Jeremy Wilson

The cervico-submental keystone island flap for locoregional head and neck reconstruction

BACKGROUND Locally advanced head and neck cancer often requires wide resections of the cheek and parotid gland, and in an ageing population preferred reconstructive options aim to avoid lengthy operating times or high risk surgery. While most large parotid defects traditionally require free flap reconstruction, we describe a new and versatile locoregional flap that has been shown to be reliable, simple and safe. METHODS We describe the cervico-submental (CSM) keystone-design perforator island flap for head and neck reconstruction, including an analysis of 33 consecutive patients with a range of head and neck defects. The flap was raised based on perforators of the external carotid artery and its branches, and designed to overlay the C2/C3 dermatomes (an aide memoire for flap design). The indications, and surgical technique are described. RESULTS In 33 consecutive patients, no major complications were encountered. Five patients developed superficial infections, one developed post-operative bleeding and one patient developed partial tip necrosis. Theatre time was considerably shorter than our alternative reconstructive options. CONCLUSION The CSM keystone-design perforator island flap is a novel and versatile flap, which can be used in a range of advanced cheek and parotidectomy defects, and may enable improved surgical management in an increasingly elderly and high-risk population.

COMPONENT SEPARATION IN THE REPAIR OF A GIANT INGUINOSCROTAL HERNIA

Uncommon in the developed countries today, giant inguinoscrotal hernias typically present after years, even decades of neglect, often following the development of complications or significant impairment of the patient’s quality of life. A number of techniques for the repair of giant inguinoscrotal hernias have been reported.1–10 Although the use of scrotal skin flaps has been described for repair of these hernias, the case under review illustrates a new technique involving component separation of the hernial sac.1 In this case, a peritoneal flap was raised from the sac and reinforced using a polypropylene (Marlex) mesh, with redundant scrotal skin fashioned as a myocutaneous flap to provide skin coverage.

The superior thyroid artery perforator flap: anatomical study and clinical series.

Summary: The redundant tissues of the anterior neck are well suited as a donor site for fasciocutaneous flaps in head and neck reconstruction, with similar skin quality and numerous underlying perforators. However, historic cadaveric research has limited the use of this as a donor site for the design of long and/or large flaps for fear of vascular compromise. The authors undertook an anatomical study to identify the vascular basis for such flaps and have modified previous designs to offer the versatile and reliable superior thyroid artery perforator (STAP) flap. Forty-five consecutive computed tomographic angiograms of the neck were reviewed, assessing the vascular supply of the anterior skin of the neck. Based on these findings, eight consecutive patients underwent head and neck reconstruction using a flap based on the dominant perforator of the region. In all cases, a perforator larger than 0.5 mm was identified within a 2-cm radius of the midpoint of the sternocleidomastoid muscle at its anterior border. This perforator was seen to emerge through the investing layer of deep cervical fascia as a fasciocutaneous perforator and to perforate the platysma on its ipsilateral side of the neck, proximal to the midline. This was seen to be a superior thyroid artery perforator in 89 of 90 sides and an inferior thyroid artery perforator in one case. Eight consecutive patients underwent preoperative imaging and successful flap planning and execution based on this dominant perforator. The superior thyroid artery perforator (STAP) flap demonstrates reliable vascular anatomy and is well suited to reconstruction of a broad range of head and neck defects. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Use of thrombin-based haemostatic matrix in head and neck reconstructions: a potential risk factor for pulmonary embolism.

Haemostatic agents including thrombin‐based haemostatic matrix are widely used in patients undergoing cardiac, vascular and spinal surgery. These agents promote local haemostasis through activation of the clotting cascade. To our knowledge, this case series is the first report of pulmonary embolization associated with FloSeal following head and neck oncology resection and free flap reconstruction.

The Microvascular Basis of the Superior Thyroid Artery Perforator Flap.

Background: The superior thyroid artery perforator flap has been presented previously in this Journal as a locoregional flap that provides an excellent tissue match with minimal donor morbidity for lateral face and temple defects. In the current study, the authors aimed to describe the microvascular anatomy of this flap. Methods: The authors used in vivo computer tomographic angiography, cadaveric dissection, and ex vivo angiography in order to improve surgical safety and application of this technique. Results: The authors provide a detailed map of the microvasculature that is critical to success in this technique, in addition to useful surface anatomical landmarks for ready application in the clinical scenario. Further, the authors discuss the anatomical basis of this flap with reference to the angiosome concept and the critical presence of true anastomoses. Conclusion: The superior thyroid artery perforator flap has been shown to be an excellent technique for reconstruction of lateral face and temporal soft tissue defects, providing a thin, pliable, hair-bearing tissue with minimal donor morbidity.

Reply: “image-guided” Perforator Flaps versus “free-style” Perforator Flaps

means of linking vessels may increase flap dimensions.3 Second, a randomized controlled trial using objective endpoint measures would be required to prove the added advantage gained from use of image-guidance during perforator flap harvest. The simplicity of flap design and the surgeon’s stress level during perforator dissection in patients undergoing an image-guided perforator flap versus a free-style perforator flap harvest may be studied using an objective scoring system. The surgeon’s stress level may be graded from 1 through 4 (none, mild, moderate, and severe levels), with more difficult dissections being assigned a higher score. The simplicity of flap design can also be graded 1 through 4, with more complex designs, depending on perforator suitability, being assigned a higher score. Third, using image guidance for perforator flap harvest is expensive and requires advanced equipment and personnel trained in perforator imaging. In conclusion, “image-guided” perforator flaps may have certain advantages, but the evidence toward the same is inconclusive.4 Further randomized controlled studies (using objective scoring systems) need to be performed before the supremacy of image-guided perforator flaps is established over free-style perforator flaps. DOI: 10.1097/PRS.0b013e31827c720a