Reconstruction of Radical Parotidectomy Defects
Daniel C. Baker, MD,’ New York, New York William W. Shaw, MD,* New York, New York John Conley, MD,t New York, New York
Reconstruction of contour defects after radical parotidectomy with or without mandibulectomy is a difficult challenge. Although the facial and cervical skin is usually preserved, the underlying soft tissue and bone are deficient. Traditional methods of reconstruction include buried dermis-fat flaps from the chest or posterior cervical region, sternocleidomastoid muscle flaps, and dermis-fat grafts. These methods, however, are associated with many undesirable problems such as unsightly donor site defects, the need for multiple stages, and unpredictable atrophy and resorption. The challenge is, therefore, to be able to reliably restore facial contour while preserving the overlying skin in one predictable operation with minimal donor site deformity. Reconstructive surgery of the head and neck with microvascular free flaps is now a well established and acceptable method. The first reported use of a microvascular free dermis-fat flap for facial reconstruction was by Fujino et al [I] in 1975. They successfully reconstructed large facial defects in one patient after trauma and in another patient with hemifacial atrophy. A de-epithelized microvascular deltopectoral flap was placed beneath the facial skin. Subsequently, de-epithelized groin flaps were employed for reconstruction in patients with hemifacial atrophy by Wells and Edgerton [2] and Harashina et al [3]. With this background we decided to use microvascular free dermis-fat flaps to reconstruct large facial defects secondary to radical parotidectomy and other ablative head and neck surgery. From the New York University School of Medicine and the Institute of Reconstructive Plastic Surgery, New York University Medical Center:* the Department of Clinical Ctolaryngology, Columbia College of Physicians and Surgeons;+ and the Head and Neck Service. St. Vincent’s Hospital and Medical Center,+ New York, New York. Reprint requests should be addressed to Daniel C. Baker, MD, Institute of Reconstructive Plastic Surgery, 580 First Avenue, New York, New York 10016. Presented at the Twenty-Fifth Annual Meeting of The Society of Head and Neck Surgeons, Pittsburgh, Pennsylvania, April 1-4. 1979.
550
Surgical Technique
Two operative teams are preferable: one working at the recipient site and the second elevating the flap. Donor and recipient vessels are mapped preoperatively with the Doppler instrument. Arteriography is rarely used as it may cause transient damage to the endothelium; preoperative Doppler examination and intraoperative evaluation of flow and vessel condition are more reliable. Initially the reliability of recipient vessels is confirmed: normal, brisk, pulsatile arterial flow must be demonstrated. The recipient vessels are usually chosen from the proximal side of the defect; however, the simplest and most convenient vessels should be chosen, and the rich vascular architecture of the head and neck usually allows for a choice of vessels. Occasionally, as in bilateral radical neck dissection where both external carotid arteries have been ligated (case 41, retrograde flow with or without a vein graft has been used. While the recipient vessels are being dissected, the second team isolates the flap vessels and completes elevation of the flap as an island. The size of the flap is estimated from the defect, and a template from the recipient site is often useful in planning. If the defect is deeper than the thickness of the flap, the design may be lengthened to permit folding of the flap on itself to double the thickness (this was done in five of our reported cases with no compromise in vascular supply to the flap). The recipient site is prepared by carefully elevating the facial and cervical skin several centimeters beyond the borders of the defect. Often this skin flap is extremely thin and fragile secondary to irradiation; structures such as the facial nerve and carotid artery may lie directly beneath the skin. The flap vessels are divided and the flap is placed beneath the defect to determine the most comfort-
The American Journal of Surgery
Microvascular
Free Dermis-Fat
Flaps
Figure 1. Left, detached free flap placed on dermatome for de-epithelization. Right, de-epithelized flap with bridge of epithelium for postoperative monitoring and relief of tension,
