SURGICAL ONCOLOGY AND RECONSTRUCTION
Regional Flaps in Head and Neck Reconstruction: A Reappraisal Giacomo Colletti, MD,* Karim Tewfik, MD,y Alessandro Bardazzi, MD,z Fabiana Allevi, MD,x Matteo Chiapasco, MD,k Marco Mandal a, MD,{ and Dimitri Rabbiosi, MD# Purpose:
Starting from our experience with 45 consecutive cases of regional pedicled flaps, we have underlined the effectiveness and reliability of a variety of flaps. The marketing laws as applied to surgical innovations are reviewed to help in the understanding of why regional flaps are regaining wide popularity in head and neck reconstruction.
Materials and Methods:
From January 2009 to January 2014, 45 regional flaps were harvested at San Paolo Hospital to reconstruct head and neck defects. These included 35 pectoralis major muscular and myocutaneous flaps, 4 lower trapezius island or pedicled flaps, 3 supraclavicular flaps, 2 latissimus dorsi pedicled flaps, and 1 fasciocutaneous temporal flap. The basic literature of marketing regarding the diffusion of new products was also reviewed.
Results:
Two myocutaneous pectoralis major flaps were complicated by necrosis of the cutaneous paddle (one complete and one partial). No complete loss of any of the 45 flaps was observed. At 6 months of follow-up, 2 patients had died of multiple organ failure after prolonged sepsis. The 43 remaining patients had acceptable morphologic and functional results.
Conclusions: Regional and free flaps appear to compete in many cases for the same indications. From the results of the present case series, regional flaps can be considered reliable reconstructive choices that are less expensive than their free flap alternatives. The ‘‘resurrection’’ of regional flaps can be partially justified by the changes in the global economy and the required adaptation of developed and developing countries. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:571.e1-571.e10, 2015
Free flaps have been considered the reference standard for head and neck reconstruction,1 even after removal of benign neoplasms.2 Local and regional flaps, however, are still a safe and useful option. After a period of apparent oblivion, an increasing number of studies have been published, with various investigators inviting surgeons to reconsider the use of these
flaps.3-5 In some cases, local or regional pedicled flaps represent the best reconstructive option. The mucosal cheek flap, Bichat fat pad flap, buccinator myomucosal flap, facial artery myomucosal flap, and temporalis muscle flap should be the first choice for limited maxillary and mandibular defects (cheek mucosa and Bichat fat pad flap6); limited tongue, {Assistant, Department of Otolaryngology, University of Verona,
*Assistant, Division of Maxillo-Facial Surgery, Department of Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Verona, Italy.
Universita degli Studi di Milano, Milan, Italy.
#Assistant, Division of Maxillo-Facial Surgery, Department of
yResident, Division of Maxillo-Facial Surgery, Department of
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Universita degli Studi di Milano, Milan, Italy.
Universita degli Studi di Milano, Milan, Italy. zResident, Division of Maxillo-Facial Surgery, Department of
Address correspondence and reprint requests to Dr Colletti: Division of Maxillo-Facial Surgery, Department of Biomedical, Surgi-
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
cal and Dental Sciences, San Paolo Hospital, Universita degli Studi di
Universita degli Studi di Milano, Milan, Italy.
Milano, Piazza della Repubblica 1/a, Milan 20121 Italy; e-mail:
xResident, Division of Maxillo-Facial Surgery, Department of Biomedical, Surgical and Dental Sciences, San Paolo Hospital, Universita degli Studi di Milano, Milan, Italy.
[email protected] Received August 25 2014 Accepted October 21 2014
kHead, Division of Oral Surgery, Department of Biomedical, Surgical and Dental Sciences, San Paolo Hospital, Universita degli Studi di Milano, Milan, Italy.
Ó 2015 American Association of Oral and Maxillofacial Surgeons 0278-2391/14/01620-6 http://dx.doi.org/10.1016/j.joms.2014.10.021
571.e1
571.e2 palatal, and oral floor defects (buccinator myomucosal flap,7 facial artery myomucosal flap8); medium size to major maxillary defects in which bony reconstruction is not needed or planned (temporalis muscle flap9). The settings in which local or regional flaps will be the preferred reconstructive technique have not been discussed. The aim of the present report was to focus on the indications and results for major regional flaps. Several factors can result in surgeons choosing a regional flap instead of a free flap. These include severe patient comorbidities, adverse anatomic conditions with a compromised blood supply, and previous radiotherapy, among others. Furthermore, other circumstances, such as the lack of a microvascular surgical team or financial issues, which can be observed in developing countries, can make free flap reconstruction unfeasible. Finally, sensitivity to the economic burden of healthcare could make regional flaps preferable to free flaps in a variety of circumstances.
REAPPRAISAL OF REGIONAL FLAPS
perform microvascular anastomoses in a difficult position. The 2 latissimus dorsi pedicled flaps were performed in patients with severe comorbidities to shorten the operative time. The region of resection (wide craniofacial resection) was close enough to obtain safe closure with a pedicled latissimus flap. All the supraclavicular flaps were performed in patients with a vessel-depleted neck from previous surgery and radiotherapy (n = 1) or as autonomized salvage flaps (n = 2) after free flap failure. The remaining patients in the present study underwent reconstruction with pedicled flaps because of severe comorbidities (eg, ischemic heart disease with diffuse atherosclerosis) or a poor prognosis. This was a retrospective study. As such, it was granted exemption from the local institutional review board. The present study adhered to the guidelines of the Declaration of Helsinki.
Results Materials and Methods From January 2010 to January 2014 at San Paolo Hospital (Milan, Italy), 45 regional flaps were used in 44 patients for head and neck reconstruction after tumor resection (Table 1). Of the 45 regional flaps, 35 were pectoralis major flaps, 4 were lower trapezius flaps, 3 were supraclavicular flaps, 2 were latissimus dorsi pedicled flaps, and 1 was a temporalis fasciocutaneous flap. Most of the reconstructions were secondary to squamous cell carcinoma (n = 41), with the remaining including 2 chordomas, 1 mixed cell carcinoma, and 1 basal cell carcinoma. Reconstruction with the buccinator myomucosal, facial artery myomucosal, Bichat fat pad, and temporalis muscle flaps was excluded from the present case series. A total of 30 reconstructions were necessary to restore intraoral defects, including 21 mandibular, 2 floor of the mouth, 5 partial tongue, and 2 hypopharyngeal defects. Of the 44 patients, 13 required skin reconstruction, including 7 cheeks, 3 scalps (1 patient with a scalp defect required reconstruction of 2 different regions), and 4 cervical-laryngeal fistulas. In 2 cases, pedicled flaps were used in association with a fibula free flap. Both patients had large mandibular defects that required through and through reconstruction. In almost all the mandibular defects (n = 20), 2.4-mm, load-bearing titanium plates were used as fixation devices. Regional flaps were chosen instead of free flaps for the following reasons. In 3 cases (3 of 4 cases in which a trapezius flap was used), the resection site was the high occipital region. Thus, a lower trapezius flap was harvested simultaneously with the reconstruction, eliminating the need to rotate the patient, perform the reconstruction in a second session, or
No evidence of complete flap failure was observed. In 1 patient, we observed complete skin loss with survival of the muscular portion of the flap. In 1 case, partial skin loss was detected. One patient required a return to the operating room because of active bleeding after closure of a pharyngocutaneous fistula with a pectoralis major flap. After the thoracic wound had been reopened and a bleeding perforator ligated, he had a full recovery with no additional complications. No fistula was observed in any case. The donor sites were closed primarily in all cases, except for the latissimus dorsi pedicled flap, which required a partial-thickness skin graft harvested from the thigh. A total of 20 load-bearing plates were used to reconstruct the bone mandibular defects. Of these plates, 7 presented with late extrusion (>12 months after the first operation) and required removal. Two patients died of multiple organ failure after prolonged sepsis at 6 months postoperatively. CASE 1
The first patient included in the present report was a 55-year-old woman (patient 41, Figs 1 to 6) affected by squamous cell carcinoma of the right border of the tongue. She had severe comorbidities, including ischemic heart disease and diffused arteriosclerotic arteriopathy. Thus, we chose a regional flap for reconstruction. With the patient under general anesthesia, she underwent temporary tracheostomy, right selective neck dissection (level I to III), right partial glossectomy, and reconstruction with a pectoralis major flap. No complications were observed during recovery. The followup examination after 1 year showed the patient had good functional and aesthetic outcomes with no evidence of relapse.
