Clin. Otolaryngol. 1992, 17, 487-490

The latissirnus dorsi flap in head and neck reconstructive surgery: a review of 121 procedures J.P.DAVIS, D.V.NIELD, R.J.N.GARTH & N.M.BREACH Department

OJ

Head and Neck Surgery, The Royal Marsden Hospital, London, UK

Accepted for publication 10 June 1992

D.V., GARTH R . J . N . (1992) Clin. Otolaryngol. 17, 487-490 DAVIS J . P . , NIELD

& BREACH N . M .

The latissimus dorsi flap in head and neck reconstructive surgery: a review of 121 procedures The results of a prospective study of 121 latissimus dorsi flaps performed during head and neck reconstructive surgery at the Royal Marsden Hospital are presented. Three-quarters of the flaps were pedicled and one-quarter were free. All the patients underwent surgery for malignant disease. The flap failure rate was 5 % , other flap related complications occurred in 19% and the overall rate of complications was 26%. Previous radiotherapy, site of reconstruction, type of flap (free or pedicled) and age of the patient were not significant risk factors. Men were more likely to have a complication than women. Keywords head and neck neoplasms surgery

surgical Paps

A superiorly based axillary skin flap was described by Tansini’ in 1896 and he later modified this to include the underlying latissimus dorsi muscle.’ The flap was described for use on the chest by D’Este3 and in the axilla by Hutchins.‘ The current popularity of the flap followed its reintroduction by Olivari’ in 1976 and its use in the head and neck was described by Quillen and colleagues in 1978.6 The flap has become more popular since then, but in many head and neck units the pectoralis major flap remains the mainstay of reconstructive surgery in this area despite comparative disadvantages in some patients.

latissimus dorsi

senior registrar. The surgery was performed for biopsy proven malignant disease in all cases. Prior to the reconstructive procedure the name of patient, age, sex, tumour histology and the nature of previous treatment were recorded. At operation the site of reconstruction and the type of flap (free or pedicled, myocutaneous or muscle) were added to the record. Post operative complications prior to discharge were noted and divided into those directly related to the reconstructive surgery and other serious complications leading to death or disability. The data were analysed by Fisher’s exact test, chi-squared and the Wilcoxon rank sum test as appropriate.

Patients and methods The techniques of raising both pedicled and free latissimus dorsi flaps are well documented6,’ and the method used by Breach has been reported.’ When the maximum length of pedicle was required the circumflex scapular artery was divided in addition to the branch of the thoracodorsal artery to serratus anterior. Separate record sheets were kept of all 118 patients in whom latissimus dorsi flaps were used for head and neck reconstruction at the Royal Marsden hospital between 1 January 1988 and 31 December 1990. All the operations were carried out by one of the authors (N.M.B.) and his Correspondence: Mr J.P.Davis, Department of Otolaryngology, Royal Free Hospital, Pond Street, London NW3 2QG, UK.

Results One hundred and twenty-one latissimus dorsi flaps were performed in 118 patients. There were 90 pedicled and 31 free flaps. The male to female ratio was similar in the two groups (pedicled flaps 1.84 : I , free flaps I .82 : I). The mean age of the patients in the pedicled flap group was 56.3 years (range 3-84) and that of the free flap group was 43.5 years (range 15-69). The lower mean age of the free flap group was significant when analysed by Wilcoxon’s rank sum test (P < 0.01). Although no free flaps were performed in patients over 70 years of age, age was not deliberately used to decide whether to perform a free or pedicled flap in a particular patient. Ten (1 1%) of the pedicled and 5 (16%) of

487

488

J.P.Davis et al.

Table 1. Tumour pathology in I18 patients

Pathology

___

Table 3. Site of reconstruction %

n

.-.

Squamous cell carcinoma Adenocarcinoma Sarcoma (various) Basal cell carcinoma Adenoidcystic carcinoma Malignant fibrous histiocytoma Undifferentiated carcinoma Malignant melanoma Lymphoma Acinic cell carcinoma Giant neurofibroma

75 6 5 3 3 2 2 2

89

7 6

4 3 2 2 2 I

1 1 1

1 1

Site

Pedicled

Free

Oral cavity Pharynx Neck Face/ear/parotid/orbit Scalp

42 17

15

15

14 2

0 0 15 1

Total n (YO) 57 (47) 17 (14) 15 (12)