able vessel position and the area to be de-epithelized. Routinely we leave a several centimeter border of epithelium on the flap for postoperative monitoring and to relieve tension. The Reese dermatome is used to remove a 0.016 inch thickness of epidermis on the completely detached free flap (Figure 1). We have found that vessel anastomosis is most easily performed with the flap in an upside down position. Standard microvascular techniques are utilized employing 10-O or 9-O nylon interrupted sutures. After completion of the anastomoses (usually one artery and two veins), the flap is placed beneath the skin to fill the defect. It is important to suture the dermis of the flap to the borders of the defect to prevent settling of the flap into a “bulky mass” [2]. The flap may be tailored and trimmed to fit the defect as long as respect for the vascular pattern is observed. The skin bridge for monitoring is usually placed along the posterior wound margin; it also
TABLE I
relieves tension in the early postoperative period when some flap edema is common. Postoperatively the flap is monitored for color, temperature, and capillary refill and with the Doppler instrument. Immediate reexploration is done when vascular compromise is evident, and an otherwise “doomed” flap may often be salvaged (case 6). Patients are generally discharged on the ninth postoperative day. After several months the skin bridge may be excised and any excess tissue trimmed under local anesthesia as an outpatient procedure. The following case reports are summarized in Table I. Case Reports Case 1 (Figure 2): The patient was a 19 year old white man who had had radical parotidectomy and partial mandibulectomy for neuroblastoma 10 years earlier. A full course of radiation (5,000 rads) and chemotherapy was
Summary of Six Cases
Case Age (yr) No. & Sex
Pathology
1
19M
Neuroblastoma
2 3
16F 53F
Osteogenic sarcoma Acinic cell
4
68M
Squamous cell adenoma
5 6
23F 31F
Neurofibromatosis Adenoid cystic
Surgery Radical parotidectomy, partial mandibulectomy Parotidectomy, mandibulectomy Parotidectomy, VII nerve graft reconstruction Laryngectomy, RND: parotidectomy, mandibulectomy, RND Parotidectomy, mandibulectomy Parotldectomy, mandibulectomy, temporal bone resection
Radiation (rads)
Flap Size (cm)
Vessels
11x17
5,000
Superior thyroid
10 X 18 7x 10
5,000 None
Lingual Superior thyroid
12 x 20
6,000
Superior temporal retrograde vein graft Occipital Lingual (reexplored)
9x 9X
15 18
None None
RND = radical neck dissection.
Volume 138, October 1979
551
Baker et al
given postoperatively. A 7 by 10 cm defect was reconstructed with an 11 by 17 cm groin flap doubled on itself. The superficial circumflex iliac artery was anastomosed to the superior thyroid artery. The total time required for anesthesia and operation was 9 hours. The patient was ambulatory on the third postoperative day and was discharged on the ninth day without complications. Case 2 (Figure 3): The patient was a 16 year old white girl who had had total parotidectomy and hemimandibulectomy for osteogenic sarcoma 7 years earlier. She received radiation (5,000 rads) and chemotherapy postoperatively. A 10 by 18 cm groin flap was de-epithelized and folded to fill a 7 by 10 cm defect. The superficial circumflex iliac artery was anastomosed to the lingual artery. The patient was discharged on the ninth postoperative day with no complications. Case 3: The patient was a 52 year old white woman who had had radical parotidectomy and facial nerve grafting for acinic cell carcinoma 5 years earlier. A 7 by 10 cm groin flap was used to fill a 5 by 7 cm defect utilizing the superior thyroid vessels. She was discharged on the 10th postoperative day with no complications, and the flap was trimmed 3 months later. Case 4 (Figure 4): The patient was a 68 year old white man who had had total laryngectomy and right radical neck dissection for squamous cell carcinoma 10 years earlier and radical parotidectomy, partial mandibulectomy, and left radical neck dissection for adenocarcinoma of the parotid gland 5 years earlier. He received postoperative radiation (6,000 rads) to the left parotid gland and neck. A 12 by 20 cm groin flap was elevated and doubled on itself to fill an 8 by 12 cm defect. Because both external carotid arteries
Figure
552