COLLETTI ET AL
FIGURE 1. Preoperative image of squamous cell carcinoma of the right border of the tongue in a 55-year-old woman (patient 41, case 1 in the present report). Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
CASE 2
The second patient was 65-year-old woman (patient 30, Figs 7 to 11) affected by an extensive squamous cell carcinoma of the scalp that had previously been treated with a nonradical excision by another unit. The resection required positioning the patient prone; therefore, we decided to simultaneously raise a pedicled flap without the need to change the patient’s position. She underwent wide scalp resection and reconstruction with a lower trapezius
571.e3
FIGURE 3. Intraoperative image showing the tongue defect after resection. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
pedicled flap. Good wound healing was observed during the weeks after surgery, and the follow-up examination after 1 year showed good functional and aesthetic outcomes without relapse.
FIGURE 2. Preoperative magnetic resonance imaging scan showing extension of the squamous cell carcinoma of the tongue.
FIGURE 4. Myocutaneous pectoralis major flap harvested to reconstruct the tongue defect.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
571.e4
REAPPRAISAL OF REGIONAL FLAPS
FIGURE 5. Intraoperative image showing complete reconstruction of the tongue. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
CASE 3
The third patient was a 71-year-old man (patient 40, Figs 12 to 16) affected by a large relapsing basal cell carcinoma of the right middle third of the face with intraorbital invasion. The patient also had chronic heart failure; therefore, the shortest procedure was chosen. Under general anesthesia, he underwent a large excision with orbital exenteration. In the same operative session, a latissimus dorsi pedicled flap was harvested. Immediately after the resection, it was rotated to reconstruct the defect. The donor site was repaired using a skin graft harvested from the patient’s thigh. At the follow-up examination after 1 year, the patient had acceptable aesthetic outcomes with no evidence of relapse.
Discussion Just as with most innovations in medical science, the introduction of a new successful surgical tech-
FIGURE 6. Image at the 1-year follow-up visit showing satisfactory morphologic and functional outcomes. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
FIGURE 7. Patient 30 (case 2 in the present report), a 65-year-old woman, with extensive squamous cell carcinoma of the scalp previously treated with nonradical excision. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
nique usually sees 3 different moments in its history. The first phase is when the technique is introduced and adopted only marginally. In the second period, an ‘‘explosion’’ of its use and multicenter discussions occur. Finally, in the third phase, a decrease occurs in its popularity, although the technique is used steadily, but with lower frequency than during its ‘‘hype’’ phase. This type of diffusion was first described by Bass10 in 1969 and is typical of many innovations in the industrial technology, agricultural, educational, pharmaceutical, and consumer durable goods markets. Mahajan et al11 in 1990 reviewed the Bass model and made additional refinements and extensions. The Bass model can be drawn visually with a curve that reflects a modification of a shifted, modified Gompertz distribution (Fig 17). At times in this distribution, a fourth phase of complete oblivion (Fig 17B) or of ‘‘resurrection’’ (Fig 17C) of the product can occur. A recent example of resurrection of a consumer product is that of Bausch and Lomb’s Ray Ban Wayfarer eyeglasses.12 These eyeglasses saw a period of high popularity from their introduction in the market in 1956 to the beginning of the 1990s. Then they became almost
COLLETTI ET AL
571.e5
FIGURE 8. Wide scalp and cranial bone resection with exposure of the dura.
FIGURE 9. Lower trapezius island flap harvested to reconstruct the scalp defect.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
forgotten. In 2007, the original Wayfarer were brought back to the market in their original form and saw a new era of widespread diffusion in the market. The diffusion of a scientific innovation (and, as such, any surgical technique) follows the same rules of marketing science. Since their introduction in the 1960s13 (although some regional pedicled flaps were described much earlier14), pedicled regional flaps went through widespread diffusion that made them the standard technique in head and neck reconstruction. However, at the end of the 1980s and the beginning of the 1990s, free flaps became popular, and pedicled regional flaps were used with decreasing frequency. It appears that in the recent history of head and neck reconstruction, pedicled and free flaps have concurred for the same indications and that their use, in some cases, can be mutually exclusive. Therefore, during the boom period of free flaps, pedicled regional flaps have been almost abandoned. In contrast, currently, when we are probably facing the steady state of free flap diffusion, the use of regional flaps is, in fact, being resurrected. Still, free flaps are considered the reference standard for many cases of head and neck reconstruction; how-
ever, a significant body of data has been increasing slowly but steadily in which pedicled flaps have been used in comparable settings. In many instances, pedicled or microvascular soft tissue flaps compete for the same indication, each technique with its advantages and disadvantages. The key question seems to be in which circumstances would free flaps have the advantage over regional flaps and in which circumstances regional flaps would be preferable or superior. It has been reported that free flaps have superior success rates compared with pedicled flaps. Free flaps appear to be extremely reliable, with a reported success rate of $95% in some reports.1 Two very large case series, however, have declared success rates ranging from 97.6 to 98% for the pectoralis major pedicled flap.15,16 Only a multicenter, prospective, randomized study could definitively prove the superior reliability of free flaps compared with pedicled flaps; however, no such study has been published. Comparing different case series with each other can only provide an idea of flap reliability. Also, if we compare these case series, it appears that pedicled and free flaps are equally reliable. Another key aspect is donor site morbidity. The proponents of different techniques have tended to declare
571.e6
REAPPRAISAL OF REGIONAL FLAPS
FIGURE 12. View of a 71-year-old man (patient 40, case 3 in the present report) affected by a large relapsing basal cell carcinoma of the right middle third of the face with intraorbital invasion. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015. FIGURE 10. Intraoperative image showing completed scalp reconstruction. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
FIGURE 11. Image at the 1-year follow-up visit showing a satisfactory morphologic outcome.
