Prevention of Hair Growth in Myocutaneous Flap Reconstruction Isaac
Eliachar, MD; Dennis H. Kraus, MD; Wilma F. Bergfeld, MD; Harvey M. Tucker, MD
\s=b\ Myocutaneous
flaps play a prominent
role in the immediate reconstruction of surgical defects following ablative oncologic procedures in the head and neck. Transfer of hair-bearing skin into the reconstructed upper digestive tract can be a major disadvantage associated with the
pectoralis major flap. De-epithelialization of skin to the dermal level, removing the majority of skin appendages, can convert a myocutaneous flap to a "myodermal" flap. Platysma myocutaneous and myodermal flaps were grafted into the oral cavity of 13 dogs. Gross and histologic evaluation confirmed decreased hair growth in the experimental myodermal flap. Wound complications and graft survival were similar for both techniques. Diminished hair growth further supports the utility of myodermal flaps in hairy male patients undergoing upper digestive tract reconstruction. (Arch Otolaryngol Head Neck Surg.
1990;116:923-927)
major myocutaneous Theflappectoralis mainstay after ablative of has become
a
in
re¬
construction surgery the head and neck since its introduc¬ tion in 1979. This flap is reliable be¬ cause of its abundant, highly vascular¬ ized tissue, and permits primary, nonstaged reconstruction with acceptable
Accepted for publication March 27,1990. From the Departments of Otolaryngology and Communicative Disorders (Drs Eliachar, Kraus, and Tucker) and Dermatology (Dr Bergfeld), Cleveland (Ohio) Clinic Foundation. Presented at the midwinter meeting of the Association for Research in Otolaryngology, St Petersburg, Fla, February 7, 1989. Reprint requests to the Department of Otolaryngology and Communicative Disorders, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195-5034 (Dr Eliachar).
aesthetic results.1 However, transfer of hair-bearing donor skin into the re¬ constructed upper digestive tract has been a disadvantage, particularly in certain male patients. Myocutaneous flap reconstruction can result in impaired deglutition due to loss of sensation, lack of lubrication, and poor elasticity of an adynamic flap.2 Hair growth in the reconstructed oral or pharyngeal cavity further ag¬ gravates this problem. Stasis of food particles may also lead to halitosis, adding to social isolation of the oncol¬ ogy
patient.
Several flap modifications have been suggested in an attempt to prevent hair growth with variable success. Preoperative chemical or electrical depilation have not eliminated hair growth.3 Skin-grafted muscle flaps may include pilosebaceous units and other hair-generating epidermal ele¬ ments.2 Postoperative radiation ther¬ apy as part of planned, combined treatment has been inconsistent in preventing hair growth.4 Symptomatic trimming and laser epilation have met with limited success.2 The current my¬ odermal modification of myocutaneous flaps was, therefore, assessed for its ability to prevent hair growth in the reconstructed upper digestive tract. MATERIALS AND METHODS Thirteen mongrel dogs placed under gen¬ eral anesthesia, each weighing 10 to 20 kg, were used in this experiment. The cervical region on the dog was shaved. In each ani¬ mal a superiorly based platysma myocuta¬ neous flap (3 cm in diameter) was rotated into the oral cavity through a split-lip inci-
sion as a control. On the contralateral side the epidermal layer of skin was removed with a dermatome, creating a platysma
"myodermal" flap (Fig 1). De-epithelialization depth ranged from 30/1000 inch to 60/ 1000 inch; in three animals at 30/1000 inch, three at 40/1000 inch, four at 50/1000, and three at 60/1000. The myodermal flap was rotated into the oral cavity in an identical manner to the control myocutaneous flap. Clinical observations were recorded at 2 and 4 months. Biopsy procedures were per¬ formed 2 months postoperatively with a 4mm punch forceps. The animals were killed after 4 months. The intraoral flaps were excised, including a surrounding border of normal mucosa. Photographs were ob¬ tained at that time. A punch biopsy of nor¬ mal skin was obtained in each animal and used for comparison with the flaps. The specimens obtained at 2 months were sectioned in the horizontal plane. Those ob¬ tained at 4 months were sectioned in both the horizontal and vertical planes. Normal skin specimens were prepared similarly. All specimens were fixed in 3.7% formalde¬ hyde solution and embedded in paraffin. Five-millimeter sections were stained with hematoxylin-eosin and inspected micro¬ scopically. The horizontal sections were used to determine hair follicle density and the vertical sections were used to assess ep¬ ithelial regeneration.