2. Case 1. Left, preoperative
had been ligated, retrograde arterial flow from the superficial temporal artery was used for anastomoses with the superficial circumflex iliac artery; an interposition vein graft was necessary to obtain adequate length. Venous anastomosis was to the angular vein. The patient was discharged on the 10th postoperative day without complications. Case 5: The patient was a 23 year old white woman with multiple resections of neurofibromatosis of the left side of the face and parotid gland. A 9 by 18 cm groin flap was used to fill a 7 by 10 cm defect. Arterial anastomosis was to the occipital artery. The patient was discharged on the 10th postoperative day. Case 6: The patient was a 31 year old white woman who had had radical parotidectomy, partial mandibulectomy, and temporal bone resection 6 years earlier for recurrent adenoid cystic carcinoma of the parotid gland. A 12 by 20 cm groin flap was elevated to fill an 8 by 11 cm defect. The superficial circumflex iliac artery was anastomosed to the lingual artery, with venous anastomosis to the superior thyroid. Twelve hours postoperatively there was evidence of venous congestion, and the patient was returned to the operating room where a small hematoma was evacuated, venous thrombosis discovered, and a reanastomosis to the external jugular vein performed. The wound healed per primam with complete flap survival, and the patient was discharged on the 10th postoperative day.
Comments Dermal-fat grafts (free grafts consisting of all layers of skin and underlying subcutaneous fat after
view. Right, postoperative
view.
The American
Journalof Surgery
Microvascular
Free Dermis-Fat Flaps
Figure 3. Case 2. Left, preoperative view. Right, postoperative view; note the bridge of epithelium.
Figure 4. Case 4. Left, preoperative view. Right, postoperative view. The arterial supply to the microvascular dermis-fat flap was from retrograde flow by way of the superficial temporal artery.
Volume 138, October 1979
553
Baker et al
removal of the epidermis) have been used extensively for breast reconstruction, hemifacial atrophy, and other contour defects. It is believed that the major advantage of dermis-fat grafts is that the dermis serves as a vasoinductive agent preventing fat absorption [4]. Presumably the rich subpapillary vascular plexus of the dermis enhances early revascularization by the recipient site, thereby increasing chances of fat survival. However, this concept has been challenged by Sawhney et al [5], who studied dermis-fat grafts in pigs and noted a decrease in volume of the graft of 6.7 per cent at 1 week, 9 per cent at 2 weeks, 20 per cent at 4 weeks, and 33.3 per cent at 8 weeks. They concluded that there was no evidence to suggest that vascularization of fat occurs through the dermis in dermal fat grafts because the growth of blood vessels was confined to the dermal portion of the graft. This finding explains the eventual complete replacement of fat by fibrous tissue. Clinically, the use of dermis-fat grafts has been disappointing in breast reconstruction as well as in large facial defects. There is usually gradual shrinkage and resorption of fat over months to years, and many patients require multiple repeat graftings. Dying fat cells either rupture into liquified fat to drain externally or are absorbed by the body. In a recent review [6] of 33 dermal-fat-fascia grafts to the head and neck, a 70 to 100 per cent absorption was noted in all instances. The process of absorption was a gradual one that was assessed over an interval of 5 to 20 years, although the major effect was obvious within 1 year postoperatively. Ten per cent of patients had complete graft loss within 2 weeks from infection or hematoma, and another 14 per cent had apparent liquification of fat which drained spontaneously within 2 weeks after surgery. It was concluded that irradiated and scarred tissue beds did not support free dermal-fat-fascia grafts well, and that the method had limited value in augmentation. It is well known that pedicle flaps of dermis and fat survive well due to better blood supply [7], although this method requires multiple stages. Regional muscle flaps have also been used, although additional incisions, loss of donor function, and muscle atrophy occur. As Hoopes [4] has stated, “clearly dermis-fat transferred on a vascular pedicle retains viability.”