FIGURE 13. Intraoperative image showing extensive resection of the right cranium and face.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
COLLETTI ET AL
FIGURE 14. Latissimus dorsi pedicled flap harvested to reconstruct the defect. The donor site closure required a split-thickness skin graft harvested from the thigh.
571.e7
FIGURE 15. Intraoperative image showing the completed reconstruction. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
that their technique is more anatomically respectful and results in lower donor site morbidity. Again, this does not appear to be related to whether the flap is a regional pedicled or distant microvascular flap. Just to cite a couple of examples, the donor site morbidity of a pectoralis major muscle flap17,18 is not superior to a latissimus dorsi microvascular flap19 and an inferior trapezius myocutaneous flap20 does not have greater donor site morbidity than a parascapular free flap.21 Considering the published data, it appears that the most fragile donor site in terms of local donor site complications is the forearm.22 The radial forearm has usually been transferred as a free flap. The amount and quality of soft tissues to be transferred might represent an argument in favor of free flaps. Again, this is debatable. Reports have been published of vast soft tissue reconstruction obtained with either free or pedicled flaps.23,24 Horn et al,25 in their recent study, compared free anterolateral thigh flaps and latissimus dorsi flaps in the reconstruction of extensive defects. The mean latissimus dorsi flap
surface was 115.8 cm2 (range 20.0 to 600.0). The mean anterolateral thigh flap surface was 67.0 cm2 (range 20.0 to 330.0). In 1978, Maxwell et al26 reported a latissimus dorsi pedicled flap dimension of 12 35 cm. In a recent study of trapezius island myocutaneous flap, Chen et al27 described a mean size of 9.8 6.3 cm. In the present case series, ample reconstructions were obtained with pedicled regional flaps. Some situations exist in which free flaps and regional flaps are simply not comparable. In major bone reconstruction, free flaps are necessary, and pedicled local or regional flaps (eg, pedicled calvarial flaps) cannot offer the same amount and quality of bone. Moreover, if soft tissues are lacking or unreliable (eg, after radiotherapy), bone from a microvascular flap is mandatory. Free flaps are the only choice for reconstruction in cases in which pedicled flaps cannot reach a too-distant defect, such as major full-thickness defects of the apex of the head. In such cases, small defects can easily be reconstructed using local scalp flaps; however, vast reconstruction will require a large amount of soft tissue not provided
571.e8
REAPPRAISAL OF REGIONAL FLAPS
FIGURE 17. Bass model diagram. Line A shows the theoretical progression of adoptions in time; line B represents complete oblivion; and line C, a phase of resurrection. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
FIGURE 16. Image at the 1-year follow-up visit showing a satisfactory morphologic outcome. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
by any regional flap. Wide skull base defects for which temporalis or pericranial flaps are insufficient or not available need to be lined with reliable, wellvascularized free flaps.28 Free flaps are needed for reconstruction that requires unusual, thin, plicated shapes, such as the soft palate and upper pharynx.29 Finally, free flaps have the advantage that their very small pedicle (compared with regional and random local flaps) can be easily and safely passed through anatomic strictures.30,31 Regional flaps will be the only choice for very select cases. The lack of donor vessels is one of these circumstances. Although it has been declared that bridge vessels can be used to reach distant donor vessels in the thorax, in the presence of a vessel-depleted neck, a regional flap will be a better option. Free flaps are more expensive procedures and require specific instruments and training, making regional flaps the preferred procedure in developing countries. Also, with the economic crisis, we are facing very high pressures for cost containment of the health expense.32 According to some recent
investigations,33 regional flaps are less expensive than their free flap counterparts. Thus, paradoxically, it could be that regional flaps will regain the role of the ‘‘workhorse’’ for head and neck reconstruction,17 leaving free flaps as the resource of choice only for select cases, even in developed countries. Two additional circumstances exist in which deciding between free and pedicled flaps is arduous. First is the case of patients with a poor oncologic prognosis and/or with severe comorbidities. Clear guidelines for major surgery in these cases are lacking in published studies. Even if some investigators might disagree,34 it would seem logical to choose the simplest and shortest procedure for these patients.35 Thus, regional flaps might seem preferable in such settings. An interesting topic is the decision of reconstruction once a previous free flap has failed. This is a debated issue, and although some investigators might consider a regional flap as the ideal ‘‘salvage’’ reconstructive procedure, other researchers could disagree and consider a second free flap the most reliable procedure after failed microvascular reconstruction.36,37 Colletti et al3 recently published their experience with autonomized regional flaps in these selected cases. Autonomizing a regional flap maximizes the chances of success, allowing the receiving site to heal from the infection that almost invariably develops after failure of a free flap and is one of the very few absolute contraindications to performing microvascular reconstruction. Finally, locoregional flaps still remain a valid option in association with free flaps to reconstruct extensive head and neck defects, such as described by Bianchi et al.4 In conclusion, despite the increasing use of free flaps, regional flaps are still a valid and safe option for head and neck reconstruction that allow good aesthetics and functional outcomes. Some issues not commonly assessed, including economic costs and
571.e9
COLLETTI ET AL
Table 1. PATIENTS RECRUITED FOR THE PRESENT STUDY
Pt. No.
Diagnosis
Tumor Site
1 2 3 4 5 6 7 8 9A 9B 10 11 12 13 14 15 16 17 18
SCC SCC SCC SCC SCC SCC SCC SCC Chordoma Chordoma SCC SCC SCC SCC SCC MCT SCC SCC SCC
Mandible Mandible Mandible Mandible Tongue Cheek Mouth floor Cheek Scalp Scalp Mandible Mouth floor Mandible Mandible Mandible Cheek Mandible Tongue Mandible
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC BCC SCC SCC SCC SCC
Cheek Mandible Mandible Mandible CLF Mandible Tongue CLF Tongue Mandible Mandible Scalp Cheek CLF Mandible Cheek Mandible CLF Mandible Hypopharynx Hypopharynx Cheek Tongue Mandible Scalp Mandible
Flap
Plate
Complications
PMF PMF PMF PMF LTF PMF PMF PMF PMF LTF PMF PMF PMF PMF PMF PMF SF PMF PMF
2.4-mm LB 2.4-mm LB 2.4-mm LB 2.4-mm LB — — — — — — 2.4-mm LB — 2.4-mm LB 2.4-mm LB 2.4-mm LB — — — 2.4-mm LB
TFF PMF PMF PMF PMF PMF PMF PMF PMF PMF PMF LTF LDF SF PMF and FFF PMF PMF PMF SF and FFF PMF PMF LDF PMF PMF LTF PMF
— 2.4-mm LB 2.4-mm LB 2.4-mm LB — 2.4-mm LB — — — 2.4-mm LB 2.4-mm LB — — — 2.4-mm LB — 2.4-mm LB — 2.4-mm LB — — — — 2.4-mm LB — 2.4-mm LB
Late plate extrusion Late plate extrusion Late plate extrusion — — Partial skin loss — — — — — — — — — — — — Late plate extrusion, partial skin loss, death — Death — — — — — Postoperative hemorrhage — — Late plate extrusion — — — — — Late plate extrusion — Late plate extrusion — — — — — — Total skin loss
Abbreviations: BSC, basal cell carcinoma; CLF, cervical-laryngeal fistula; FFF, free fibula flap; LB, load bearing; LDF, latissimus dorsi flap; LTF, lower trapezius flap; MCT, mixed cell tumor; PFM, pectoralis major flap; Pt. No., patient number; SCC, squamous cell carcinoma; SF, supraclavicular flap; TFF, temporalis fasciocutaneous flap. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
571.e10 oncologic prognosis, should be carefully considered in the evaluation of the best flap to use.
