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ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 2  |  Page : 888-891

Reconstruction of full-thickness cheek defects with a folded extended supraclavicular fasciocutaneous island flap following ablation of advanced oral cancer


1 Department of Oral and Maxillofacial Surgery, The Sixth Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
2 Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou 510120, China

Date of Web Publication25-Jul-2016

Correspondence Address:
Wei-Liang Chen
Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, 107 Yan-jiang Road, Guangzhou
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.177497

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 > Abstract 


Purpose: The aim of the present clinical study was to evaluate the feasibility of a folded extended supraclavicular fasciocutaneous island flap (SFIF) for full-thickness cheek defect reconstruction following ablative oral cancer surgery.
Patients and Methods: The nine patients with advanced squamous cell carcinoma of the buccal mucosa were six men and three women, with a mean age of 60.8 years. All patients were treated with surgery including ipsilateral radical neck dissection. A folded extended SFIF with a skin paddle ranging between 6 × (6 + 5) cm and 7 × (10 + 9) cm were used to reconstruct the full-thickness cheek defects.
Results: One minor flap failure and one wound dehiscence in donor site occurred, but all flaps survived, and there was no major complication in any patient. All patients were able to receive all of their nutrition orally and had normal speech. The patients were followed-up for 9–28 months; six patients were living with no evidence of disease, two was living with disease, and one died of local recurrence.
Conclusion: The folded extended SFIF to reconstruct full-thickness cheek defects is reliable and an excellent alternative to other options for patients who have full-thickness defect of the cheek.

Keywords: Cheek defect, head and neck reconstruction, supraclavicular flap, transverse cervical vessels


How to cite this article:
Fang SL, Zhang DM, Chen WL, Wang YY, Fan S. Reconstruction of full-thickness cheek defects with a folded extended supraclavicular fasciocutaneous island flap following ablation of advanced oral cancer. J Can Res Ther 2016;12:888-91

How to cite this URL:
Fang SL, Zhang DM, Chen WL, Wang YY, Fan S. Reconstruction of full-thickness cheek defects with a folded extended supraclavicular fasciocutaneous island flap following ablation of advanced oral cancer. J Can Res Ther [serial online] 2016 [cited 2019 Sep 15];12:888-91. Available from: http://www.cancerjournal.net/text.asp?2016/12/2/888/177497




 > Introduction Top


Full-thickness cheek defects involve both the oral lining and the external facial skin. Many types of pedicle flaps and microvascular free flaps have been used for the reconstruction of full-thickness cheek defects. Pallua and Magnus Noah used the supraclavicular artery island flap to reconstruct skin defects of the cheek, chin, neck, and chest.[1] Recently, we reported that the supraclavicular fasciocutaneous island flaps (SFIFs) extended to include the shoulder skin based on the cutaneous feeder vessels and perforator vessels in the deep fascia of the transverse cervical artery (TCA) and its branches. The superficial cervical veins (SCVs) and nerves from the superficial cervical plexus entering the flap from its superior margin is a useful, viable option for defects of the head and neck following cancer ablation.[2] Combining the use of the extensive SFIFs with the extended vertical lower trapezius island myocutaneous flaps to reconstruct major through-and-through cheek soft tissue defects is reliable and an excellent alternative.[3] The folded extended SFIF is a simple and reliable flap preferred for the reconstruction of large oropharyngocutaneous fistulas.[4] In this article, we present our experience using the folded extended SFIF to provide both inner and outer linings for full-thickness cheek defect reconstruction following ablative oral cancer surgery.


 > Patients and Methods Top


Folded extended SFIFs were designed to provide both an inner and an outer lining for major full-thickness cheek defects following oncological resections taking place between April-July 2010 and July 2013. The nine patients with advanced squamous cell carcinoma of the buccal mucosa were six men and three women, with a mean age of 60.8 years (range, 53–68 years). All patients were treated with surgery including ipsilateral radical neck dissection. A folded extended SFIF with a skin paddle ranging between 6 × (6 + 5) cm and 7 × (10 + 9) cm and the inner and outer lining ranged in size from 6 × 5 and 7 × 9 cm to 6 × 6 and 7 × 10 cm, respectively (average 6.6 × 6.9 and 6.6 × 7.6 cm) were used to reconstruct the full-thickness cheek defects. Four patients underwent adjuvant radiotherapy [Table 1].
Table 1: Diagnosis, treatments, and outcome of nine patients with squamous cell carcinoma of the buccal mucosa