29 (24) 3 (2)

with residual hemiparesis, and one had cervical vertebral collapse with cord compression. At the donor site primary closure was possible in all but one case. Two donor site wounds subsequently dehisced and required split skin grafting. One patient developed a seroma which settled with repeated aspiration. At thc site of reconstruction. 3 pedicled and 3 free flaps failed. Two pedicled failures were due to haematoma compressing the pedicle in its tunnel. The cause of failure in the third case was not known. One free flap failed because of atheromatous disease resulting in 5 unsuccessful attempts at arterial anastomosis. The second free flap failure was in a patient who had undergone a total glossectomy. The flap was anastomosed to the superior thyroid artery but this resulted in kinking of the pedicle. A revision arterial anastomosis to the transverse cervical artery was unsuccessful. The third failure was due to thrombosis of the arterial anastomosis 10 hours post operatively. Of the 19 other complications at the site of reconstruction, 7 were cases of partial flap loss and 4 were fistulae. Two of these required revision surgery, the others responding to conservative management. One pedicled and one free flap required early re-exploration to evacuate haematomas. Two free flaps were successfully re-explored for anastomotic problems (one arterial revision, one venous). Two wound abscesses were drained. One pedicled flap was successfully converted to a free flap when the pedicle was accidcntally divided. One patient had severe overspill following a total glossectomy and required a laryngectomy. The overall complication rate was 26% and that directly related to the reconstruction was 24%.

the free flaps were of muscle only, all the others were myocutaneous. All the patients had biopsy proven disease prior to surgical excision. As might be expcctcd in this region, most of the tumours were squamous cell carcinomas with a variety of malignancies accounting for the other 25% of the total (Table I). Ninety-six flaps (79%)were performed on patients who had had previous radiotherapy, either alone o r combined with another treatment. Only 12 (10%) flaps were performed in patients who had had no previous treatment (Table 2). Reconstructions were carried out in most of the extracranial sites in the head and ncck (Table 3). Both pedicled and frcc flaps were used in the oral cavity and in external sites on the head. In the ncck and pharynx only pedicled flaps werc used. In the pharynx the bulk of the latissimus dorsi flap makes it unsuitable for repair of small defects and the radial free forearm flap was preferred. In cases where a wider cxcision was necessary a radical neck dissection was usually carried out providing an easy route of acccss for a pediclcd latissimus dorsi flap to the pharynx. Complications were divided into those occurring at the site of reconstruction, those at the donor site and other major complications resulting in death or serious disability (Table 4). There were 3 major complications: one patient died of a pulmonary embolus, one had a cerebrovascular accident

Table 2. Treatment prior to reconstructive

Total

Previous treatment

Pedicled

Free

Surgery and radiotherapy Radiotherapy Surgery, chemotherapy and radiotherapy

36 17 10 12

24

60 (50)

0 4

17 (14)

No previous treatment

Surgery Chemotherapy and radiotherapy Chemotherapy

6 5

4

0 3 G 0

n (X)

14 (12) 12 (10) 9 (7) 5 (4) 4 (3)

procedure

Latissimus dorsifirap in head and neck surgery 489

Table 5. Reported complication rates in series of latissimus dorsi and pectoralis major flaps in the head and neck

Table 4. Complications following 12I procedures

Complications _

_

_

Pedicled ~

Free

Total n (YO) Latissimus dorsi flaps Chowdhury el a/., 1988 Sabatier & Bakamjian, 1985 Barton et a/., 1983

Flap related At donor site

Failed closure/dehiscence Seroma At site of reconstruction

Total flap loss Partial flap loss Fistula Haematoma comp. pedicle Wound abscess Pedicle divided Overspill, laryngectomy Anastomotic failure

No. of flaps Complications (YO)

__

..

3 5 4 I 2 1 1 nia

Other major Death Disability Total

A number of factors which might have resulted in an increased rate of flap related complications were analysed by Fisher's exact test or chi-squared where appropriate. The type of flap (free or pedicled), age over 60, site of reconstruction and previous radiotherapy were not significant risk factors. Men were more likely to have a complication than women (Fisher's exact test P < 0.05).

Discussion There are many instances in head and neck reconstructive surgery where a Rap is required which will provide both skin and muscle. A choice often has to be made between the latissimus dorsi flap and the pectoralis major flap. Where a pedicled flap is required which reaches above the zygomatic arch the pectoralis major flap is excluded.' The pedicled latissimus dorsi Rap will often reach onto the scalp, especially if the circumflex scapular artery is divided. Other authors'' have been concerned that dividing this artery might cause complications but we did not experience any related problems. The complication rates reported here compare favourably with those reported elsewhere for both latissimus dorsi and pectoralis major flaps used in the head and neck""-" (Table 5). The difficulties of comparing complication rates in reports from different centres was discussed by Shah et uL13 They gave 'an honest and thorough analysis of all the observed facts regarding complications' in their reported series of pectoralis major flaps and we have endeavoured to d o the

Pectoralis major flaps Shah et a/., 1990 Kroll et a/., 1990 Wilson el a/., 1984 Mehrof el a/., 1983 Ossof er a/.. 1983 Schuller, 1983 Baek el a / . . 1982 Biller et al., 1981

80" 56t 60t 21 1 168 112 73 95 50 I33 42

60 38 28 63 63 16 54

35 42 40 55

*Pedicled and free. tPedicled only.