REAPPRAISAL OF REGIONAL FLAPS
19.
Acknowledgments 20. The authors acknowledge Dr Leonard Kaban for his help with the discussion section. This was influenced very much by the concept of ‘ Leonard’s Law’’ regarding the acceptance of new surgical techniques.
21.
22.
References 1. Gusenoff JA, Vega SJ, Jiang S, et al: Comparison of outcomes between university hospitals and community hospitals. Plast Reconstr Surg 118:671, 2006 2. Biglioli F, Pedrazzoli M, Autelitano L, et al: The free fibula flap for treating benign mandibular lesions. Minerva Stomatol 56:349, 2007 3. Colletti G, Autelitano L, Tewfik K, et al: Autonomized flaps in secondary head and neck reconstructions. Acta Otorhinolaryngol Ital 32:329, 2012 4. Bianchi B, Ferri A, Ferrari S, et al: Flap associations in the reconstruction of extensive head and neck defects. Int J Oral Maxillofac Surg 37:723, 2008 5. Massarelli O, Baj A, Gobbi R, et al: Cheek mucosa: A versatile donor site of myomucosal flaps: Technical and functional considerations. Head Neck 35:109, 2013 6. Tostevin PM, Ellis H: The buccal pad of fat: A review. Clin Anat 8: 403, 1995 7. Rahpeyma A, Khajehahmadi S: Buccinator-based myomucosal flaps in intraoral reconstruction: A review and new classification. Natl J Maxillofac Surg 4:25, 2013 8. Albert S, Carmantrant R, Panajotopoulos A, et al: Reconstruction of hard palate defects using a facial artery musculomucosal flap. Ann Chir Plast Esthet 53:281, 2008 9. Abubaker A, Abouzgia MB: The temporalis muscle flap in reconstruction of intraoral defects: An appraisal of the technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94:24, 2002 10. Bass F: A new product growth model for consumer durables. Manag Sci 15:215, 1969 11. Mahajan V, Muller E, Bass F: Diffusion of new products: Empirical generalizations and managerial uses. Market Sci 14: G79, 1995 12. Ray-ban wayfahrer. Available at: http://en.wikipedia.org/wiki/ Ray-Ban_Wayfarer. Accessed December 3, 2014. 13. Bakamjian VY: A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 36:174, 1965 14. Tansini I: Sopra il mio nuovo processo di amputazione della mammella. Gaz Med Hal 57:141, 1906 15. Shah JP, Haribhakti V, Loree TR, et al: Complications of the pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 160:352, 1990 16. Kroll SS, Goepfert H, Jones M, et al: Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. Ann Plast Surg 25:93, 1990 17. Gadre KS, Gadre P, Sane VD, et al: Pectoralis major myocutaneous flap—Still a workhorse for maxillofacial reconstruction in developing countries. J Oral Maxillofac Surg 71:2005.e1, 2013 18. Hsing CY, Wong YK, Wang CP, et al: Comparison between free flap and pectoralis major pedicled flap for reconstruction in
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35. 36.
37.
oral cavity cancer patients—A quality of life analysis. Oral Oncol 47:522, 2011 Frederick JW, Sweeny L, Carroll WR, et al: Outcomes in head and neck reconstruction by surgical site and donor site. Laryngoscope 123:1612, 2013 Ou KL, Dai YH, Wang HJ, et al: The lower trapezius musculocutaneous flap for head and neck reconstruction: Two decades of clinical experience. Ann Plast Surg 71(suppl 1):S48, 2013 Gibber MJ, Clain JB, Jacobson AS, et al: The subscapular system of flaps: An 8-year experience with 105 patients. Head Neck Epub 2014 May 7. Orlik JR, Horwich P, Bartlett C, et al: Long-term functional donor site morbidity of the free radial forearm flap in head and neck cancer survivor. J Otolaryngol Head Neck Surg 43:1, 2014 Hayden RE, Nagel TH: The evolving role of free flaps and pedicled flaps in head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 21:305, 2013 Vucak MC, Masic T, Hassouba M, et al: Reconstructive option of extensive head and neck defects in cancer surgery. Med Arch 67: 275, 2013 Horn D, Jonas R, Engel M, et al: A comparison of free anterolateral thigh and latissimus dorsi flaps in soft tissue reconstruction of extensive defects in the head and neck region. Craniomaxillofac Surg 42:1551, 2014 Maxwell GP, Manson PW, Hooper J: Experience with thirteen latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg 64:1, 1979 Chen WL, Deng YF, Peng GG, et al: Extended vertical lower trapezius island myocutaneous flap for reconstruction of craniomaxillofacial defects. Int J Oral Maxillofac Surg 36:165, 2007 Biglioli F, Mortini P, Pedrazzoli M, et al: The reconstruction of the spheno-orbital region using latissimus dorsi flap and costal graft. J Craniofac Surg 24:e379, 2013 Biglioli F, Brusati R: The folded radial forearm flap in soft-palate and tonsillary fossa reconstruction: Technical note. Int J Oral Maxillofac Surg 37:76, 2008 Colletti G, Allevi F, Valassina D, et al: Repair of cocaine-related oronasal fistula with forearm radial free flap. J Craniofac Surg 24:1734, 2013 Colletti G, Autelitano L, Chiapasco M, et al: Comprehensive surgical management of cocaine-induced midline destructive lesions. J Oral Maxillofac Surg 72:1395.e1, 2014 Tsue TT, Desyatnikova SS, Deleyiannis FW, et al: Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx: Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg 123:731, 1997 Deganello A, Gitti G, Parrinello G, et al: Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps. Acta Otorhinolaryngol Ital 33: 380, 2013 Kim AJ, Suh JD, Sercarz JA, et al: Salvage surgery with free flap reconstruction: Factors affecting outcome after treatment of recurrent head and neck squamous carcinoma. Laryngoscope 117:1019, 2007 Lian TS, Nathan CA: What is the role of flap reconstruction in salvage total laryngectomy? Laryngoscope 124:2441, 2014 Wei FC, Demirkan F, Chen HC, et al: The outcome of failed free flaps in head and neck and extremity reconstruction: What is next in the reconstructive ladder? Plast Reconstr Surg 108: 1154, 2001 Okazaki M, Asato H, Takushima A, et al: Analysis of salvage treatments following the failure of free flap transfer caused by vascular thrombosis in reconstruction for head and neck cancer. Plast Reconstr Surg 119:1223, 2007
Regional Flaps in Head and Neck Reconstruction: A Reappraisal Giacomo Colletti, MD,* Karim Tewfik, MD,y Alessandro Bardazzi, MD,z Fabiana Allevi, MD,x Matteo Chiapasco, MD,k Marco Mandal a, MD,{ and Dimitri Rabbiosi, MD# Purpose:
Starting from our experience with 45 consecutive cases of regional pedicled flaps, we have underlined the effectiveness and reliability of a variety of flaps. The marketing laws as applied to surgical innovations are reviewed to help in the understanding of why regional flaps are regaining wide popularity in head and neck reconstruction.