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Anatomy

The TCA is a branch of the subclavian artery that may arise from either the thyrocervical trunk or from the subclavian artery directly in a minority of cases. The TCA gives off superficial TCA (STCA) and deep TCA (DTCA) branches.[5] The TCA arose from the thyrocervical trunk in 54.2% and from the subclavian artery in 45.8%; the diameter of the artery ranged from 0.15 to 0.24 cm (mean 0.18 ± 0.036 cm).[2] The TCA runs posteriorly and laterally toward the trapezius muscle and travels beneath the omohyoid muscle and superficial to the scalene muscles and brachial plexus within the fibro-fatty tissue of the supraclavicular fossa. After passing underneath the omohyoid muscle, it gives off the supraclavicular artery [6] and perforators to the supraclavicular skin.[7] Before reaching the trapezius muscle, it divides into two branches: the STCA to the upper third of the trapezius muscle and the DTCA to the middle third of the trapezius muscle.

Subplatysmal dissection of the posterior triangle of the neck shows the perforators going toward the skin. These perforators came from the STCA in 75%, the TCA itself in 25%, and the DTCA in 15%; the total exceeds 100% because, in some cases, the perforators came from both the TCA and one of its branches or from both branches.[8] The arterial branches penetrate the platysma, which was supplied by small vessels from the arterial branches. Little connection occurred between the vascular plexus of the platysma and that of the skin layer with adipofascial tissue above the platysma and the platysma located in the subcutaneous tissue.[9] The supraclavicular skin is nourished by an average of four perforators coming from the TCA. Venous drainage occurs via the SCV and not through the venae comitantes of the TCA.[10] Two SCVs are usually present. The supraclavicular nerves consist of a group of three to five main branches arborizing from the supraclavicular notch toward the neck and shoulder and one or two branches from the cervical plexus run alongside the vessels into the shoulder region.[1] Nerves coming from the superficial cervical plexus enter the flap from its superior margin.

Surgical technique

Preoperatively, three-dimensional computed tomography (3D-CT) was performed for all patients to reveal the patency of the TCA and its STCA and DTCA branches. Under general anesthesia, each patient was placed on his/her side at an angle of approximately 45° with the head and neck extended moderately. Tumor resection and neck dissection were performed in this position. The folded extended SFIF and incisions for the neck tunnel are outlined in [Figure 1]. The TCA should be identified during the creation of the neck tunnel, with care taken to protect the transverse cervical vessels. Then, the flap was elevated from distal to proximal, and the incision was extended to the deltoid muscle. In the subfascial plane, the flap, which included the platysma muscle, was raised from lateral to medial. In the medial third of the flap, the pedicle could be identified readily by transillumination. It was necessary to sever several perforators from the deltoid muscle. After reaching the previously outlined medial edge of the required island flap, the skin was incised superficially while taking care not to damage the pedicle at the supraclavicular level.
Figure 1: A 64-year-old woman presented with T4N1M0 squamous cell carcinoma of the left buccal mucosa. The incision line of the incisions for the folded extended supraclavicular fasciocutaneous island flap and the tumor was outlined

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Further preparation of the pedicle was carried out precisely at the subcutaneous level on the upper side, and at the subfascial level on the lower side. The vessels of the supraclavicular triangle were exposed and dissected. The SFIF is nourished mainly by the TCA. The cervical plexus was dissected in the superior lateral triangle of the neck, where the STCA passes suprafascially toward the shoulder and the DTCA passes deeply toward the trapezius muscle and its overlying skin. In the inferior lateral triangle of the neck, venous drainage occurs via the SCV and not through the venae comitantes of the TCA; thus, two SCVs could be dissected. The TCA, medial SCV, and cervical plexus were saved, whereas the distal STCA, distal DTCA, and lateral SCV were cut and ligated. A foldable flap for reconstructing the full-thickness cheek defects was created by removing a 0.8-cm-wide band of skin [Figure 2]. The flap was characterized by a 17–20-cm-long subcutaneous pedicle. The flaps are pulled through a tunnel to reach distant defects of the cheek, which the medial portion of the flap was used for the buccal mucosa, and the distal portion was used for the skin of the cheek [Figure 3] and [Figure 4]. The donor site is closed directly.
Figure 2: The transverse cervical artery, superficial cervical vein, and the cervical plexus nerve were dissected while harvesting the folded extended supraclavicular fasciocutaneous island flap. A foldable flap was created by removing a 1.0-cm-wide band of skin

