tsndmut

Operative Techniques in Otolaryngology (2013) 24, 45-54

Reconstructive options for the neck after resection ofcutaneous malignancies

Neerav Goyal, MD, MPH, Fred G. Fedok, MD, FACS

From the Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, The Pennsylvania State University,

Milton S. Hershey Medical Center, Hershey, Pennsylvania.

Cutaneous defects of the neck require a different algorithm for reconstruction as compared to facial defects.Depending on the location and size of the defect, a variety of reconstructive techniques can be used, fromsecondary healing to pedicled or free flaps. Additionally, patient co-morbidities can negatively affect theoutcomes of certain reconstructive options. We will describe a variety of techniques that are available to thehead and neck or facial plastic surgeon for reconstruction of neck defects.© 2013 Elsevier Inc. All rights reserved.

KEYWORDSNeck defect;Skin graft;Deltopectoral flap;Pectoral flap;Cervicopectoralrotation;Latissimus dorsi flap;Reconstruction

sa

Head and neck surgeons and facial plastic surgeons areoften responsible for reconstructing defects secondary toMohs surgery (chemosurgery) or wide local excisions ofcutaneous malignancies of the neck. Approaching neck re-construction requires a different algorithm compared withthat used in reconstructing the face to yield the best func-tional and cosmetic outcome. This chapter will focus on thevariety of techniques available to the surgeon in reconstruct-ing defects of the neck, with specific focus on skin grafts,local flaps, and regional flaps.

Although there is a well-established literature defining theaesthetic units of the face, a similar consensus does not existregarding the neck. In his 1994 report, Angrigiani1 consideredhe neck as the anterior and posterior neck regions, with theeparation between these 2 regions demarcated by an imagi-ary line from the earlobe to the middle of the clavicle. Heefined the anterior neck as going from the lower border of theandible to the sternal notch. Zhang et al2 defined aesthetic

nits of the neck, as it related to patients who suffered burns tohe neck, and chose to subdivide the anterior neck unit into the

Address reprint requests and correspondence: Fred G. Fedok, MD,FACS, Division Chief of the Division of Otolaryngology-Head and NeckSurgery, Penn State Hershey Medical Center, Hershey, PA.

E-mail address: ffedok@hmc.psu.edu

1043-1810/$ -see front matter © 2013 Elsevier Inc. All rights reserved.http://dx.doi.org/10.1016/j.otot.2013.01.001

uprahyoid and infrahyoid aesthetic units by defining the hyoids a “pivot point of the neck”.

Patient evaluation

Location/size

In evaluating a defect and developing a reconstructive plan,the location, depth, and size of the defect all play a significantrole. Larger defects may not be amenable to closure with a skingraft or local flap and will likely require a regional flap.Similarly, defects that involve exposure of the great vesselswill need a vascular flap of significant bulk (usually a regionalflap) to ensure adequate coverage of the great vessels. Thelocation of the defect will dictate reconstructive options on thebasis of proximity to certain regional or local flaps, as well asin determining color and texture match of a graft.

Host factors/recipient site factors

The method of reconstruction is dependent not only onthe defect itself but also on the patient’s ability to heal and

incorporate the reconstruction. The deleterious effects of

cb

twm

on from

46 Operative Techniques in Otolaryngology, Vol 24, No 1, March 2013

radiation on local tissue diminish the vascularity, inducefibrosis, and reduce the ability of the skin to repair and heal.

Additionally, nutritional factors and other comorbiditiesas well as patient lifestyle can adversely affect the successof a reconstructive surgery. Patients with hypoalbuminemiaor general malnutrition will have delayed wound healingand an increased likelihood of wound breakdown. More-over, comorbidities such as hypercholesterolemia, periph-eral vascular disease and coronary arterial disease can affectthe patency, compliance, and resilience of pedicled flapsand decrease the success of grafts and free flaps. Addition-ally, research shows that diabetics have significant intracel-lular metabolic defects that lead to delays in signaling tolimit tissue destruction and to initiate the reparative pro-cesses within the body.3 Patients undergoing free-flap re-onstruction with a diagnosis of diabetes have been found toe more likely to have a negative outcome.4 Smokers are

also associated with greater flap and healing complicationssecondary to the vasoconstrictive effect of nicotine and thehigher likelihood of small-vessel disease, although thesechanges are thought to be reversible.5

Reconstructive options

When considering options for reconstruction, we can use thereconstructive ladder to guide our options to manage asoft-tissue defect. The ladder consists of closure by second-ary intention, primary closure, delayed primary closure,split-thickness skin graft, full-thickness skin graft, tissue

Figure 1 Reconstructive ladder. Figure of options for reconstructi

expansion, random flaps, axial flaps, and, finally, free flaps a

(as shown in Figure 1). When there is exposure of the greatvessels, the wound may need to be closed immediately.