Materials and Methods:
From January 2009 to January 2014, 45 regional flaps were harvested at San Paolo Hospital to reconstruct head and neck defects. These included 35 pectoralis major muscular and myocutaneous flaps, 4 lower trapezius island or pedicled flaps, 3 supraclavicular flaps, 2 latissimus dorsi pedicled flaps, and 1 fasciocutaneous temporal flap. The basic literature of marketing regarding the diffusion of new products was also reviewed.
Results:
Two myocutaneous pectoralis major flaps were complicated by necrosis of the cutaneous paddle (one complete and one partial). No complete loss of any of the 45 flaps was observed. At 6 months of follow-up, 2 patients had died of multiple organ failure after prolonged sepsis. The 43 remaining patients had acceptable morphologic and functional results.
Conclusions: Regional and free flaps appear to compete in many cases for the same indications. From the results of the present case series, regional flaps can be considered reliable reconstructive choices that are less expensive than their free flap alternatives. The ‘‘resurrection’’ of regional flaps can be partially justified by the changes in the global economy and the required adaptation of developed and developing countries. Ó 2015 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 73:571.e1-571.e10, 2015
Free flaps have been considered the reference standard for head and neck reconstruction,1 even after removal of benign neoplasms.2 Local and regional flaps, however, are still a safe and useful option. After a period of apparent oblivion, an increasing number of studies have been published, with various investigators inviting surgeons to reconsider the use of these
flaps.3-5 In some cases, local or regional pedicled flaps represent the best reconstructive option. The mucosal cheek flap, Bichat fat pad flap, buccinator myomucosal flap, facial artery myomucosal flap, and temporalis muscle flap should be the first choice for limited maxillary and mandibular defects (cheek mucosa and Bichat fat pad flap6); limited tongue, {Assistant, Department of Otolaryngology, University of Verona,
*Assistant, Division of Maxillo-Facial Surgery, Department of Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Verona, Italy.
Universita degli Studi di Milano, Milan, Italy.
#Assistant, Division of Maxillo-Facial Surgery, Department of
yResident, Division of Maxillo-Facial Surgery, Department of
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
Universita degli Studi di Milano, Milan, Italy.
Universita degli Studi di Milano, Milan, Italy. zResident, Division of Maxillo-Facial Surgery, Department of
Address correspondence and reprint requests to Dr Colletti: Division of Maxillo-Facial Surgery, Department of Biomedical, Surgi-
Biomedical, Surgical and Dental Sciences, San Paolo Hospital,
cal and Dental Sciences, San Paolo Hospital, Universita degli Studi di
Universita degli Studi di Milano, Milan, Italy.
Milano, Piazza della Repubblica 1/a, Milan 20121 Italy; e-mail:
xResident, Division of Maxillo-Facial Surgery, Department of Biomedical, Surgical and Dental Sciences, San Paolo Hospital, Universita degli Studi di Milano, Milan, Italy.
[email protected] Received August 25 2014 Accepted October 21 2014
kHead, Division of Oral Surgery, Department of Biomedical, Surgical and Dental Sciences, San Paolo Hospital, Universita degli Studi di Milano, Milan, Italy.
Ó 2015 American Association of Oral and Maxillofacial Surgeons 0278-2391/14/01620-6 http://dx.doi.org/10.1016/j.joms.2014.10.021
571.e1
571.e2 palatal, and oral floor defects (buccinator myomucosal flap,7 facial artery myomucosal flap8); medium size to major maxillary defects in which bony reconstruction is not needed or planned (temporalis muscle flap9). The settings in which local or regional flaps will be the preferred reconstructive technique have not been discussed. The aim of the present report was to focus on the indications and results for major regional flaps. Several factors can result in surgeons choosing a regional flap instead of a free flap. These include severe patient comorbidities, adverse anatomic conditions with a compromised blood supply, and previous radiotherapy, among others. Furthermore, other circumstances, such as the lack of a microvascular surgical team or financial issues, which can be observed in developing countries, can make free flap reconstruction unfeasible. Finally, sensitivity to the economic burden of healthcare could make regional flaps preferable to free flaps in a variety of circumstances.
REAPPRAISAL OF REGIONAL FLAPS
perform microvascular anastomoses in a difficult position. The 2 latissimus dorsi pedicled flaps were performed in patients with severe comorbidities to shorten the operative time. The region of resection (wide craniofacial resection) was close enough to obtain safe closure with a pedicled latissimus flap. All the supraclavicular flaps were performed in patients with a vessel-depleted neck from previous surgery and radiotherapy (n = 1) or as autonomized salvage flaps (n = 2) after free flap failure. The remaining patients in the present study underwent reconstruction with pedicled flaps because of severe comorbidities (eg, ischemic heart disease with diffuse atherosclerosis) or a poor prognosis. This was a retrospective study. As such, it was granted exemption from the local institutional review board. The present study adhered to the guidelines of the Declaration of Helsinki.
Results Materials and Methods From January 2010 to January 2014 at San Paolo Hospital (Milan, Italy), 45 regional flaps were used in 44 patients for head and neck reconstruction after tumor resection (Table 1). Of the 45 regional flaps, 35 were pectoralis major flaps, 4 were lower trapezius flaps, 3 were supraclavicular flaps, 2 were latissimus dorsi pedicled flaps, and 1 was a temporalis fasciocutaneous flap. Most of the reconstructions were secondary to squamous cell carcinoma (n = 41), with the remaining including 2 chordomas, 1 mixed cell carcinoma, and 1 basal cell carcinoma. Reconstruction with the buccinator myomucosal, facial artery myomucosal, Bichat fat pad, and temporalis muscle flaps was excluded from the present case series. A total of 30 reconstructions were necessary to restore intraoral defects, including 21 mandibular, 2 floor of the mouth, 5 partial tongue, and 2 hypopharyngeal defects. Of the 44 patients, 13 required skin reconstruction, including 7 cheeks, 3 scalps (1 patient with a scalp defect required reconstruction of 2 different regions), and 4 cervical-laryngeal fistulas. In 2 cases, pedicled flaps were used in association with a fibula free flap. Both patients had large mandibular defects that required through and through reconstruction. In almost all the mandibular defects (n = 20), 2.4-mm, load-bearing titanium plates were used as fixation devices. Regional flaps were chosen instead of free flaps for the following reasons. In 3 cases (3 of 4 cases in which a trapezius flap was used), the resection site was the high occipital region. Thus, a lower trapezius flap was harvested simultaneously with the reconstruction, eliminating the need to rotate the patient, perform the reconstruction in a second session, or
No evidence of complete flap failure was observed. In 1 patient, we observed complete skin loss with survival of the muscular portion of the flap. In 1 case, partial skin loss was detected. One patient required a return to the operating room because of active bleeding after closure of a pharyngocutaneous fistula with a pectoralis major flap. After the thoracic wound had been reopened and a bleeding perforator ligated, he had a full recovery with no additional complications. No fistula was observed in any case. The donor sites were closed primarily in all cases, except for the latissimus dorsi pedicled flap, which required a partial-thickness skin graft harvested from the thigh. A total of 20 load-bearing plates were used to reconstruct the bone mandibular defects. Of these plates, 7 presented with late extrusion (>12 months after the first operation) and required removal. Two patients died of multiple organ failure after prolonged sepsis at 6 months postoperatively. CASE 1
The first patient included in the present report was a 55-year-old woman (patient 41, Figs 1 to 6) affected by squamous cell carcinoma of the right border of the tongue. She had severe comorbidities, including ischemic heart disease and diffused arteriosclerotic arteriopathy. Thus, we chose a regional flap for reconstruction. With the patient under general anesthesia, she underwent temporary tracheostomy, right selective neck dissection (level I to III), right partial glossectomy, and reconstruction with a pectoralis major flap. No complications were observed during recovery. The followup examination after 1 year showed the patient had good functional and aesthetic outcomes with no evidence of relapse.
