Sang Ha Oh

Reconstruction of the Head and Neck Region Using Lower Trapezius Musculocutaneous Flaps

Background Recent literature has indicated that free flaps are currently considered the preferred choice for head and neck reconstruction. However, head and neck cancer patients are frequently treated with chemoradiotherapy, which is often associated with a poor general and local condition, and thus, such patients are ineligible for free flap reconstruction. Therefore, other reconstruction modalities should be considered. Methods We used lower trapezius musculocutaneous (LTMC) flap based on the dorsal scapular artery to reconstruct head and neck defects that arose from head and neck cancer in 8 patients. All of the patients had undergone preoperative chemoradiotherapy. Results There were no complications except one case of partial flap necrosis; it was treated with secondary intention. Healing in the remaining patients was uneventful without hematoma, seroma, or infection. The donor sites were closed primarily. Conclusions The LTMC flap is the preferred flap for a simple, reliable, large flap with a wide arc of rotation and minor donor-site morbidity. The authors recommend this versatile island flap as an alternative to microvascular free tissue transfer for the reconstruction of defects in the head and neck region, for patients that have undergone preoperative chemoradiotherapy.

Peroneal Flap: Clinical Application and Cadaveric Study

Background The goal of this study was to investigate the anatomy of the peroneal artery and its perforators, and to report the clinical results of reconstruction with peroneal artery perforator flaps. Methods The authors dissected 4 cadaver legs and investigated the distribution, course, origin, number, type, and length of the perforators. Peroneal artery perforator flap surgery was performed on 29 patients. Results We identified 19 perforators in 4 legs. The mean number of perforators was 4.8 per leg, and the mean length was 4.8 cm. Five perforators were found proximally, 9 medially, and 5 distally. We found 12 true septocutaneous perforators and 7 musculocutaneous perforators. Four emerged from the posterior tibia artery, and 15 were from the peroneal artery. The peroneal artery perforator flap was used in 29 patients. Retrograde island peroneal flaps were used in 8 cases, anterograde island peroneal flaps in 5 cases, and free peroneal flaps in 16 cases. The mean age was 59.9 years, and the defect size ranged from 2.0 cm×4.5 cm to 8.0 cm×8.0 cm. All the flaps survived. Five flaps developed partial skin necrosis. In 2 cases, a split-thickness skin graft was performed, and the other 3 cases were treated without any additional procedures. Conclusions The peroneal artery perforator flap is a good alternative for the reconstruction of soft tissue defects, with a constant and reliable vascular pedicle, thin and pliable skin, and the possibility of creating a composite tissue flap.

The Use of a Mechanical Stapler in Jejunal Free Flaps in Laryngopharyngectomy Defects.

The reconstruction of laryngopharyngectomy defects requires the creation of a tubular passage that connects the pharyngeal remnant to the cervical esophagus. Tubed fasciocutaneous flaps (e.g., from the anterolateral thigh or radial forearm) are most commonly used, because they permit good postoperative speech and result in low systemic morbidity. However, if a fasciocutaneous flap is unavailable due to a lack of perforators or an obese thigh, the next choice is a jejunal flap. The most common method of securing visceral graft anastomoses was previously one or two layers of hand sewing. However, circular mechanical staplers have been commonly used by general surgeons for enteric anastomosis and lead to similar or lower anastomotic leakage and stricture rates than hand sewing [1,2]. Stapled anastomoses may also reduce the mean operating time by reducing the time required for anastomosis, and also probably reduce blood loss and the likelihood of intraoperative contamination [3]. The ischemic time seems to be a very important factor affecting the likelihood of postoperative complications, especially for free flaps. In particular, the intestine is more vulnerable to ischemia than the skin and bone [4]. In this report, the use of circular mechanical stapling for jejunoesophageal anastomosis was reviewed to assess whether it is a good alternative to hand-sewn anastomoses in the reconstruction area. Jejunal free flap surgery was performed in six patients with a total laryngopharyngectomy defect between March 2009 and January 2013. Total laryngopharyngectomy was performed to treat hypopharyngeal cancer in four cases and to treat glottis cancer in two cases. All patient specimens were diagnosed as squamous cell carcinoma by a pathologist. A single general surgeon harvested the jejunal flap segment in all six cases. A distal jejunoesophageal anastomosis was performed using a 25-mm end-to-end anastomosis (EEA) circular mechanical stapler (Covidien, Mansfield, MA, USA) in all cases. The anastomosis process for the flap was as follows. First, traction sutures were placed in the cervical esophagus to dilate the esophageal lumen. Purse-string sutures were placed at the end of the esophagus prior to stapling. The jejunal flap was pierced with a sharp trocar end, seated in position within the stapler cartridge, and the safety lock was then removed (Fig. 1). Stapling was performed by triggering. After confirming anastomosis of the entire tubular margin, the device was gently removed via the flap lumen (Fig. 2). Proximal flap anastomosis was performed using hand-sewn sutures in an interrupted fashion. At this point, the conduit was trimmed to eliminate redundancy. The suturing was performed with a double layer of interrupted (Covidien, Mansfield, MA, USA) (Fig. 3). We then performed revascularization of the pedicle vessels. We recorded the duration of stapler usage in each case. Two to three months after surgery, patients were assessed for anastomotic leakage or stricture by barium esophagography and endoscopy. Fig. 1 Diagram of the anastomosis process. (A) Diagram showing the proximal esophagus with the trocar in place and retraction (purse-string) sutures for dilating and sizing the esophageal lumen. (B) The pierced jejunum is seated within the stapler cartridge. ... Fig. 2 Diagram of the stapling process. (A) Firing the stapler. After firing, the end-to-end anastomosis device is removed gently via the jejunal flap lumen. (B) Inset, jejunum flap. Fig. 3 A case of total laryngopharyngeal defect reconstruction. (A) Preoperative photograph. (B) The trocar and purse-string sutures are placed on the end of the esophagus prior to stapling