RESULTS Twelve myocutaneous
flaps and 11 myodermal flaps were evaluated. Clin¬ ical evaluation of the flaps was re¬ corded at 4 months (Table). The con¬ trol myocutaneous flaps retained hair growth and texture similar to external skin. There was no apparent graft contracture. Hair growth in each my¬ odermal flap was judged by compari¬ son
with that of its contralateral,
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con-
Fig 1.—Top left, Donor site adjacent to canine oral cavity, platysma flap outlined. Top right, Removal of epidermis and su¬ perficial dermis forming a myodermal flap. Bottom left, Myodermal flap rotated into buccal surface through split-lip incision. Bottom right, Myodermal flap in place in oral cavity.
trol myocutaneous
flap on a scale of 0 to4.Sixflapswerej udged to have 25 %,
three 50%, and two 75% of normal hair growth (Fig 2). No experimental flaps showed total absence of hair or com¬ pletely normal hair growth. Decreased quantity and finer hair growth was believed to be associated with increas¬ ing depth of de-epithelialization. Con¬ tracture of the flap was evident in four of the myodermal specimens; two had constricted to 75% of the original flap area and two to 50% of normal (Table). Seven specimens had no evidence of flap contracture. Contracture in the flaps correlated with increased depth of de-epithelialization. Microscopic histologie evaluation was performed on the 2- and 4-month specimens. Similar hair follicle den¬ sity was noted between normal skin
biopsy specimens and corresponding myocutaneous control flaps. Of the ex¬ perimental myodermal flaps, six spec¬ imens had mildly decreased hair folli¬ cle density, one had a moderate de¬
and four had a marked decrease (Table). There was no differ¬ ence in hair follicle density between the 2- and 4-month myodermal biopsy specimens, nor was there a correlation between depth of de-epithelialization and decrease in hair follicle density. Rather, hair follicle reduction ap¬ peared to be randomly distributed among the varying depths of de-epi¬ thelialization. However, decrease in hair follicle density was directly re¬ lated to fibrosis and scar formation (Fig 3). In those specimens with a large decrease in hair follicle density, marked scar formation was noted in crease,
the upper and middle dermal layers. In those specimens with limited reduc¬ tion in follicle density, only mild scar formation was present. Occasional folliculitis and hair granulomas occurred in the myodermal flaps. A diffuse,
patchy inflammatory reaction was found in two myocutaneous flaps and in five myodermal flaps. The in¬ flammatory reaction consisted prima¬ rily of neutrophils and occasional lym¬ phocytes and plasma cells. The pres¬ of such inflammation was not a factor in the degree of hair reduction. Specimens were examined for sur¬ face characteristics of keratinizing squamous epithelium and mucous membrane. Normal keratinizing, squa¬ mous cell epithelium was identified in the myocutaneous grafts. Similarly, keratinizing squamous cell epithelium ence
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Alterations in Skin and Skin
Depth, No.
in 1/1000 Inch 30
Clinical Hair Growth 3
Clinical Texture 3
Graft Size 4
Appendages
in
Myodermal Flaps*
Hair Follicle
Density
Scar
1
1
3
3
Inflammation +
Normal +i
Normal/transitional Normal
+
Normal
+
Hyperplastic Hyperplastic /transitional
-
6t
_3_4_3_3
50
2
60
114
Epithelium Normal
Normal
Hyperplastic/hypoplastic
11 —
60
11
*Hair growth: 0,
1
12
3
3
Normal Normal
-
1, 25%; 2, 50%; 3, 75%; and 4, 100%. Texture: 1, fine; 4, coarse. Graft size: 1, 25%; 2, 50%; 3, 75%; and 4, 100%. Decrease in hair follicle density: 1, mild; 2, moderate; and 3, marked. Scar formation: 1, mild; 2, moderate; and 3, marked. Diffuse inflammation: plus sign, present; minus sign, absent. Epithelium: normal, 0.14 mm; hypoplastic,
Eliachar, MD; Dennis H. Kraus, MD; Wilma F. Bergfeld, MD; Harvey M. Tucker, MD
\s=b\ Myocutaneous
flaps play a prominent
role in the immediate reconstruction of surgical defects following ablative oncologic procedures in the head and neck. Transfer of hair-bearing skin into the reconstructed upper digestive tract can be a major disadvantage associated with the
pectoralis major flap. De-epithelialization of skin to the dermal level, removing the majority of skin appendages, can convert a myocutaneous flap to a "myodermal" flap. Platysma myocutaneous and myodermal flaps were grafted into the oral cavity of 13 dogs. Gross and histologic evaluation confirmed decreased hair growth in the experimental myodermal flap. Wound complications and graft survival were similar for both techniques. Diminished hair growth further supports the utility of myodermal flaps in hairy male patients undergoing upper digestive tract reconstruction. (Arch Otolaryngol Head Neck Surg.