COLLETTI ET AL
FIGURE 1. Preoperative image of squamous cell carcinoma of the right border of the tongue in a 55-year-old woman (patient 41, case 1 in the present report). Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
CASE 2
The second patient was 65-year-old woman (patient 30, Figs 7 to 11) affected by an extensive squamous cell carcinoma of the scalp that had previously been treated with a nonradical excision by another unit. The resection required positioning the patient prone; therefore, we decided to simultaneously raise a pedicled flap without the need to change the patient’s position. She underwent wide scalp resection and reconstruction with a lower trapezius
571.e3
FIGURE 3. Intraoperative image showing the tongue defect after resection. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
pedicled flap. Good wound healing was observed during the weeks after surgery, and the follow-up examination after 1 year showed good functional and aesthetic outcomes without relapse.
FIGURE 2. Preoperative magnetic resonance imaging scan showing extension of the squamous cell carcinoma of the tongue.
FIGURE 4. Myocutaneous pectoralis major flap harvested to reconstruct the tongue defect.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
571.e4
REAPPRAISAL OF REGIONAL FLAPS
FIGURE 5. Intraoperative image showing complete reconstruction of the tongue. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
CASE 3
The third patient was a 71-year-old man (patient 40, Figs 12 to 16) affected by a large relapsing basal cell carcinoma of the right middle third of the face with intraorbital invasion. The patient also had chronic heart failure; therefore, the shortest procedure was chosen. Under general anesthesia, he underwent a large excision with orbital exenteration. In the same operative session, a latissimus dorsi pedicled flap was harvested. Immediately after the resection, it was rotated to reconstruct the defect. The donor site was repaired using a skin graft harvested from the patient’s thigh. At the follow-up examination after 1 year, the patient had acceptable aesthetic outcomes with no evidence of relapse.
Discussion Just as with most innovations in medical science, the introduction of a new successful surgical tech-
FIGURE 6. Image at the 1-year follow-up visit showing satisfactory morphologic and functional outcomes. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
FIGURE 7. Patient 30 (case 2 in the present report), a 65-year-old woman, with extensive squamous cell carcinoma of the scalp previously treated with nonradical excision. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
nique usually sees 3 different moments in its history. The first phase is when the technique is introduced and adopted only marginally. In the second period, an ‘‘explosion’’ of its use and multicenter discussions occur. Finally, in the third phase, a decrease occurs in its popularity, although the technique is used steadily, but with lower frequency than during its ‘‘hype’’ phase. This type of diffusion was first described by Bass10 in 1969 and is typical of many innovations in the industrial technology, agricultural, educational, pharmaceutical, and consumer durable goods markets. Mahajan et al11 in 1990 reviewed the Bass model and made additional refinements and extensions. The Bass model can be drawn visually with a curve that reflects a modification of a shifted, modified Gompertz distribution (Fig 17). At times in this distribution, a fourth phase of complete oblivion (Fig 17B) or of ‘‘resurrection’’ (Fig 17C) of the product can occur. A recent example of resurrection of a consumer product is that of Bausch and Lomb’s Ray Ban Wayfarer eyeglasses.12 These eyeglasses saw a period of high popularity from their introduction in the market in 1956 to the beginning of the 1990s. Then they became almost
COLLETTI ET AL
571.e5
FIGURE 8. Wide scalp and cranial bone resection with exposure of the dura.
FIGURE 9. Lower trapezius island flap harvested to reconstruct the scalp defect.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
forgotten. In 2007, the original Wayfarer were brought back to the market in their original form and saw a new era of widespread diffusion in the market. The diffusion of a scientific innovation (and, as such, any surgical technique) follows the same rules of marketing science. Since their introduction in the 1960s13 (although some regional pedicled flaps were described much earlier14), pedicled regional flaps went through widespread diffusion that made them the standard technique in head and neck reconstruction. However, at the end of the 1980s and the beginning of the 1990s, free flaps became popular, and pedicled regional flaps were used with decreasing frequency. It appears that in the recent history of head and neck reconstruction, pedicled and free flaps have concurred for the same indications and that their use, in some cases, can be mutually exclusive. Therefore, during the boom period of free flaps, pedicled regional flaps have been almost abandoned. In contrast, currently, when we are probably facing the steady state of free flap diffusion, the use of regional flaps is, in fact, being resurrected. Still, free flaps are considered the reference standard for many cases of head and neck reconstruction; how-
ever, a significant body of data has been increasing slowly but steadily in which pedicled flaps have been used in comparable settings. In many instances, pedicled or microvascular soft tissue flaps compete for the same indication, each technique with its advantages and disadvantages. The key question seems to be in which circumstances would free flaps have the advantage over regional flaps and in which circumstances regional flaps would be preferable or superior. It has been reported that free flaps have superior success rates compared with pedicled flaps. Free flaps appear to be extremely reliable, with a reported success rate of $95% in some reports.1 Two very large case series, however, have declared success rates ranging from 97.6 to 98% for the pectoralis major pedicled flap.15,16 Only a multicenter, prospective, randomized study could definitively prove the superior reliability of free flaps compared with pedicled flaps; however, no such study has been published. Comparing different case series with each other can only provide an idea of flap reliability. Also, if we compare these case series, it appears that pedicled and free flaps are equally reliable. Another key aspect is donor site morbidity. The proponents of different techniques have tended to declare
571.e6
REAPPRAISAL OF REGIONAL FLAPS
FIGURE 12. View of a 71-year-old man (patient 40, case 3 in the present report) affected by a large relapsing basal cell carcinoma of the right middle third of the face with intraorbital invasion. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015. FIGURE 10. Intraoperative image showing completed scalp reconstruction. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
FIGURE 11. Image at the 1-year follow-up visit showing a satisfactory morphologic outcome.
FIGURE 13. Intraoperative image showing extensive resection of the right cranium and face.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
COLLETTI ET AL
FIGURE 14. Latissimus dorsi pedicled flap harvested to reconstruct the defect. The donor site closure required a split-thickness skin graft harvested from the thigh.