Delayed reconstruction

Delayed reconstruction can be of significant utility incases where there is concern for recurrence or positivemargins from the initial resection. In these cases, a tempo-rary split-thickness skin draft or other biological dressingcan be used. As noted previously, delayed reconstructionusually cannot be entertained when there is exposure of thegreat vessels.

Closure by secondary intention

Closing by secondary intention can be a reliable methodof closing, especially along defects that lie over well-vas-cularized tissues and without exposure of the great vesselsof other critical structures. Additionally, convex structuresand areas with lax skin are more amenable to closure bysecondary intention. This can yield healing that is cosmet-ically and functionally acceptable in many circumstances. Itis not universally used and is of generally limited applica-tion. This method of closure might be used in patients whoprefer not to have another surgery, when there are comor-bidities or contraindications to other methods of closure. Toaid with healing by secondary intention, Dhir et al6 describehe use of vacuum-assisted closure (VAC) systems for neckounds. In their case series, the VAC dressings were usedostly in patients who experienced a wound dehiscence of

least to most invasive. (Color version of figure is available online.)

neck dissection incision.

47Goyal and Fedok Reconstructive Options for the Neck

Primary closure

Give the redundancy inherent in many patients’ neck soft-tissues, there is enormous latitude of the size of defects that canbe closed by simple advancement and closure. Defects �4 cmin vertical dimension can be closed with ease in many patients.The laxity of the neck skin and the ability to undermine thetissues surrounding the defect allow for a significant variety ofdefects of the neck to be closed primarily. Ideally, the long axisof the defect should lie along a relaxed skin tension line, andalso have an elliptical shape. A 3:1 ratio of the long axis to theshort axis for the ellipse is an ideal proportion, and oftenundermining the equivalent of one width of the defect shouldbe undertaken around the entire defect.7 Figure 2 demonstratesan example of a primary closure.

Skin grafts

Skin grafts consist of epidermis and a variable amount of

Figure 2 Primary closure. This image demonstrates the typicalelliptical incision that is fashioned around a neck lesion (A) witha primary closure of the resulting defect (B). (Color version offigure is available online.)

dermis that is transferred to the defect. Split-thickness skin

grafts contain a portion of the dermis, whereas full-thick-ness skin grafts contain the whole dermis. There are 3 majorsteps in the integration of a skin graft: imbibition, inoscu-lation, and neovascularization. Imbibition or “drinking” in-volves “plasmatic circulation” and capillary action as wellas direct diffusion of nutrients from the recipient wound bedinto the graft.8 This phase lasts between 24 and 48 hours.After this, the donor and recipient capillary ends realign toestablish a preliminary vascular network through a processknown as inosculation or “kissing.” By 4 to 7 days of skingraft placement, the graft enters the third phase—neovas-cularization—where new vessels grow into the graft.

Split-thickness skin graftA split-thickness skin graft typically varies between 0.012

and 0.030 inches in thickness and consists of both epidermisand a variable thickness of dermis. The thicker the dermis isthe better the skin texture and, at times, the color of the skingraft will be to the surrounding skin. Additionally, the thickerthe dermis, the less overall contracture of the graft, althoughthe degree of immediate contracture is less, as there is lesselastin in the transferred dermis. An electric dermatome isoften used to harvest the graft. The donor site should bemarked with an additional 15% to 20% length to account forgraft shrinkage.9 Often the thigh is used as a donor site, as it isan easily concealed region. To lubricate the skin, mineral oil orchlorhexidine can be used. After this, traction counter to thedermatome should be applied with a pair of skin hooks. Thedermatome is lightly pressed against the skin and advancedforward. While the graft is being elevated, forceps can be usedto prevent the graft from being caught in the dermatome. Asthe graft is being completed, the dermatome should be taperedoff the skin while running. Lidocaine- and epinephrine-soakedgauze can be placed over the donor site while the skin graft isplaced in the defect. The donor site can be dressed with asterile clear watertight dressing such as a translucent surgicaladhesive dressing.