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Figure 3: The flap was pulled through the neck tunnel to the full cheek defect, which the medial portion of the flap was used for the buccal mucosa and the distal portion was used for the skin of the cheek

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Figure 4: The appearance of the recipient site

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 > Results Top


One minor flap failure and one wound dehiscence in donor site occurred, but all flaps survived, and there was no major complication in any patient. All patients were able to receive all of their nutrition orally and had normal speech. The patients were followed up for 9–28 months (average, 19.6 months); six patients were living with no evidence of disease, two was living with disease, and one died of local recurrence [Table 1].


 > Discussion Top


There are several options for treating through-and-through defects of the head and neck including reconstruction with a folded forehead flap,[11] double faced pectoralis major flap,[12] folded trapezius island myocutaneous flap,[13] folded submental island flap,[14] double continuous radial forearm flap,[15] and chimeric anterolateral thigh flap.[16] Recent reconstruction efforts have focused on the creative use of microvascular free flaps for this purpose; however, this requires microsurgical experience and achieves less desirable esthetic results, with significant donor morbidity. Through-and-through defects of the head and neck may include full-thickness cheek defects, through-and-through palate defects, and through-and-through defects of the floor of the mouth. We believe that the folded forehead flap and folded submental island flap can be used to repair small to intermediate through-and-through defects. Double faced pectoralis major flap and folded trapezius island myocutaneous flap, which is usually the first choice for full-thickness cheek defects, is too bulky, although the pectoralis major myocutaneous pedicled flap is preferred in females when a myocutaneous flap is not ideal. The development of an adenocarcinoma in breast tissue accidentally displaced with a pectoralis major flap was reported.[17]

In this study, folded extended SFIFs were used to reconstruct nine full-thickness cheek defects following oncological resections. All flaps survived and no major complication was observed in any patient, and all patients were able to receive all nutrition orally and had normal speech. The flap includes the shoulder skin and is based on the TCA is a thin fasciocutaneous flap with a well-defined vascular supply. In our previous study, the flap survival rate was 95.8%, and the form and function of the recipient sites recovered well.[2] This study showed that the SFIF can be readily created as a folded flap and provides healthy tissue for reconstructing the full-thickness cheek defects.

The SFIF offers several advantages: The flap can be raised with technical ease and thus requires a relatively short operating time; the flap donor site is in the same operative field and can be closed primarily; the thin pedicle allows easy transfer of the island flap, which can be tunneled into a defect in the head and neck; it can be used in patients who have previously undergone radiation of the head and neck; low donor site morbidity has been reported; and it is well hidden. The flap is preferred by female patients, but a disadvantage is that it cannot be used in patients undergoing radical neck dissection in which the TCA has been damaged. The successful utilization of the extensive SFIF requires careful consideration of the vascular anatomy and preoperative 3D-CT.[2]

In our series, one minor flap failure and one wound dehiscence in donor site occurred and was treated conservatively to achieve secondary wound healing. All patients presented with advanced oral squamous cell carcinoma. The patients were followed for an average of 19.6 months: six patients were living with no evidence of disease, two was living with disease, and one died of local recurrence at 24 months.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are No Conflicts of Interest.