571.e7
FIGURE 15. Intraoperative image showing the completed reconstruction. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
that their technique is more anatomically respectful and results in lower donor site morbidity. Again, this does not appear to be related to whether the flap is a regional pedicled or distant microvascular flap. Just to cite a couple of examples, the donor site morbidity of a pectoralis major muscle flap17,18 is not superior to a latissimus dorsi microvascular flap19 and an inferior trapezius myocutaneous flap20 does not have greater donor site morbidity than a parascapular free flap.21 Considering the published data, it appears that the most fragile donor site in terms of local donor site complications is the forearm.22 The radial forearm has usually been transferred as a free flap. The amount and quality of soft tissues to be transferred might represent an argument in favor of free flaps. Again, this is debatable. Reports have been published of vast soft tissue reconstruction obtained with either free or pedicled flaps.23,24 Horn et al,25 in their recent study, compared free anterolateral thigh flaps and latissimus dorsi flaps in the reconstruction of extensive defects. The mean latissimus dorsi flap
surface was 115.8 cm2 (range 20.0 to 600.0). The mean anterolateral thigh flap surface was 67.0 cm2 (range 20.0 to 330.0). In 1978, Maxwell et al26 reported a latissimus dorsi pedicled flap dimension of 12 35 cm. In a recent study of trapezius island myocutaneous flap, Chen et al27 described a mean size of 9.8 6.3 cm. In the present case series, ample reconstructions were obtained with pedicled regional flaps. Some situations exist in which free flaps and regional flaps are simply not comparable. In major bone reconstruction, free flaps are necessary, and pedicled local or regional flaps (eg, pedicled calvarial flaps) cannot offer the same amount and quality of bone. Moreover, if soft tissues are lacking or unreliable (eg, after radiotherapy), bone from a microvascular flap is mandatory. Free flaps are the only choice for reconstruction in cases in which pedicled flaps cannot reach a too-distant defect, such as major full-thickness defects of the apex of the head. In such cases, small defects can easily be reconstructed using local scalp flaps; however, vast reconstruction will require a large amount of soft tissue not provided
571.e8
REAPPRAISAL OF REGIONAL FLAPS
FIGURE 17. Bass model diagram. Line A shows the theoretical progression of adoptions in time; line B represents complete oblivion; and line C, a phase of resurrection. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
FIGURE 16. Image at the 1-year follow-up visit showing a satisfactory morphologic outcome. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
by any regional flap. Wide skull base defects for which temporalis or pericranial flaps are insufficient or not available need to be lined with reliable, wellvascularized free flaps.28 Free flaps are needed for reconstruction that requires unusual, thin, plicated shapes, such as the soft palate and upper pharynx.29 Finally, free flaps have the advantage that their very small pedicle (compared with regional and random local flaps) can be easily and safely passed through anatomic strictures.30,31 Regional flaps will be the only choice for very select cases. The lack of donor vessels is one of these circumstances. Although it has been declared that bridge vessels can be used to reach distant donor vessels in the thorax, in the presence of a vessel-depleted neck, a regional flap will be a better option. Free flaps are more expensive procedures and require specific instruments and training, making regional flaps the preferred procedure in developing countries. Also, with the economic crisis, we are facing very high pressures for cost containment of the health expense.32 According to some recent
investigations,33 regional flaps are less expensive than their free flap counterparts. Thus, paradoxically, it could be that regional flaps will regain the role of the ‘‘workhorse’’ for head and neck reconstruction,17 leaving free flaps as the resource of choice only for select cases, even in developed countries. Two additional circumstances exist in which deciding between free and pedicled flaps is arduous. First is the case of patients with a poor oncologic prognosis and/or with severe comorbidities. Clear guidelines for major surgery in these cases are lacking in published studies. Even if some investigators might disagree,34 it would seem logical to choose the simplest and shortest procedure for these patients.35 Thus, regional flaps might seem preferable in such settings. An interesting topic is the decision of reconstruction once a previous free flap has failed. This is a debated issue, and although some investigators might consider a regional flap as the ideal ‘‘salvage’’ reconstructive procedure, other researchers could disagree and consider a second free flap the most reliable procedure after failed microvascular reconstruction.36,37 Colletti et al3 recently published their experience with autonomized regional flaps in these selected cases. Autonomizing a regional flap maximizes the chances of success, allowing the receiving site to heal from the infection that almost invariably develops after failure of a free flap and is one of the very few absolute contraindications to performing microvascular reconstruction. Finally, locoregional flaps still remain a valid option in association with free flaps to reconstruct extensive head and neck defects, such as described by Bianchi et al.4 In conclusion, despite the increasing use of free flaps, regional flaps are still a valid and safe option for head and neck reconstruction that allow good aesthetics and functional outcomes. Some issues not commonly assessed, including economic costs and
571.e9
COLLETTI ET AL
Table 1. PATIENTS RECRUITED FOR THE PRESENT STUDY
Pt. No.
Diagnosis
Tumor Site
1 2 3 4 5 6 7 8 9A 9B 10 11 12 13 14 15 16 17 18
SCC SCC SCC SCC SCC SCC SCC SCC Chordoma Chordoma SCC SCC SCC SCC SCC MCT SCC SCC SCC
Mandible Mandible Mandible Mandible Tongue Cheek Mouth floor Cheek Scalp Scalp Mandible Mouth floor Mandible Mandible Mandible Cheek Mandible Tongue Mandible
19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44
SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC BCC SCC SCC SCC SCC
Cheek Mandible Mandible Mandible CLF Mandible Tongue CLF Tongue Mandible Mandible Scalp Cheek CLF Mandible Cheek Mandible CLF Mandible Hypopharynx Hypopharynx Cheek Tongue Mandible Scalp Mandible
Flap
Plate
Complications
PMF PMF PMF PMF LTF PMF PMF PMF PMF LTF PMF PMF PMF PMF PMF PMF SF PMF PMF
2.4-mm LB 2.4-mm LB 2.4-mm LB 2.4-mm LB — — — — — — 2.4-mm LB — 2.4-mm LB 2.4-mm LB 2.4-mm LB — — — 2.4-mm LB
TFF PMF PMF PMF PMF PMF PMF PMF PMF PMF PMF LTF LDF SF PMF and FFF PMF PMF PMF SF and FFF PMF PMF LDF PMF PMF LTF PMF
— 2.4-mm LB 2.4-mm LB 2.4-mm LB — 2.4-mm LB — — — 2.4-mm LB 2.4-mm LB — — — 2.4-mm LB — 2.4-mm LB — 2.4-mm LB — — — — 2.4-mm LB — 2.4-mm LB
Late plate extrusion Late plate extrusion Late plate extrusion — — Partial skin loss — — — — — — — — — — — — Late plate extrusion, partial skin loss, death — Death — — — — — Postoperative hemorrhage — — Late plate extrusion — — — — — Late plate extrusion — Late plate extrusion — — — — — — Total skin loss
Abbreviations: BSC, basal cell carcinoma; CLF, cervical-laryngeal fistula; FFF, free fibula flap; LB, load bearing; LDF, latissimus dorsi flap; LTF, lower trapezius flap; MCT, mixed cell tumor; PFM, pectoralis major flap; Pt. No., patient number; SCC, squamous cell carcinoma; SF, supraclavicular flap; TFF, temporalis fasciocutaneous flap. Colletti et al. Reappraisal of Regional Flaps. J Oral Maxillofac Surg 2015.
