Britirh Jmmal
of Plastic Surm~y (1991). 44,11-74
Ideas and Innovations Subclavicular approach in head and neck reconstruction with the latissimus dorsi musculocutaneous flap A. Hayashi and Y. Maruyama Department of Plastic and Reconstructive
Surgery, Toho University School of Medicine, Tokyo, Japan
SUMMARY. As ~JI alternative procedure in transferring the pedicled latisshnus dorsi musculocutaneous flap to the head and neck, we bave devised a subclavicular approach and applied it successfully in our clinic. This approach reduces the distance of the transfer and leaves no bulkiness over the clavicle. The subclavian vessels, the bra&al plexus and the cervical pleura are retracted safely beyond the periosteum during the procedure, and the pedicle of the flap is protected under the clavicle postoperatively.
Surgical procedure
and the flap is carried upwards through these tunnels (Fig. 2). The width of the tunnel between the clavicle and the periosteum can be extended to more than 3 cm with the upper arm in 90” of flexion and adduction.
The latissimus dorsi flap is dissected and raised in the usual way. The loose areolar tissue between the pectoralis major and minor muscles is carefully dissected to create the pectoral tunnel. A linear incision about 5 to 7 cm long, parallel to the midportion of the clavicle, is carried down to the periosteum. The periosteum is detached circumferentially from the clavicle and the subclavicular tunnel is completed (Fig. 1). Next, the muscle fibres of the pectoralis major, near its clavicular origin, are divided
Case reports Case 1 A 52-year-old man presented with an eosinophilic granuloma of his left submandibular region and radiation dermatitis of his left lateral neck (Fig. 3). Excision left a 14 x 12 cm defect of the neck and submandibular region. The latissimus dorsi musculocutaneous flap was elevated in the conventional manner, which included the thoracodorsal vessels and the
ectoralis minor m.
\
pectoralis major m. Fig. 1
Figure l-Schematic representation of the subclavicular approach (A) passing first through the pectoral tunnel and then the space between the clavicle (cl.) and the first rib ; the conventional “pectoral tunnel” approach (B); and the subcutaneous approach (C). Figure 2-The clavicle and its periosteum are divided to make the subclavicular tunnel.
Fig. 2
71
72
Figure J-Case 1. (A) A 52-year-old man with an eosinophilic left a 14 x 12 cm defect. A latissimus dorsi musculocutaneous tunnels. (C) Immediate postoperative view shows no bulkiness
British Journal of Plastic Surgery
Fig. 3 granuloma in his left submandibular region. (B) Wide resection of the lesion flap was raised and carried upwards through the pectoral and subclavicular over the clavicle. (D) Postoperative view.
muscle bundle in its pedicle. The flap was carried subclavicularly and then transferred to the recipient site. Postoperatively the flap survived completely and no bulkiness remained over the clavicle.
contracture, a 20 x 12 cm extended latissimus dorsi musculocutaneous flap was raised. The flap was transferred to the defect through the subclavicular tunnel. The flap survived completely and her postoperative course was uneventful.
Case 2 A 24-year-old woman was suffering from post-bum contracture of her neck (Fig. 4). After releasing
scar the
The latissimus dorsi musculocutaneous flap is widely applied in head and neck reconstruction, both as a
Ideas
and Innovations
73
Figure 4-Case 2. (A) A 24-year-old woman with post-bum scar contracture of the neck. (B) Preoperative lateral view. (C) After releasing the contracture, a latissimus dorsi musculocutaneous flap, measuring 20 x 12 cm, raised and transferred subclavicularly. (D, E) Postoperative views.
pedicled flap (Krishna and Green, 1980; Barton et al., 1983; Maruyama et at., 1985) and by microvascular anastomosis (Watson er al., 1979; Robson ef al., 1989). In cases of pedicled flap transfer, the flap is usually carried to the recipient site through a subcutaneous tunnel or through the tunnel between the pectoralis major and minor (the “pectoral tunnel”). However, in both of these ways the pedicle must cross over the clavicle, causing an unnatural bulkiness. Moreover, the pedicle is likely to be exposed to accidental trauma or pressure. Habal(1988) described a clavicular osteotomy and internal rigid fixation for passing the pectoralis major musculocutaneous flap to regions of the head and neck. This method could be applied to the latissimus dorsi flap but seemed rather troublesome and would increase operation time. The subclavicular approach, in which the pedicle passes through the pectoral tunnel and then through the space between the clavicle and its periosteum, has the following advantages : 1. The distance between the donor and recipient sites
is short and straight so the tension on the pedicle is reduced and the rotation arc of the Aap is extended. 2. Because of (l), the surgeon can use the more
proximal portion of the flap, which is more reliable than the distal one, for covering the defect. 3. No unnatural bulge remains over the clavicle. This aesthetic effect is obvious, especially in thin persons. 4. The vascular bundle is safely protected by the clavicle from accidental trauma or compression. During the procedure, the subclavian vessels, the brachial plexus and the cervical pleura are retracted safely beyond the periosteum of the clavicle. The width of the subclavicular tunnel can be extended to more than 3 cm in most instances so that even a riblatissimus dorsi osteomusculocutaneous flap may be able to pass through it (Maruyama et al., 1985). Complete survival of the flaps obtained in our clinical series suggests that the subclavicular tunnel does not impair flap circulation postoperatively.