A split-thickness graft can be ideal for larger superficialcutaneous defects that cannot be completely covered by localflaps, or regions where there is concern for recurrence. Itshould be used selectively for deeper subplatysmal defects, andcannot provide suitable coverage of the great vessels. Anabsorbable suture placed in a running or interrupted fashion isused to secure the graft to the recipient bed. Intermittent smallincisions can be placed to allow for drainage through the graftand prevent hematoma formation, which is often referred to as“pie-crusting.” Additionally, a bolster is often placed on top ofthe skin graft to ensure adequate contact with the wound bed.Bolsters can be fashioned from foam or xeroform and tied inplace to apply pressure to the graft. Additionally, the use ofVAC systems over split-thickness skin grafts acts as an air-tight bolster.10

Full-thickness skin graftA full-thickness skin graft is similar to the split-thickness

skin graft but it involves harvesting the entire dermis. It canprovide a better color and texture match to the native skin.

Owing to its thicker dermis, it often undergoes more sig-

taFueotsapa

48 Operative Techniques in Otolaryngology, Vol 24, No 1, March 2013

nificant immediate contracture due to the increased elastin,but it does not suffer from as much secondary contracture.As a result, it contracts less than a similarly sized split-thickness skin graft.9 Full-thickness grafts require a morevascularized wound bed for survival and potentially have alower survival rate as compared with split-thickness grafts11

Common donor sites include the supraclavicular, preauric-ular, and postauricular regions. The supraclavicular regionis especially versatile, as a large full-thickness skin graft canbe obtained from this region and the donor site can still beprimarily closed. The major limitation of the size of graftbeing used is the size of the resultant donor defect.

In obtaining a full-thickness skin graft, a region should bemarked slightly larger than the defect to allow for contracture.Creating “corners” when shaping the defect can reduce thechance of a trap-door deformity or pincushioning.9 Once theentative graft design and size is marked out on the donor area,n incision can be made to the level of the subcutaneous fat.acelift scissors can be used to dissect in a subdermal planenderneath the entirety of the graft. After this, the graft can bexcised with broad cuts using the scissors with one tine in andne tine out of the wound. The graft should be defatted suchhat the shiny dermal surface is exposed. The graft can then beecured to the recipient site with slight redundancy with eitherbsorbable or nonabsorbable sutures. Figure 3 demonstrates aosterior neck lesion that was resected and reconstructed withfull-thickness skin graft.

Local flaps

If the defect is small enough, often a local flap will besufficient to allow for an esthetic closure of the wound. Thisinvolves tissue rearrangement using the surrounding skin. Lo-cal flaps can be categorized as one or a combination of 3 types:an advancement flap, a rotation flap, or a transposition flap. Anadvancement flap involves advancing tissue in a linear vector,whereas a rotation flap uses a radial vector to advance tissuealong a pivot point. A transposition flap is similar to a rotationflap; however, the tissue is rotated over a bridge of normaltissue. In comparison with a rotation flap, a transposition flapis often smaller and is able to be moved more freely along itspivot point. The biomechanics of the neck skin allow for thefrequent use of advancement and transposition flaps.

Regional flaps

Regional flaps can provide significant reconstructive op-tions for larger neck defects with good outcomes. Additionally,they allow the surgeon to harvest tissue for regions that mayhave been spared from irradiation. In discussing reconstructionof cutaneous defects of the neck, the major regional flaps arefasciocutaneous and musculocutaneous flaps. The fasciocuta-neous flaps incorporate epidermis, dermis, subcutaneous fat,and fascia overlying a muscle, whereas the musculocutaneousflaps also incorporate the muscle.

DeltopectoralThe deltopectoral flap is a fasciocutaneous transposition

flap that is versatile and can help provide coverage of large

neck defects. Additionally, it can be used without sacrificingthe ability to simultaneously raise another flap such as thepectoralis major flap. It was first described by Bakamjian12 in

Figure 3 Full-thickness skin graft. Here we see the demarcatedlesion with appropriate margins (A). The patient underwent aresection and placement of a full-thickness skin graft (B—beforebolstering). The last picture (C) shows a 6-week follow-up (photocredit: Todd Cartee, MD; Penn State Milton S. Hershey MedicalCenter, Department of Dermatology). (Color version of figure isavailable online.)

