap groups. Results: Success rates were 93.33% in the CDP flap group and 94.12% in the LEDP flap group. Overall complication rates of the transferred flaps were 6.67% and 11.76% for CDP and LEDP flaps, respectively. Flap failure rates were 6.67% and 5.88% with CDP flaps and LEDP flaps, respectively. Conclusions: Although the CDP flap is the “aged workhorse” in contemporary head and neck reconstructions, it was shown to be a beneficial regional flap with a dependable pedicle and easy technique. The LEDP flap is of value particularly when used to treat full thickness defects of the head and neck or in cases when higher reach is required.
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RESULTS Of the 32 head and neck cancers, all were squamous cell carcinomas (SSCs). All were male patients. The mean ages of the patients were almost similar (46.07 ± 8.79 years for CDP flaps vs 44.47 ± 12.15 years Annals of Plastic Surgery • Volume 80, Number 2, February 2018
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Annals of Plastic Surgery • Volume 80, Number 2, February 2018
TABLE 2. Areas Reconstructed Areas Reconstructed
RC LC RC, N LC, N RC, RUL, RLL LC, LUL, LLL RC, RLL LC, LLL
CDP Flap (n = 15)
LEDP Flap (n = 17)
Pearson χ2 Test
P
3 2 2 1 0 0 2 5
4 2 2 1 2 5 0 1
0.058 0.018 0.180 0.008 1.882 5.229 2.418 3.943
0.810 (IS) 0.893 (IS) 0.893 (IS) 0.927 (IS) 0.170 (IS) 0.022 (S) 0.120 (IS) 0.047 (S)
IS indicates insignificant; LC, left cheek; LLL, left lower lip; LUL, left upper lip; N, neck; RC, right cheek; RLL, right lower lip; RUL, right upper lip; S, significant.
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for LEDP flaps). Preoperative chemotherapy or radiotherapy was received by 3 patients in each group. Patient characteristics are summarized in (Table 1). In most of our cases, the left cheek (17 of 32) alone or in combination with lip or neck area was reconstructed. The defect involving the upper lip or above the subnasale plane often required LEDP flaps for reconstruction. Areas reconstructed are summarized in Table 2. The average times of flap harvest were 45.53 ± 3.04 minutes in the CDP flap group and 54.00 ± 5.61 minutes in the LEDP flap group. Mean flap inset area were 48.48 ± 10.14 cm2 in the CDP flap group and 74.94 ± 25.99 cm2 in the LEDP flap group. None of the CDP flaps were folded, whereas there were 6 folded flaps in the LEDP flap group. Donor sites were mostly closed primarily medially over chest and with split thickness skin grafting (STSG) laterally over shoulders. Regarding the success of flap reconstructions, one in the CDP flap group and one in the LEDP flap group exhibited partial flap necrosis. Compared with the CDP flap group, the LEDP flap group had a higher rate of minor complications (6.67% of CDP flaps and 11.76% of LEDP flaps), which were managed conservatively. Overall complication rates of flap transfers were 6.67% for CDP and 11.76% for LEDP flaps. Characteristics of the flaps transferred are given in Table 3. There was no statistically significant difference in complication rates between the CDP and LEDP flap groups (Table 3, 4). Risk factors such as chemotherapy and radiotherapy, smoking, tobacco, betel nut chewing, and alcohol consumption were not observed as significant confounding factors in our study (Table 1). Mean follow-up periods were 8.33 ± 1.29 months in the CDP flap group and 7.76 ± 2.05 months in the LEDP flap group. The functional outcomes regarding speech and swallowing between the 2 groups were assessed on follow-up examination and found satisfactory. The speech was comprehensible in all patients in both the groups. There was no difficulty in swallowing in any patient in either group. Summary of statistical significances of CDP flap versus LEDP flap are summarized in (Table 4).
Lateral Extension Deltopectoral Flap
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A 50-year-old man who is a smoker and a betel nut chewer presented with a well-differentiated left cheek SSC stage IVa with involvement of commissure. The tumor extirpation with margin negativity was achieved. A full thickness defect was reconstructed and performed with ipsilateral LEDP flap with L-shaped extension on the shoulder without delay. The donor site was closed primarily in medial over the chest and TABLE 1. Summary of Patient Characteristics Parameters
CDP Flap
Patients Male Female Age, mean±SD, y
LEDP Flap
15 17 15 17 0 0 46.07 ± 8.79 44.47 ± 12.15
Diagnosis (SCC) Preoperative chemotherapy/ Radiotherapy Alcohol, smoking, betel nut, tobacco
A 35-year-old man who is a smoker, an alcoholic, and a betel nut chewer presented with a poorly differentiated right cheek SSC stage IVa with involvement of right maxilla. The tumor extirpation with margin negativity was achieved. The lining was provided with ipsilateral pectoralis major myocutaneous (PMMC) flap. Coverage was performed with ipsilateral LEDP flap without L-shaped extension and without delay. The donor site was closed primarily in medial over the chest and covered with STSG over the shoulder. The postoperative outcome of flap and donor site remained uneventful (Figs. 6–9).
Case 3
We discuss here 2 cases of LEDP flap for the reconstruction of head and neck defects after extirpation of tumor. In case 1, postsurgical defect was reconstructed with nondelayed LEDP flap with L-shaped extension and in case 2 with LEDP flap without L-shaped extension.
Case 1
Case 2
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Case Representations
covered with STSG over the shoulder. The postoperative outcome of flap and donor site remained uneventful (Figs. 1–5).