554
We believe that the microvascular free dermis-fat flap should be the procedure of choice for large soft tissue augmentation in the head and neck. The advantages of this flap include a high reliability with over 90 per cent success, minimal complications, and a cosmetically acceptable donor site. In addition, large volumes of tissue may be transferred in one stage independent of the vascular quality of the recipient bed, and massive overcorrection is unnecessary because survival is assured by the independent vascular supply. Some of the disadvantages of microvascular dermis-fat flaps are the longer operating time required and the need for two surgical teams, which we believe are well compensated for by the gratifying results. Summary
The technique of microvascular free dermis-fat flaps is an efficient method of restoring cervicofacial contour after ablative head and neck surgery. Our success in six consecutive patients, including three who had received irradiation, establishes this as a reliable technique associated with gratifying results and minimal complications. Acknowledgment: The authors thank Dr. Harry Bunke for his advice and assistance in Case 4, and Dr. John Converse for his guidance.
References 1. Fujino T, Tanino R, Sugimoto C: Microvascular transfer of free deltopectoral dermal-fat flap. Plasf Reconsfr Surg 55: 428, 1975. 2. Wells JH, Edgerton MT: Correction of severe hemifacial atrophy with a free dermis-fat flap from the lower abdomen. Plasf Reconstr Surg 59: 223, 1977. 3. Harashina T, Nakajima T, Yoshimura Y: A tree groin flap in progressive facial herniatrophy. Br J Plast Surg 30: 14, 1977. 4. Hoopes JE: Dermis-fat grafts. In Symposium on Basic Science in Plastic Surgery (Krizek TJ, Hoopes JE, eds). St. Louis, CV Mosby, 1976. 5. Sawhney CP, Banerjee TN, Chakravarti RN: Behavior of dermal fat transplants. Br J Plasf Surg 22: 169, 1969. 6. Conley J, Clairmont AA: Dermal-fat-fascia grafts. J Ofolaryngol, 1978. 7. Converse JM. Betson RJ: A 20 year follow-up of a patient with hemifacial atrophy treated with a buried de-epithelized flap. Plast Reconsfr Surg 48: 278, 1969.
The American Journal of Surgery
Daniel C. Baker, MD,’ New York, New York William W. Shaw, MD,* New York, New York John Conley, MD,t New York, New York
Reconstruction of contour defects after radical parotidectomy with or without mandibulectomy is a difficult challenge. Although the facial and cervical skin is usually preserved, the underlying soft tissue and bone are deficient. Traditional methods of reconstruction include buried dermis-fat flaps from the chest or posterior cervical region, sternocleidomastoid muscle flaps, and dermis-fat grafts. These methods, however, are associated with many undesirable problems such as unsightly donor site defects, the need for multiple stages, and unpredictable atrophy and resorption. The challenge is, therefore, to be able to reliably restore facial contour while preserving the overlying skin in one predictable operation with minimal donor site deformity. Reconstructive surgery of the head and neck with microvascular free flaps is now a well established and acceptable method. The first reported use of a microvascular free dermis-fat flap for facial reconstruction was by Fujino et al [I] in 1975. They successfully reconstructed large facial defects in one patient after trauma and in another patient with hemifacial atrophy. A de-epithelized microvascular deltopectoral flap was placed beneath the facial skin. Subsequently, de-epithelized groin flaps were employed for reconstruction in patients with hemifacial atrophy by Wells and Edgerton [2] and Harashina et al [3]. With this background we decided to use microvascular free dermis-fat flaps to reconstruct large facial defects secondary to radical parotidectomy and other ablative head and neck surgery. From the New York University School of Medicine and the Institute of Reconstructive Plastic Surgery, New York University Medical Center:* the Department of Clinical Ctolaryngology, Columbia College of Physicians and Surgeons;+ and the Head and Neck Service. St. Vincent’s Hospital and Medical Center,+ New York, New York. Reprint requests should be addressed to Daniel C. Baker, MD, Institute of Reconstructive Plastic Surgery, 580 First Avenue, New York, New York 10016. Presented at the Twenty-Fifth Annual Meeting of The Society of Head and Neck Surgeons, Pittsburgh, Pennsylvania, April 1-4. 1979.