1965 for pharyngoesophageal reconstruction. It provides a

49Goyal and Fedok Reconstructive Options for the Neck

regional pedicled flap that can often be harvested fromoutside of an irradiated field. The vascular supply for thisflap arises from the first, second, third, and fourth perforatingbranches of the internal mammary artery. A more specificanalysis by Daniel et al13 found that whereas the flap from thesternum to the deltopectoral groove is supplied by these per-forators, the portion of the flap overlying the deltoid is suppliedby perforators from the deltoid itself, and also that a portion ofthe flap is supplied by the thoracoacromial artery. This flap cancover a large variety of defects on the ipsilateral neck.

The flap can be raised in 1 or 2 stages. The advantage ofdelayed flap is to allow for improved survival of the distalaspect of the flap and also to allow the surgeon to extend thedistal aspect of the flap onto the shoulder. Designing the flapinvolves marking the infraclavicular line beyond the delt-opectoral grove onto the anterior shoulder or to the tip of theshoulder if the flap is being delayed.14 The inferior aspect ofthe flap is parallel to this superior line and is marked a fewcentimeters above the nipple. The base of the flap is cen-tered over the second, third, and fourth coastal cartilages,thus capturing the perforators from the internal mammaryartery. An incision should be made through the epidermisand dermis and subcutaneous tissues down to the fascia ofthe deltoid along the designed flap. If the flap is going to bedelayed, the distal aspect of the flap that lies beyond thedeltopectoral groove is elevated and then inset back into thedonor bed, with the final raising of the flap occurring 10 to14 days later. When elevating the flap to reconstruct thedefect, the flap is elevated in a plane just over the deltoidmuscle and deep to the fascia of the deltoid muscle. Thisbloodless plane is carried out over the deltoid, deltopectoralgroove, and the pectoralis major. Dissection should bestopped approximately 5 to 6 cm from the midsternal line toavoid skeletonization of or trauma to the perforators. Theflap can then be tunneled in a subcutaneous plane to coverthe neck defect with deepithelialization of the subcutaneousaspect of flap, or it can be inset above the bridge of skinsuch that the pedicle is divided at a later date.

Part of the donor site may be able to be primarily closed,whereas the remainder can be covered with a split-thicknessskin graft.15 Figure 4 illustrates the relevant anatomy for thisflap.

Cervicopectoral rotationThe cervicopectoral flap is a fasciocutaneous rotational

flap that can be used to cover large neck defects and can alsobe used on the lower parts of the face. This flap was firstdescribed by Becker in 1978 and is designed similarly to thedeltopectoral flap. It is also an axially-based flap off of theinternal mammary perforators, but instead of extending lat-erally beyond the deltopectoral groove, it extends superiorlyon the neck. The supraclavicular portion is a randomly-based flap. Again the plane of dissection is just deep to thefascia overlying the pectoralis major, as well as deep to theplatysma and deep to the superficial layer of the deepcervical fascia.16-18 This flap can then be rotated into placeto cover the defect and secured through primary closure

with interrupted sutures. There will likely be a dog-ear

deformity secondary to the rotation that can be trimmed.Authors advocate the use of closed suction drains under-neath the flap, and usually there is no need for extra tissuecoverage of the donor site.17 Figure 5 displays a patient whounderwent a large cervicopectoral rotation to close a preau-ricular defect.

Pectoralis major flap (thoracoacromial artery)The pectoralis major flap is a muscular or musculocutane-

ous flap that can provide significant soft-tissue coverage as

Figure 4 Deltopectoral flap. (A) The illustration demonstrates aneck defect and the outlined incision for a deltopectoral flap withthe location of the internal mammary perforators. (B) This dem-onstrates the location of the flap after rotation and inset.

well as bulk for neck defects. Additionally, it is a hearty flap

50 Operative Techniques in Otolaryngology, Vol 24, No 1, March 2013

with a low major complication rate. It can be raised in a singlestage and reach the anterior neck as well as the midline overthe pretracheal area.14 The dominant vascular supply for thepectoralis major flap is from the thoracoacromial, although it isalso supplied laterally by the lateral thoracic artery and medi-ally by the perforators of the internal mammary. Occasionally,the lateral thoracic artery is the dominant pedicle to this flap.