same with this report. The improvement in the complication rate compared to a smaller study previously reported from the Royal Marsden presumably reflects the 'learning curve' inherent in surgery of this nature. Our finding of a lower complication rate in women contrasts with the reports of an increased risk in women for pectoralis major The latissimus dorsi flap offers much better donor site cosmesis, especially in the female, as it does not distort the breast. In the mouth the pedicled latissimus dorsi is easier to support than the pectoralis major flap as it is less susceptible to being dragged down by its pedicle. In the study of Shah et d.I3 there was an increased risk of complications when pectoralis major flaps were used following total glossectomy, which again contrasts with our report which did not show an increased complication rate when latissimus dorsi flaps were used in the oral cavity. The latissimus dorsi flap does take longer to perform than the pectoralis major flap because of the relative inaccessibility of the donor site. However we believe that the latissimus dorsi flap should still be used in those patients in whom it is likely to produce the best result when compared to other flaps. This study shows that the latissimus dorsi flap, both free and pedicled, has a continuing role to play in head and neck reconstructive surgery. Its use should be strongly considered in female patients, in floor of mouth reconstructions needing both skin and muscle, and in cases where a pedicled flap is required which reaches above the zygoma.

References I TANSINI1. (1896) Nuovo processo per l'amputazione delta mammaella per cancre. Riforma Medica 12, 3-5

490 J.P.Davis et al.

2 TANSINI 1. (1906) Sopra il mio nuovo process0 di amputazione della mammella. Riforma Medica (Palermo, Napoli) 12, 757 3 D’ESTES. (1912) La technique de I’amputation de la mammelle pour carcinome mammaire. Rev. Chir. 45, 164-210 4 HUTCHINSE.H. (1939) A method for the prevention of elephantiasis chirurgica. Surg. Gynecol. Ohster. 69, 795-804 5 OLIVARI N. (1976) The latissimus Rap. Br. J. Plasi. Surg. 29, 126- 128 C.G., SHEARIN JR J.C. & GEORGIADE N.G. (1978) Use 6 QUILLEN of the latissimus dorsi myocutaneous flap for reconstruction in the head and neck area. Plasi. Reconstr. Surg. 62, 113-1 17 7 WATSONJ.S., CRAIGR.D.P. & ORTONC.1. (1979) The free latissimus dorsi myocutaneous flap. Plast. Reconstr. Surg. 64, 299-305 8 CHOWDHURY C.R., MCLEANN.R., HARROP-GRIFFITHS K. & BREACH N.M. (1988) The repair of defects in the head and neck region with the latissimus dorsi myocutaneous flap. J. Laryngol. 0101.102, 1 127- I 132 9 DlERKs E.J. (1989) Myocutaneous Raps in head and neck surgery. Facial Plast. Surg. 6, 265-278 10 MAVESD.M., PANJEW.R. & SHAGETS F.W. (1984) Extended latissimus dorsi myocutaneous Rap reconstruction of major head and neck defects. Oiolaryngol. Head Neck Surg. 92, 551-558 I 1 SABATIER R.E. & BAKAMJIAN V.Y. (1985) Transaxillary latissimus dorsi flap reconstruction in head and neck cancer. Am. J. Surg. 150,421434 12 BARTONJR, F.E., SPICERT.E. & BYRD H.S. (1983) Head and neck reconstruction with the latissimus dorsi myocutaneous flap:

anatomic observations and report of 60 cases. Plast. Reconsir. Surg. 7 1, 199-204 13 SHAHJ.P., HARIBHAKTI V., LOREET.R. & SUTARIA P. (1990) Complications of the pectoralis major myocutaneous flap in head and neck reconstruction. Am. J. Surg. 160, 352-355 14 KROLLS.S., GOEPFERT H., JONESM., GUILLAMONDEGUI 0. & SCHUSTERMAN M. (1990) Analysis of complications in 168 pectoralis major myocutaneous Raps used for head and neck reconstruction. Ann. Plasi. Surg. 25, 93-97 15 WILSONJ.S.P., YIACOUMETTIS A.M. & ONEILLT. (1984) Some observations on 112 pectoralis major myocutaneous Raps. A m . J. Surg. 147, 273-279 16 MEHRHOF A.I., ROSENSTOCK A,, NEIFELDJ.P., MERRITT W.H., THEOGARAJ S.D. & COHENI.K. (1983) The pectoralis major myocutaneous Rap in head and neck reconstruction. Am. J . Surg. 146, 478482 17 OSSOFR.H., WURSTERC.F., BERKTOLD R.E., KRESPIY.P. & SISSON G.A. (1983) Complications after pectoralis major myocutaneous flap reconstruction of head and neck defects. Arch. 0iolar.vngol. 109, 812-814 18 SCHULLER D.E. (1983) Pectoralis major flap in head and neck cancer reconstruction. Arch. Orolaryngol. 109, 185-189 19 BAEKSE-M., LAWSON W. & BILLERH.F. (1982) An analysis of 133 pectoralis major myocutaneous flaps. Plasf. Reconslr. Surg. 69, 460-467 20 BILLER H.F., BAEK SE-M., LAWSONW., KRESPI Y.P. & BLAUCRUND S.M. (I98 1) Pectoralis major myocutaneous island flap in head and neck surgery. Arch. Otolaryngol. 107, 23-26