550
Surgical Technique
Two operative teams are preferable: one working at the recipient site and the second elevating the flap. Donor and recipient vessels are mapped preoperatively with the Doppler instrument. Arteriography is rarely used as it may cause transient damage to the endothelium; preoperative Doppler examination and intraoperative evaluation of flow and vessel condition are more reliable. Initially the reliability of recipient vessels is confirmed: normal, brisk, pulsatile arterial flow must be demonstrated. The recipient vessels are usually chosen from the proximal side of the defect; however, the simplest and most convenient vessels should be chosen, and the rich vascular architecture of the head and neck usually allows for a choice of vessels. Occasionally, as in bilateral radical neck dissection where both external carotid arteries have been ligated (case 41, retrograde flow with or without a vein graft has been used. While the recipient vessels are being dissected, the second team isolates the flap vessels and completes elevation of the flap as an island. The size of the flap is estimated from the defect, and a template from the recipient site is often useful in planning. If the defect is deeper than the thickness of the flap, the design may be lengthened to permit folding of the flap on itself to double the thickness (this was done in five of our reported cases with no compromise in vascular supply to the flap). The recipient site is prepared by carefully elevating the facial and cervical skin several centimeters beyond the borders of the defect. Often this skin flap is extremely thin and fragile secondary to irradiation; structures such as the facial nerve and carotid artery may lie directly beneath the skin. The flap vessels are divided and the flap is placed beneath the defect to determine the most comfort-
The American Journal of Surgery
Microvascular
Free Dermis-Fat
Flaps
Figure 1. Left, detached free flap placed on dermatome for de-epithelization. Right, de-epithelized flap with bridge of epithelium for postoperative monitoring and relief of tension,
able vessel position and the area to be de-epithelized. Routinely we leave a several centimeter border of epithelium on the flap for postoperative monitoring and to relieve tension. The Reese dermatome is used to remove a 0.016 inch thickness of epidermis on the completely detached free flap (Figure 1). We have found that vessel anastomosis is most easily performed with the flap in an upside down position. Standard microvascular techniques are utilized employing 10-O or 9-O nylon interrupted sutures. After completion of the anastomoses (usually one artery and two veins), the flap is placed beneath the skin to fill the defect. It is important to suture the dermis of the flap to the borders of the defect to prevent settling of the flap into a “bulky mass” [2]. The flap may be tailored and trimmed to fit the defect as long as respect for the vascular pattern is observed. The skin bridge for monitoring is usually placed along the posterior wound margin; it also
TABLE I
relieves tension in the early postoperative period when some flap edema is common. Postoperatively the flap is monitored for color, temperature, and capillary refill and with the Doppler instrument. Immediate reexploration is done when vascular compromise is evident, and an otherwise “doomed” flap may often be salvaged (case 6). Patients are generally discharged on the ninth postoperative day. After several months the skin bridge may be excised and any excess tissue trimmed under local anesthesia as an outpatient procedure. The following case reports are summarized in Table I. Case Reports Case 1 (Figure 2): The patient was a 19 year old white man who had had radical parotidectomy and partial mandibulectomy for neuroblastoma 10 years earlier. A full course of radiation (5,000 rads) and chemotherapy was
Summary of Six Cases
Case Age (yr) No. & Sex
Pathology
1
19M
Neuroblastoma
2 3
16F 53F
Osteogenic sarcoma Acinic cell
4
68M
Squamous cell adenoma
5 6
23F 31F
Neurofibromatosis Adenoid cystic
Surgery Radical parotidectomy, partial mandibulectomy Parotidectomy, mandibulectomy Parotidectomy, VII nerve graft reconstruction Laryngectomy, RND: parotidectomy, mandibulectomy, RND Parotidectomy, mandibulectomy Parotldectomy, mandibulectomy, temporal bone resection
Radiation (rads)
Flap Size (cm)
Vessels
11x17
5,000
Superior thyroid
10 X 18 7x 10
5,000 None
Lingual Superior thyroid
12 x 20
6,000
Superior temporal retrograde vein graft Occipital Lingual (reexplored)
9x 9X
15 18
None None
RND = radical neck dissection.