Designing the flap requires incorporation of the thora-coacromial artery and vein. The pedicle can be identified bydrawing a line from the acromion to the xyphoid and thendrawing a perpendicular line from this line to a point on theipsilateral clavicle such that one-third of the clavicle islateral to the point and two-thirds of it lies medial to thepoint. The skin paddle should be designed superior andmedial to the nipple along the line between the acromionand xyphoid, although it can extend below the inferioraspect of the pectoralis muscle if abdominal fascia is har-vested with the flap. After designing the skin paddle, anincision can be made along the lateral aspect of the skinpaddle down to the pectoralis fascia and carried to the axilla.After this, blunt dissection can be used to identify the lateralborder of the pectoralis muscle. Using this guide, the inferiorborder of the pectoralis should also be identified. The rest ofthe skin paddle incision can be dissected to the level of themuscle. If the paddle extends below the inferior border of thepectoralis major, care should be taken to include rectus abdo-minus fascia in the flap—this portion of the paddle will have a

Figure 5 Cervicopectoral rotation flap. (A) The preauricular defits original anatomic location. (B) This shows the completed closversion of figure is available online.)

random vasculature. The inferior border (including rectus ab-

dominus fascia if necessary) should then be identified andelevated. Shearing forces on the skin paddle should be mini-mized, and tacking sutures into the muscle can help preventthis.11 Blunt dissection between the pectoralis major and minorcan be carried superiorly until the pedicle is identified. Both themedial and lateral aspects of the pectoralis major can be freed,with care taken to identify the perforators of the internal mammaryas well as the lateral thoracic artery. Often the lateral thoracicartery needs to be ligated to allow for sufficient rotation of theflap. The lateral pectoral nerve (or lateral anterior thoracic)arises medial to the pectoralis minor and can be transected toallow for muscular atrophy and avoid synkinesis. After eleva-tion of the flap, the flap is often rotated and tunneled in asubplatysmal plane to the neck defect (Figure 6). If there issignificant bulk, the skin and adipose can be removed from theflap and replaced with a skin graft. Depending on the size ofthe skin paddle, the donor site may need a secondary flap or asplit-thickness skin graft to close.11

Trapezius flap (transverse cervical, dorsal scapular,occipital)

The trapezius flap is a versatile musculocutaneous flapthat can also provide carotid coverage and help to recon-struct neck cutaneous defects. It has a robust vascular sup-ply with contributions from the transverse cervical artery aswell as the dorsal scapular and occipital arteries.14 Depend-ing on how the flap is designed, a different pedicle will

xposed and the raised cervicopectoral rotation flap can be seen ining the rotation flap with multiple suction drains in place. (Color

ect is eure us

provide the dominant supply to the flap. An inferiorly-based

apaPd

apfltttidaa

ttt

51Goyal and Fedok Reconstructive Options for the Neck

flap will rely on the transverse cervical and dorsal scapular,whereas a superiorly-based flap will rely on the occipitalartery and paraspinous perforators. Additionally, a lateraltrapezius flap can be created based on the transverse cervi-cal artery.11 It is important to note whether a patient has had

previous ipsilateral neck dissection, as this could raise theossibility of a previously transected transverse cervicalrtery and limit the surgeon to using a superiorly-based flap.atients need to be in the lateral decubitus position foresigning and harvesting these flaps.

The superiorly-based flap is the most reliable of the flapsnd does not require the transverse cervical artery. It canrovide excellent coverage of ipsilateral neck defects. Theap is designed with incisions at the anterior border of the

rapezius and a parallel incision is marked inferiorly, suchhat the paraspinous perforators are included at the base ofhe flap. Its arc of rotation will be limited by the inferiorncision. The lateral incision lies over the shoulder. Theissection is carried out just deep to the trapezius muscle,nd efforts should be made to save the transverse cervical

Figure 6 Pectoralis major flap. (A) Resection of primary tumor ivessels. (C) Elevation of pectoralis major flap. (D) Completed insetof figure is available online.)

rtery and vein as they are encountered. The flap can cover

he defect with a delayed division of the pedicle or it can beunneled underneath the skin. Often a skin graft is necessaryo close the donor defect.11

The inferiorly-based, or lower, trapezius island flaphas a significant arc of rotation and can reach the midlineof the neck. It is important to ensure that the transversecervical artery is intact. Skin paddle should be markedbetween the spine and medial border of the scapula. Anincision can be marked along the medial aspect of thepaddle rising superiorly to the neck. Once the trapezius isidentified, it is dissected laterally off the rhomboids andthen freed medially. The course of the artery should beexposed. Once the paddle is freed, it can be tunneledunderneath the tissues toward the defect and the donorsite can be primarily closed.