 
 > References Top

1.
Pallua N, Magnus Noah E. The tunneled supraclavicular island flap: An optimized technique for head and neck reconstruction. Plast Reconstr Surg 2000;105:842-51.  Back to cited text no. 1
    
2.
Chen WL, Zhang DM, Yang ZH, Huang ZQ, Wang JG, Zhang B, et al. Extended supraclavicular fasciocutaneous island flap based on the transverse cervical artery for head and neck reconstruction after cancer ablation. J Oral Maxillofac Surg 2010;68:2422-30.  Back to cited text no. 2
    
3.
Chen WL, Yang ZH, Zhang DM, Huang ZQ, Fan S, Wang L. Reconstruction of major full cheek defects with combined extensive pedicled supraclavicular fasciocutaneous island flaps and extended vertical lower trapezius island myocutaneous flaps after ablation of advanced oral cancer. J Oral Maxillofac Surg 2012;70:1224-31.  Back to cited text no. 3
    
4.
You YH, Chen WL, Zhang DM. Closure of large oropharyngocutaneous fistulas using a folded extensive supraclavicular fasciocutaneous island flap. J Oral Maxillofac Surg Med Pathol 2013;25:310-3.  Back to cited text no. 4
    
5.
Weiglein AH, Moriggl B, Schalk C, Künzel KH, Müller U. Arteries in the posterior cervical triangle in man. Clin Anat 2005;18:553-7.  Back to cited text no. 5
    
6.
Lamberty BG. The supra-clavicular axial patterned flap. Br J Plast Surg 1979;32:207-12.  Back to cited text no. 6
    
7.
Chin T, Ogawa R, Murakami M, Hyakusoku H. An anatomical study and clinical cases of 'super-thin flaps' with transverse cervical perforator. Br J Plast Surg 2005;58:550-5.  Back to cited text no. 7
    
8.
Cordova A, Pirrello R, D'Arpa S, Jeschke J, Brenner E, Moschella F. Vascular anatomy of the supraclavicular area revisited: Feasibility of the free supraclavicular perforator flap. Plast Reconstr Surg 2008;122:1399-409.  Back to cited text no. 8
    
9.
Imanishi N, Nakajima H, Kishi K, Chang H, Aiso S. Is the platysma flap musculocutaneous? Angiographic study of the platysma. Plast Reconstr Surg 2005;115:1018-24.  Back to cited text no. 9
    
10.
Cordova A, D'Arpa S, Pirrello R, Brenner E, Jeschke J, Moschella F. Anatomic study on the transverse cervical vessels perforators in the lateral triangle of the neck and harvest of a new flap: The free supraclavicular transverse cervical artery perforator flap. Surg Radiol Anat 2009;31:93-100.  Back to cited text no. 10
    
11.
Shah JP. Folded forehead flap for reconstruction of full-thickness defects of the cheek. Head Neck Surg 1980;2:248-52.  Back to cited text no. 11
[PUBMED]    
12.
Towpik E, Meyza J. The “double faced” pectoralis major island flap. A valuable alternative in full-thickness cheek reconstruction. J Craniomaxillofac Surg 1990;18:85-7.  Back to cited text no. 12
    
13.
Yang ZH, Zhang DM, Chen WL, Wang YY, Fan S. Reconstruction of through-and-through oral cavity defects with folded extended vertical lower trapezius island myocutaneous flap. Br J Oral Maxillofac Surg 2013;51:731-5.  Back to cited text no. 13
    
14.
Zhang DM, Chen WL, Lin ZY, Yang ZH. Use of a folded reverse facial-submental artery submental island flap to reconstruct soft palate defects following cancer ablation. J Craniomaxillofac Surg 2014;42:910-4.  Back to cited text no. 14
    
15.
Kang SH, Nam W, Cha IH, Kim HJ. Double continuous radial forearm flap for the reconstruction of full-thickness buccal cheek defect. J Plast Reconstr Aesthet Surg 2009;62:e95-6.  Back to cited text no. 15
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16.
Chiu WK, Lin WC, Chen SY, Tzeng WD, Liu SC, Lee TP, et al. Computed tomography angiography imaging for the chimeric anterolateral thigh flap in reconstruction of full thickness buccal defect. ANZ J Surg 2011;81:142-7.  Back to cited text no. 16
    
17.
Depprich RA, Handschel JG, Braunstein S, Kubler NR. Breast carcinoma in a pectoralis major myocutaneous flap used for reconstruction of the oral cavity: A case report and review of the literature. Oral Oncol Extra 2005;41:238-41.  Back to cited text no. 17
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
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