1990;116:923-927)
major myocutaneous Theflappectoralis mainstay after ablative of has become
a
in
re¬
construction surgery the head and neck since its introduc¬ tion in 1979. This flap is reliable be¬ cause of its abundant, highly vascular¬ ized tissue, and permits primary, nonstaged reconstruction with acceptable
Accepted for publication March 27,1990. From the Departments of Otolaryngology and Communicative Disorders (Drs Eliachar, Kraus, and Tucker) and Dermatology (Dr Bergfeld), Cleveland (Ohio) Clinic Foundation. Presented at the midwinter meeting of the Association for Research in Otolaryngology, St Petersburg, Fla, February 7, 1989. Reprint requests to the Department of Otolaryngology and Communicative Disorders, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195-5034 (Dr Eliachar).
aesthetic results.1 However, transfer of hair-bearing donor skin into the re¬ constructed upper digestive tract has been a disadvantage, particularly in certain male patients. Myocutaneous flap reconstruction can result in impaired deglutition due to loss of sensation, lack of lubrication, and poor elasticity of an adynamic flap.2 Hair growth in the reconstructed oral or pharyngeal cavity further ag¬ gravates this problem. Stasis of food particles may also lead to halitosis, adding to social isolation of the oncol¬ ogy
patient.
Several flap modifications have been suggested in an attempt to prevent hair growth with variable success. Preoperative chemical or electrical depilation have not eliminated hair growth.3 Skin-grafted muscle flaps may include pilosebaceous units and other hair-generating epidermal ele¬ ments.2 Postoperative radiation ther¬ apy as part of planned, combined treatment has been inconsistent in preventing hair growth.4 Symptomatic trimming and laser epilation have met with limited success.2 The current my¬ odermal modification of myocutaneous flaps was, therefore, assessed for its ability to prevent hair growth in the reconstructed upper digestive tract. MATERIALS AND METHODS Thirteen mongrel dogs placed under gen¬ eral anesthesia, each weighing 10 to 20 kg, were used in this experiment. The cervical region on the dog was shaved. In each ani¬ mal a superiorly based platysma myocuta¬ neous flap (3 cm in diameter) was rotated into the oral cavity through a split-lip inci-
sion as a control. On the contralateral side the epidermal layer of skin was removed with a dermatome, creating a platysma
"myodermal" flap (Fig 1). De-epithelialization depth ranged from 30/1000 inch to 60/ 1000 inch; in three animals at 30/1000 inch, three at 40/1000 inch, four at 50/1000, and three at 60/1000. The myodermal flap was rotated into the oral cavity in an identical manner to the control myocutaneous flap. Clinical observations were recorded at 2 and 4 months. Biopsy procedures were per¬ formed 2 months postoperatively with a 4mm punch forceps. The animals were killed after 4 months. The intraoral flaps were excised, including a surrounding border of normal mucosa. Photographs were ob¬ tained at that time. A punch biopsy of nor¬ mal skin was obtained in each animal and used for comparison with the flaps. The specimens obtained at 2 months were sectioned in the horizontal plane. Those ob¬ tained at 4 months were sectioned in both the horizontal and vertical planes. Normal skin specimens were prepared similarly. All specimens were fixed in 3.7% formalde¬ hyde solution and embedded in paraffin. Five-millimeter sections were stained with hematoxylin-eosin and inspected micro¬ scopically. The horizontal sections were used to determine hair follicle density and the vertical sections were used to assess ep¬ ithelial regeneration.