References Barton, F. E. Jr., Spicer, T. E. and 3yrd, H. T. (1983). Head and neck reconstruction with the latissimus dorsi myocutaneous flap: anatomic observations and report of 60 cases. Plastic and Reconstmcrive Surgery, 71, 199.
British
14 Habal, M. B. (1988). Clavicular osteotomy and internal rigid fixation to the super extended pectoralis major musculocutaneous flap. Surgery, Gynecology and Obstetrics, 166,283. Krishna, B. V. and Green, M. F. (1980). Extended role of latissimus dorsi myocutaneous flap in reconstruction of the neck. British Journal of Plastic Surgery, 33,233. Maruyama, Y., Urita, Y. and Oh&hi, K. (1985). Rib-latissimus dorsi osteomyocutaneous flap in reconstruction of a mandibular defect. British Journalof Plastic Surgery, 38,234. Robson, M. C., Zachary, L. S., Schmidt, D. R., Faibiiff, B. and Hekmatpaaah, J. (1989). Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses. Plastic and Reconstructive Surgery, 83,438. Watson, J. S., Craig, R. D. P. and Orton, C. I. (1979). The free latissimus dorsi myocutaneous flap. Plastic and Reconstructive Surgery, 64,299.
Journal of Plastic Surgery
The Authors AkiteruHayashi, MD, Instructor Yu Maruyama, MD, Associate
Professor
Department of Plastic and Reconstructive School of Medicine, 6-1 l-l Ohmorinishi, 143.
Requests
for reprints
to Dr Hayashi.
Paper received 31 May 1990. Accepted 26 June 1990.
and Chief
Surgery, Toho University Ohta-ku, Tokyo, Japan
of Plastic Surm~y (1991). 44,11-74
Ideas and Innovations Subclavicular approach in head and neck reconstruction with the latissimus dorsi musculocutaneous flap A. Hayashi and Y. Maruyama Department of Plastic and Reconstructive
Surgery, Toho University School of Medicine, Tokyo, Japan
SUMMARY. As ~JI alternative procedure in transferring the pedicled latisshnus dorsi musculocutaneous flap to the head and neck, we bave devised a subclavicular approach and applied it successfully in our clinic. This approach reduces the distance of the transfer and leaves no bulkiness over the clavicle. The subclavian vessels, the bra&al plexus and the cervical pleura are retracted safely beyond the periosteum during the procedure, and the pedicle of the flap is protected under the clavicle postoperatively.
Surgical procedure
and the flap is carried upwards through these tunnels (Fig. 2). The width of the tunnel between the clavicle and the periosteum can be extended to more than 3 cm with the upper arm in 90” of flexion and adduction.
The latissimus dorsi flap is dissected and raised in the usual way. The loose areolar tissue between the pectoralis major and minor muscles is carefully dissected to create the pectoral tunnel. A linear incision about 5 to 7 cm long, parallel to the midportion of the clavicle, is carried down to the periosteum. The periosteum is detached circumferentially from the clavicle and the subclavicular tunnel is completed (Fig. 1). Next, the muscle fibres of the pectoralis major, near its clavicular origin, are divided
Case reports Case 1 A 52-year-old man presented with an eosinophilic granuloma of his left submandibular region and radiation dermatitis of his left lateral neck (Fig. 3). Excision left a 14 x 12 cm defect of the neck and submandibular region. The latissimus dorsi musculocutaneous flap was elevated in the conventional manner, which included the thoracodorsal vessels and the
ectoralis minor m.
\
pectoralis major m. Fig. 1
Figure l-Schematic representation of the subclavicular approach (A) passing first through the pectoral tunnel and then the space between the clavicle (cl.) and the first rib ; the conventional “pectoral tunnel” approach (B); and the subcutaneous approach (C). Figure 2-The clavicle and its periosteum are divided to make the subclavicular tunnel.