Volume 138, October 1979
551
Baker et al
given postoperatively. A 7 by 10 cm defect was reconstructed with an 11 by 17 cm groin flap doubled on itself. The superficial circumflex iliac artery was anastomosed to the superior thyroid artery. The total time required for anesthesia and operation was 9 hours. The patient was ambulatory on the third postoperative day and was discharged on the ninth day without complications. Case 2 (Figure 3): The patient was a 16 year old white girl who had had total parotidectomy and hemimandibulectomy for osteogenic sarcoma 7 years earlier. She received radiation (5,000 rads) and chemotherapy postoperatively. A 10 by 18 cm groin flap was de-epithelized and folded to fill a 7 by 10 cm defect. The superficial circumflex iliac artery was anastomosed to the lingual artery. The patient was discharged on the ninth postoperative day with no complications. Case 3: The patient was a 52 year old white woman who had had radical parotidectomy and facial nerve grafting for acinic cell carcinoma 5 years earlier. A 7 by 10 cm groin flap was used to fill a 5 by 7 cm defect utilizing the superior thyroid vessels. She was discharged on the 10th postoperative day with no complications, and the flap was trimmed 3 months later. Case 4 (Figure 4): The patient was a 68 year old white man who had had total laryngectomy and right radical neck dissection for squamous cell carcinoma 10 years earlier and radical parotidectomy, partial mandibulectomy, and left radical neck dissection for adenocarcinoma of the parotid gland 5 years earlier. He received postoperative radiation (6,000 rads) to the left parotid gland and neck. A 12 by 20 cm groin flap was elevated and doubled on itself to fill an 8 by 12 cm defect. Because both external carotid arteries
Figure
552
2. Case 1. Left, preoperative
had been ligated, retrograde arterial flow from the superficial temporal artery was used for anastomoses with the superficial circumflex iliac artery; an interposition vein graft was necessary to obtain adequate length. Venous anastomosis was to the angular vein. The patient was discharged on the 10th postoperative day without complications. Case 5: The patient was a 23 year old white woman with multiple resections of neurofibromatosis of the left side of the face and parotid gland. A 9 by 18 cm groin flap was used to fill a 7 by 10 cm defect. Arterial anastomosis was to the occipital artery. The patient was discharged on the 10th postoperative day. Case 6: The patient was a 31 year old white woman who had had radical parotidectomy, partial mandibulectomy, and temporal bone resection 6 years earlier for recurrent adenoid cystic carcinoma of the parotid gland. A 12 by 20 cm groin flap was elevated to fill an 8 by 11 cm defect. The superficial circumflex iliac artery was anastomosed to the lingual artery, with venous anastomosis to the superior thyroid. Twelve hours postoperatively there was evidence of venous congestion, and the patient was returned to the operating room where a small hematoma was evacuated, venous thrombosis discovered, and a reanastomosis to the external jugular vein performed. The wound healed per primam with complete flap survival, and the patient was discharged on the 10th postoperative day.
Comments Dermal-fat grafts (free grafts consisting of all layers of skin and underlying subcutaneous fat after
view. Right, postoperative
view.
The American
Journalof Surgery
Microvascular
Free Dermis-Fat Flaps
Figure 3. Case 2. Left, preoperative view. Right, postoperative view; note the bridge of epithelium.
Figure 4. Case 4. Left, preoperative view. Right, postoperative view. The arterial supply to the microvascular dermis-fat flap was from retrograde flow by way of the superficial temporal artery.