RESULTS Twelve myocutaneous
flaps and 11 myodermal flaps were evaluated. Clin¬ ical evaluation of the flaps was re¬ corded at 4 months (Table). The con¬ trol myocutaneous flaps retained hair growth and texture similar to external skin. There was no apparent graft contracture. Hair growth in each my¬ odermal flap was judged by compari¬ son
with that of its contralateral,
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con-
Fig 1.—Top left, Donor site adjacent to canine oral cavity, platysma flap outlined. Top right, Removal of epidermis and su¬ perficial dermis forming a myodermal flap. Bottom left, Myodermal flap rotated into buccal surface through split-lip incision. Bottom right, Myodermal flap in place in oral cavity.
trol myocutaneous
flap on a scale of 0 to4.Sixflapswerej udged to have 25 %,
three 50%, and two 75% of normal hair growth (Fig 2). No experimental flaps showed total absence of hair or com¬ pletely normal hair growth. Decreased quantity and finer hair growth was believed to be associated with increas¬ ing depth of de-epithelialization. Con¬ tracture of the flap was evident in four of the myodermal specimens; two had constricted to 75% of the original flap area and two to 50% of normal (Table). Seven specimens had no evidence of flap contracture. Contracture in the flaps correlated with increased depth of de-epithelialization. Microscopic histologie evaluation was performed on the 2- and 4-month specimens. Similar hair follicle den¬ sity was noted between normal skin
biopsy specimens and corresponding myocutaneous control flaps. Of the ex¬ perimental myodermal flaps, six spec¬ imens had mildly decreased hair folli¬ cle density, one had a moderate de¬
and four had a marked decrease (Table). There was no differ¬ ence in hair follicle density between the 2- and 4-month myodermal biopsy specimens, nor was there a correlation between depth of de-epithelialization and decrease in hair follicle density. Rather, hair follicle reduction ap¬ peared to be randomly distributed among the varying depths of de-epi¬ thelialization. However, decrease in hair follicle density was directly re¬ lated to fibrosis and scar formation (Fig 3). In those specimens with a large decrease in hair follicle density, marked scar formation was noted in crease,
the upper and middle dermal layers. In those specimens with limited reduc¬ tion in follicle density, only mild scar formation was present. Occasional folliculitis and hair granulomas occurred in the myodermal flaps. A diffuse,
patchy inflammatory reaction was found in two myocutaneous flaps and in five myodermal flaps. The in¬ flammatory reaction consisted prima¬ rily of neutrophils and occasional lym¬ phocytes and plasma cells. The pres¬ of such inflammation was not a factor in the degree of hair reduction. Specimens were examined for sur¬ face characteristics of keratinizing squamous epithelium and mucous membrane. Normal keratinizing, squa¬ mous cell epithelium was identified in the myocutaneous grafts. Similarly, keratinizing squamous cell epithelium ence
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Alterations in Skin and Skin
Depth, No.
in 1/1000 Inch 30
Clinical Hair Growth 3
Clinical Texture 3
Graft Size 4
Appendages
in
Myodermal Flaps*
Hair Follicle
Density
Scar
1
1
3
3
Inflammation +
Normal +i
Normal/transitional Normal
+
Normal
+
Hyperplastic Hyperplastic /transitional
-
6t
_3_4_3_3
50
2
60
114
Epithelium Normal
Normal
Hyperplastic/hypoplastic
11 —
60
11
*Hair growth: 0,
1
12
3
3
Normal Normal
-
1, 25%; 2, 50%; 3, 75%; and 4, 100%. Texture: 1, fine; 4, coarse. Graft size: 1, 25%; 2, 50%; 3, 75%; and 4, 100%. Decrease in hair follicle density: 1, mild; 2, moderate; and 3, marked. Scar formation: 1, mild; 2, moderate; and 3, marked. Diffuse inflammation: plus sign, present; minus sign, absent. Epithelium: normal, 0.14 mm; hypoplastic,