15 3
17 3
7
10
IS indicates insignificant.
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Statistics
— — — t = 0.42, P = 0.67 (IS) — χ2 = 0.03, P = 0.86 (IS) χ2 = 0.47, P = 0.49 (IS)
A 39-year-old man who is a smoker and a betel nut chewer presented with an operated case of well-differentiated left cheek SSC stage IVa with left cheek radionecrotic ulcer and a surgical scar on the left side of chest. The postradiation ulcer extirpation with margin negativity was achieved. Coverage was achieved with contralateral CDP flap without delay. The donor site was covered with STSG. The postoperative outcome of flap and donor site remained uneventful (Figs. 10–14).
DISCUSSION
The head and neck defects are challenging to a reconstructive surgeon because of the facial deformities and masticatory disabilities after tumor extirpation. However, there are several methods to choose from the reconstructive ladder when reconstructing a head or neck defect, include secondary intention, primary closure, skin grafting, and mobilizing local or regional tissues.1 The PMMC flaps have been used often than DP flaps for head and neck reconstruction because of its reliable vascular pedicle.5 However, there are 2 significant drawbacks with using this flap.5,6 First, the PMMC flap is too bulky and leads to facial and neck cosmetic issues. Second, it can cause shoulder deformities and disability because of loss of the pectoralis major muscle function. The DP flap is thinner than the PMMC flap and does not compromise the pectoralis major muscle function; thus, it causes neither injury to the chest nor results in functional disabilities. Lateral extension area of DP flap is often hairless, which make it feasible for intraoral reconstruction as well as coverage of nonhairy areas of head and neck. However, there are several drawbacks to using DP flaps, such as the need for a second stage operation for flap division, longer hospitalization, more attention for wound care, and resulting cosmetic problems in the deltoid area. Anatomically, CDP flap is described as a cutaneous pedicle medial to the cephalic vein or deltopectoral groove.7 However, when cutaneous www.annalsplasticsurgery.com
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Annals of Plastic Surgery • Volume 80, Number 2, February 2018
Mir et al
TABLE 3. Summary of Flap Characteristics
Mean Flap Breadth, cm Length, cm Size, cm2 Inset area, cm2 Harvest time, min Mean blood loss During flap harvest, mL Flap reach Above subnasale Folded flap Early complication rate Flap failure rate Flap success rate Follow-up, mean±SD, mo
CDP Flap
LEDP Flap
Student t Test
P
7.20 ± 1.08 16.07 ± 0.80 116.07 ± 20.91 48.48 ± 10.14 45.53 ± 3.04
7.94 ± 0.75 21.56 ± 2.21 171.85 ± 28.17 74.94 ± 25.99 54.00 ± 5.61
t = −2.276 t = −9.111 t = −6.287 t = −3.697 t = −5.200
0.030 (S) 0.000 (S) 0.000 (S) 0.001 (S) 0.000 (S)
27.20 ± 3.75
28.12 ± 3.89
t = −0.678
0.503 (IS)
0 0 1 1 14 8.33 ± 1.29
17 6 2 1 16 7.76 ± 2.05
χ2 = 32.000 χ2 = 6.516 χ2 = 0.244 χ2 = 0.008 χ2 = 0.008 t = 0.925
0.000 (S) 0.011 (S) 0.621 (IS) 0.927 (IS) 0.927 (IS) 0.362 (IS)
IS indicates insignificant; S, significant.
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Parameters
of the flap and early recognition of issues can minimize the postoperative complications.10 Risk factors such as chemotherapy and radiotherapy, smoking, tobacco, betel nut chewing, and alcohol consumption were not observed as significant confounding factors in our study because only 1 patient in each group exhibited flap partial flap loss, and both were not
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pedicle extending laterally beyond the cephalic vein or deltopectoral groove over the shoulder or around the upper arm it is called LEDP flap. In LEDP flaps, medial perfusion is very important. However, the second perforating branch of the internal mammary artery is believed to be the main blood supply to the flap, to help maintain healthy vascularity and adequate perfusion pressure we always used a wide base, which includes the 3 intercostal vessels, as suggested by Bakamjian.3 Muscle-perforating arteries are vital contributors to the cutaneous vascular bed.1 Perfusion pressure and vascularity of the pedicle base are the most important factors in maintaining viability of the flap, even more so than the breadth to length ratio.1 However, the breadth to length ratio is important for maintaining the perfusion pressure and viability of the random lateral part of the LEDP flaps. Flaps are harvested by sharp dissection, and it is important to avoid damaging the subfascial plexus. By allowing preservation of many dermal and subdermal plexuses, LEDP flaps can become as reliable and predictable as CDP flaps. The LEDP flap harvest time takes around 10 to 15 minutes longer than CDP flap harvest, can provide greater length, and make it easier to repair defects of the orbitozygomaticomaxillary region. In addition, LEDP flap can be folded on itself to provide bilayered flaps to achieve both lining and cover, eliminating any requirement for a skin graft or second flap for the lining or coverage. On thorough review of literature, donor site complications and morbidities of CDP and LEDP flaps are fewer than for PMMC and microvascular forearm flaps.8,9 Careful preoperative planning of design TABLE 4. Summary of Statistical Analysis LEDP Flap Versus CDP Flap Statistical Significance, P
Parameters
Flap size Flap harvest time Flap reach Flap folding Bleeding during flap harvest Overall complications Flap necrosis Overall success IS indicates insignificant; S, significant.
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