Finally, the lateral trapezius flap is also based on the trans-verse cervical artery and vein, with the skin paddle overlyingthe superior lateral aspect of the trapezius. The pedicle shouldbe identified in the posterior neck, and the paddle should becentered over this pedicle. Then the anterior border of the

bloc fashion (B) Resulting defect with evidence of exposed greattoralis flap with placement of closed suction drains. (Color version

n an enof pec

trapezius should be identified, and an incision can be made

L

Pyustt

52 Operative Techniques in Otolaryngology, Vol 24, No 1, March 2013

through the skin and muscle. Of note, the transverse cervicalartery may be in proximity if not involved with the brachialplexus. This flap can also be extended laterally to incorporatea cervicohumeral fasciocutaneous flap to assist with furthercutaneous coverage.14 The donor site will often require a skingraft, although with undermining, the defect can be partiallyclosed primarily. Figure 7 shows the use of an inferiorly-basedtrapezius myocutaneous flap.

Latissimus dorsi flapThe latissimus dorsi flap is a muscular or myocutane-

ous flap that can provide the largest transferable pedicledsoft-tissue for head and neck reconstruction. It is basedoff of the thoracodorsal artery and vein. Harvesting theflap requires the patient to be in the lateral decubitusposition. The skin paddle can be drawn over the muscle,and an incision is made from the superior aspect of theincision to the axial. The muscles is then identified andreleased anteriorly and inferiorly, and the pedicle can beidentified just medial to the anterior border of the latis-simus dorsi. After freeing the inferior aspect of the mus-

Figure 7 Trapezius flap. (A) Evidence of large exophytic tumorwith margins and outlined inferiorly pedicled trapezius flap. (C) C

is available online.)

cle, the entire muscle can be elevated superiorly towardthe axilla. The medial attachments to the serratus anterioras well as the anterior attachments to the humerus shouldbe freed. For additional rotation of the flap, the superiorinsertion of the muscle can also be transected. The flapcan then be tunneled under the axilla to defects in theneck (Figure 8). Elevation of the arm for few days afterthe reconstruction is recommended to avoid constrictionof the flap.11 Primary closure of donor site defect �10 cmis possible, otherwise closure is completed using skingrafts.11,14 A suction drain is recommended.

esser used flaps

latysma flap (submental or suprasternal artery). The plat-sma flap is a muscle or musculocutaneous flap that can besed for anterior neck defects. It is supplied by either theubmental or the suprasternal artery, depending on whetherhe flap is superiorly or inferiorly based. The reliability ofhe flap suffers from the occasional loss of the skin paddle

ing the posterior neck and scalp. (B) Defect after primary excisionefect with closed suction drains in place. (Color version of figure

involvlosed d

sohpoloasp

53Goyal and Fedok Reconstructive Options for the Neck

due to its variable venous supply through anterior commu-nicating veins. Additionally, this flap may not be able to beused on patients who have had extensive neck dissections orprevious neck operations secondary to transaction of itsvascular supply during those operations. Irradiated neckswill also have a decreased viability of this flap.

Whether the flap design is inferiorly or superiorly based,the skin paddle should be designed in an elliptical fashionalong the axis of a relaxed skin tension line. For superiorly-based flaps, the skin paddle design can be placed as inferi-orly as the clavicle, allowing for significant length and arcof rotation. Once the skin is incised around the paddle,dissection is carried out superficial to the platysma.19 Carehould be taken to preserve the submental artery (a branchf the facial artery) or the suprasternal artery depending onow the flap is based. Once this has been ensured, a sub-latysmal dissection should be carried out toward the basef the flap. Care should be taken to include the superficialayer of the deep cervical fascia and a width of at least 4 cmf platysma should be included in the pedicled flap. Thenterior jugular and external jugular veins should be dis-ected with the flap. The donor site can often be closedrimarily.14

Sternocleidomastoid flap. The sternocleidomastoid flap isanother muscular or musculocutaneous flap that is suppliedby the occipital artery and suprascapular artery. Similar tothe platysma flap, a proximally- or distally-based flap willallow coverage to different regions of the neck.