Volume 138, October 1979
553
Baker et al
removal of the epidermis) have been used extensively for breast reconstruction, hemifacial atrophy, and other contour defects. It is believed that the major advantage of dermis-fat grafts is that the dermis serves as a vasoinductive agent preventing fat absorption [4]. Presumably the rich subpapillary vascular plexus of the dermis enhances early revascularization by the recipient site, thereby increasing chances of fat survival. However, this concept has been challenged by Sawhney et al [5], who studied dermis-fat grafts in pigs and noted a decrease in volume of the graft of 6.7 per cent at 1 week, 9 per cent at 2 weeks, 20 per cent at 4 weeks, and 33.3 per cent at 8 weeks. They concluded that there was no evidence to suggest that vascularization of fat occurs through the dermis in dermal fat grafts because the growth of blood vessels was confined to the dermal portion of the graft. This finding explains the eventual complete replacement of fat by fibrous tissue. Clinically, the use of dermis-fat grafts has been disappointing in breast reconstruction as well as in large facial defects. There is usually gradual shrinkage and resorption of fat over months to years, and many patients require multiple repeat graftings. Dying fat cells either rupture into liquified fat to drain externally or are absorbed by the body. In a recent review [6] of 33 dermal-fat-fascia grafts to the head and neck, a 70 to 100 per cent absorption was noted in all instances. The process of absorption was a gradual one that was assessed over an interval of 5 to 20 years, although the major effect was obvious within 1 year postoperatively. Ten per cent of patients had complete graft loss within 2 weeks from infection or hematoma, and another 14 per cent had apparent liquification of fat which drained spontaneously within 2 weeks after surgery. It was concluded that irradiated and scarred tissue beds did not support free dermal-fat-fascia grafts well, and that the method had limited value in augmentation. It is well known that pedicle flaps of dermis and fat survive well due to better blood supply [7], although this method requires multiple stages. Regional muscle flaps have also been used, although additional incisions, loss of donor function, and muscle atrophy occur. As Hoopes [4] has stated, “clearly dermis-fat transferred on a vascular pedicle retains viability.”
554
We believe that the microvascular free dermis-fat flap should be the procedure of choice for large soft tissue augmentation in the head and neck. The advantages of this flap include a high reliability with over 90 per cent success, minimal complications, and a cosmetically acceptable donor site. In addition, large volumes of tissue may be transferred in one stage independent of the vascular quality of the recipient bed, and massive overcorrection is unnecessary because survival is assured by the independent vascular supply. Some of the disadvantages of microvascular dermis-fat flaps are the longer operating time required and the need for two surgical teams, which we believe are well compensated for by the gratifying results. Summary
The technique of microvascular free dermis-fat flaps is an efficient method of restoring cervicofacial contour after ablative head and neck surgery. Our success in six consecutive patients, including three who had received irradiation, establishes this as a reliable technique associated with gratifying results and minimal complications. Acknowledgment: The authors thank Dr. Harry Bunke for his advice and assistance in Case 4, and Dr. John Converse for his guidance.
References 1. Fujino T, Tanino R, Sugimoto C: Microvascular transfer of free deltopectoral dermal-fat flap. Plasf Reconsfr Surg 55: 428, 1975. 2. Wells JH, Edgerton MT: Correction of severe hemifacial atrophy with a free dermis-fat flap from the lower abdomen. Plasf Reconstr Surg 59: 223, 1977. 3. Harashina T, Nakajima T, Yoshimura Y: A tree groin flap in progressive facial herniatrophy. Br J Plast Surg 30: 14, 1977. 4. Hoopes JE: Dermis-fat grafts. In Symposium on Basic Science in Plastic Surgery (Krizek TJ, Hoopes JE, eds). St. Louis, CV Mosby, 1976. 5. Sawhney CP, Banerjee TN, Chakravarti RN: Behavior of dermal fat transplants. Br J Plasf Surg 22: 169, 1969. 6. Conley J, Clairmont AA: Dermal-fat-fascia grafts. J Ofolaryngol, 1978. 7. Converse JM. Betson RJ: A 20 year follow-up of a patient with hemifacial atrophy treated with a buried de-epithelized flap. Plast Reconsfr Surg 48: 278, 1969.
The American Journal of Surgery