571.e10 oncologic prognosis, should be carefully considered in the evaluation of the best flap to use.
REAPPRAISAL OF REGIONAL FLAPS
19.
Acknowledgments 20. The authors acknowledge Dr Leonard Kaban for his help with the discussion section. This was influenced very much by the concept of ‘ Leonard’s Law’’ regarding the acceptance of new surgical techniques.
21.
22.
References 1. Gusenoff JA, Vega SJ, Jiang S, et al: Comparison of outcomes between university hospitals and community hospitals. Plast Reconstr Surg 118:671, 2006 2. Biglioli F, Pedrazzoli M, Autelitano L, et al: The free fibula flap for treating benign mandibular lesions. Minerva Stomatol 56:349, 2007 3. Colletti G, Autelitano L, Tewfik K, et al: Autonomized flaps in secondary head and neck reconstructions. Acta Otorhinolaryngol Ital 32:329, 2012 4. Bianchi B, Ferri A, Ferrari S, et al: Flap associations in the reconstruction of extensive head and neck defects. Int J Oral Maxillofac Surg 37:723, 2008 5. Massarelli O, Baj A, Gobbi R, et al: Cheek mucosa: A versatile donor site of myomucosal flaps: Technical and functional considerations. Head Neck 35:109, 2013 6. Tostevin PM, Ellis H: The buccal pad of fat: A review. Clin Anat 8: 403, 1995 7. Rahpeyma A, Khajehahmadi S: Buccinator-based myomucosal flaps in intraoral reconstruction: A review and new classification. Natl J Maxillofac Surg 4:25, 2013 8. Albert S, Carmantrant R, Panajotopoulos A, et al: Reconstruction of hard palate defects using a facial artery musculomucosal flap. Ann Chir Plast Esthet 53:281, 2008 9. Abubaker A, Abouzgia MB: The temporalis muscle flap in reconstruction of intraoral defects: An appraisal of the technique. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 94:24, 2002 10. Bass F: A new product growth model for consumer durables. Manag Sci 15:215, 1969 11. Mahajan V, Muller E, Bass F: Diffusion of new products: Empirical generalizations and managerial uses. Market Sci 14: G79, 1995 12. Ray-ban wayfahrer. Available at: http://en.wikipedia.org/wiki/ Ray-Ban_Wayfarer. Accessed December 3, 2014. 13. Bakamjian VY: A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 36:174, 1965 14. Tansini I: Sopra il mio nuovo processo di amputazione della mammella. Gaz Med Hal 57:141, 1906 15. Shah JP, Haribhakti V, Loree TR, et al: Complications of the pectoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 160:352, 1990 16. Kroll SS, Goepfert H, Jones M, et al: Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. Ann Plast Surg 25:93, 1990 17. Gadre KS, Gadre P, Sane VD, et al: Pectoralis major myocutaneous flap—Still a workhorse for maxillofacial reconstruction in developing countries. J Oral Maxillofac Surg 71:2005.e1, 2013 18. Hsing CY, Wong YK, Wang CP, et al: Comparison between free flap and pectoralis major pedicled flap for reconstruction in
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35. 36.
37.
oral cavity cancer patients—A quality of life analysis. Oral Oncol 47:522, 2011 Frederick JW, Sweeny L, Carroll WR, et al: Outcomes in head and neck reconstruction by surgical site and donor site. Laryngoscope 123:1612, 2013 Ou KL, Dai YH, Wang HJ, et al: The lower trapezius musculocutaneous flap for head and neck reconstruction: Two decades of clinical experience. Ann Plast Surg 71(suppl 1):S48, 2013 Gibber MJ, Clain JB, Jacobson AS, et al: The subscapular system of flaps: An 8-year experience with 105 patients. Head Neck Epub 2014 May 7. Orlik JR, Horwich P, Bartlett C, et al: Long-term functional donor site morbidity of the free radial forearm flap in head and neck cancer survivor. J Otolaryngol Head Neck Surg 43:1, 2014 Hayden RE, Nagel TH: The evolving role of free flaps and pedicled flaps in head and neck reconstruction. Curr Opin Otolaryngol Head Neck Surg 21:305, 2013 Vucak MC, Masic T, Hassouba M, et al: Reconstructive option of extensive head and neck defects in cancer surgery. Med Arch 67: 275, 2013 Horn D, Jonas R, Engel M, et al: A comparison of free anterolateral thigh and latissimus dorsi flaps in soft tissue reconstruction of extensive defects in the head and neck region. Craniomaxillofac Surg 42:1551, 2014 Maxwell GP, Manson PW, Hooper J: Experience with thirteen latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg 64:1, 1979 Chen WL, Deng YF, Peng GG, et al: Extended vertical lower trapezius island myocutaneous flap for reconstruction of craniomaxillofacial defects. Int J Oral Maxillofac Surg 36:165, 2007 Biglioli F, Mortini P, Pedrazzoli M, et al: The reconstruction of the spheno-orbital region using latissimus dorsi flap and costal graft. J Craniofac Surg 24:e379, 2013 Biglioli F, Brusati R: The folded radial forearm flap in soft-palate and tonsillary fossa reconstruction: Technical note. Int J Oral Maxillofac Surg 37:76, 2008 Colletti G, Allevi F, Valassina D, et al: Repair of cocaine-related oronasal fistula with forearm radial free flap. J Craniofac Surg 24:1734, 2013 Colletti G, Autelitano L, Chiapasco M, et al: Comprehensive surgical management of cocaine-induced midline destructive lesions. J Oral Maxillofac Surg 72:1395.e1, 2014 Tsue TT, Desyatnikova SS, Deleyiannis FW, et al: Comparison of cost and function in reconstruction of the posterior oral cavity and oropharynx: Free vs pedicled soft tissue transfer. Arch Otolaryngol Head Neck Surg 123:731, 1997 Deganello A, Gitti G, Parrinello G, et al: Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps. Acta Otorhinolaryngol Ital 33: 380, 2013 Kim AJ, Suh JD, Sercarz JA, et al: Salvage surgery with free flap reconstruction: Factors affecting outcome after treatment of recurrent head and neck squamous carcinoma. Laryngoscope 117:1019, 2007 Lian TS, Nathan CA: What is the role of flap reconstruction in salvage total laryngectomy? Laryngoscope 124:2441, 2014 Wei FC, Demirkan F, Chen HC, et al: The outcome of failed free flaps in head and neck and extremity reconstruction: What is next in the reconstructive ladder? Plast Reconstr Surg 108: 1154, 2001 Okazaki M, Asato H, Takushima A, et al: Analysis of salvage treatments following the failure of free flap transfer caused by vascular thrombosis in reconstruction for head and neck cancer. Plast Reconstr Surg 119:1223, 2007