Fig. 2
71
72
Figure J-Case 1. (A) A 52-year-old man with an eosinophilic left a 14 x 12 cm defect. A latissimus dorsi musculocutaneous tunnels. (C) Immediate postoperative view shows no bulkiness
British Journal of Plastic Surgery
Fig. 3 granuloma in his left submandibular region. (B) Wide resection of the lesion flap was raised and carried upwards through the pectoral and subclavicular over the clavicle. (D) Postoperative view.
muscle bundle in its pedicle. The flap was carried subclavicularly and then transferred to the recipient site. Postoperatively the flap survived completely and no bulkiness remained over the clavicle.
contracture, a 20 x 12 cm extended latissimus dorsi musculocutaneous flap was raised. The flap was transferred to the defect through the subclavicular tunnel. The flap survived completely and her postoperative course was uneventful.
Case 2 A 24-year-old woman was suffering from post-bum contracture of her neck (Fig. 4). After releasing
scar the
The latissimus dorsi musculocutaneous flap is widely applied in head and neck reconstruction, both as a
Ideas
and Innovations
73
Figure 4-Case 2. (A) A 24-year-old woman with post-bum scar contracture of the neck. (B) Preoperative lateral view. (C) After releasing the contracture, a latissimus dorsi musculocutaneous flap, measuring 20 x 12 cm, raised and transferred subclavicularly. (D, E) Postoperative views.
pedicled flap (Krishna and Green, 1980; Barton et al., 1983; Maruyama et at., 1985) and by microvascular anastomosis (Watson er al., 1979; Robson ef al., 1989). In cases of pedicled flap transfer, the flap is usually carried to the recipient site through a subcutaneous tunnel or through the tunnel between the pectoralis major and minor (the “pectoral tunnel”). However, in both of these ways the pedicle must cross over the clavicle, causing an unnatural bulkiness. Moreover, the pedicle is likely to be exposed to accidental trauma or pressure. Habal(1988) described a clavicular osteotomy and internal rigid fixation for passing the pectoralis major musculocutaneous flap to regions of the head and neck. This method could be applied to the latissimus dorsi flap but seemed rather troublesome and would increase operation time. The subclavicular approach, in which the pedicle passes through the pectoral tunnel and then through the space between the clavicle and its periosteum, has the following advantages : 1. The distance between the donor and recipient sites
is short and straight so the tension on the pedicle is reduced and the rotation arc of the Aap is extended. 2. Because of (l), the surgeon can use the more
proximal portion of the flap, which is more reliable than the distal one, for covering the defect. 3. No unnatural bulge remains over the clavicle. This aesthetic effect is obvious, especially in thin persons. 4. The vascular bundle is safely protected by the clavicle from accidental trauma or compression. During the procedure, the subclavian vessels, the brachial plexus and the cervical pleura are retracted safely beyond the periosteum of the clavicle. The width of the subclavicular tunnel can be extended to more than 3 cm in most instances so that even a riblatissimus dorsi osteomusculocutaneous flap may be able to pass through it (Maruyama et al., 1985). Complete survival of the flaps obtained in our clinical series suggests that the subclavicular tunnel does not impair flap circulation postoperatively.
References Barton, F. E. Jr., Spicer, T. E. and 3yrd, H. T. (1983). Head and neck reconstruction with the latissimus dorsi myocutaneous flap: anatomic observations and report of 60 cases. Plastic and Reconstmcrive Surgery, 71, 199.
British
14 Habal, M. B. (1988). Clavicular osteotomy and internal rigid fixation to the super extended pectoralis major musculocutaneous flap. Surgery, Gynecology and Obstetrics, 166,283. Krishna, B. V. and Green, M. F. (1980). Extended role of latissimus dorsi myocutaneous flap in reconstruction of the neck. British Journal of Plastic Surgery, 33,233. Maruyama, Y., Urita, Y. and Oh&hi, K. (1985). Rib-latissimus dorsi osteomyocutaneous flap in reconstruction of a mandibular defect. British Journalof Plastic Surgery, 38,234. Robson, M. C., Zachary, L. S., Schmidt, D. R., Faibiiff, B. and Hekmatpaaah, J. (1989). Reconstruction of large cranial defects in the presence of heavy radiation damage and infection utilizing tissue transferred by microvascular anastomoses. Plastic and Reconstructive Surgery, 83,438. Watson, J. S., Craig, R. D. P. and Orton, C. I. (1979). The free latissimus dorsi myocutaneous flap. Plastic and Reconstructive Surgery, 64,299.
Journal of Plastic Surgery
The Authors AkiteruHayashi, MD, Instructor Yu Maruyama, MD, Associate
Professor
Department of Plastic and Reconstructive School of Medicine, 6-1 l-l Ohmorinishi, 143.
Requests
for reprints
to Dr Hayashi.
Paper received 31 May 1990. Accepted 26 June 1990.
and Chief
Surgery, Toho University Ohta-ku, Tokyo, Japan