Figure 9 Free flap. This patient had a resection of a largeposterior neck/scalp lesion (A), resulting in a large soft-tissuedefect (B). Reconstruction was performed using a latissimus dorsifree flap, which can be seen attached to the wound bed (C).Postoperatively, the flap healed well (D). (Color version of figure

Figure 8 Latissimus dorsi flap (illustration as an example). Thisshows an outlined latissimus dorsi flap with the skin paddle de-marcated.

is available online.)

btte

54 Operative Techniques in Otolaryngology, Vol 24, No 1, March 2013

The skin paddle of this flap can be designed with a supe-riorly- or inferiorly-based pedicle. After designing the flap, theincision should be made through the skin and platysma to thelevel of the sternocleidomastoid muscle. The anterior fasciallayer of the muscles should be left intact. After defining theborders of the skin paddle, it is advised that the paddle betacked to the muscle to avoid shearing or avulsion of the skin,given the relatively tenuous blood supply to the skin from themuscle perforators.20 The flap should be elevated, leaving theposterior fascia of the sternocleidomastoid in the donor bed,thus avoiding exposure of deeper structures. Additionally, careshould be taken to avoid transecting the spinal accessory nerveor injuring the internal jugular vein.14 Once the skin paddle haseen sufficiently freed and can be mobilized to the defect site,he muscle should be sutured to the defect, thus decreasing theension applied to the skin. This is to decrease the risk ofpidermal loss.20

Free flaps

Over the past few decades, there has been an increased useof free-tissue transfer for the reconstruction of cutaneous neckdefects. Kakarala et al21 demonstrate an increase in the numberof free flaps with concomitant increase in efficiency and flapsurvival. Recipient vessels are usually available on the side ofthe neck to be reconstructed, unless the patient has undergonean extensive neck dissection. For relatively small defects, theradial forearm flap can be used. Larger defects can be coveredwith flaps, yielding a larger surface area and bulk such as theanterolateral thigh flap, latissimus dorsi, and the rectus abdo-minus. Figure 9 depicts an example of a free flap.

Skin expansion

For patients with large skin defects, tissue expandersprovide an alternative method for reconstruction and clo-sure. This method was first described by Neumann in 1957,and involves the use of saline-filled silicone envelopes. Asthese envelopes are injected with more saline, they create anew local supply of skin and subcutaneous tissues. Theliterature describes their use for burns of the head and neckas well as for closure of scalp, face, and neck skin de-fects.22-24 Handschel et al22 describe expanding the enve-lope in a serial fashion multiple times a week until enoughtissue is expanded to cover the defect. Complications in-clude dehiscence over the expander as well dehiscence afterexplantation of the expanders. Lasheen et al24 describe theuse of an external expander that uses negative pressure tocause the skin to grow to cover the defect.

Conclusions

Defects of the neck after resection of cutaneous lesions canyield varying size defects. It is important to include second-ary intention as a possibility for closure of a cutaneousdefect of the neck. Having a variety of options to reconstruct

these defects will allow the surgeon to carefully evaluate

each scenario to determine the best reconstructive methodfor the individual defect.

References

1. Angrigiani C: Aesthetic microsurgical reconstruction of anterior neckburn deformities. Plast Reconstr Surg 93:507-518, 1994

2. Zhang YX, Wang D, Follmar KE, et al: A treatment strategy for postburnneck reconstruction: emphasizing the functional and aesthetic importanceof the cervicomental angle. Ann Plast Surg 65:528-534, 2010

3. Schaper NC, Havekes B: Diabetes: impaired damage control. Diabe-tologia 55:18-20, 2012

4. Valentini V, Cassoni A, Marianetti TM, et al: Diabetes as main riskfactor in head and neck reconstructive surgery with free flaps. JCraniofac Surg 19:1080-1084, 2008

5. Kinsella JB, Rassekh CH, Wassmuth ZD, et al: Smoking increasesfacial skin flap complications. Ann Otol Rhinol Laryngol 108:139-142, 1999

6. Dhir K, Reino AJ, Lipana J: Vacuum-assisted closure therapy in themanagement of head and neck wounds. Laryngoscope 119:54-61, 2009

7. Calhoun KH, Seikaly H, Quinn FB: Teaching paradigm for decisionmaking in facial skin defect reconstructions. Arch Otolaryngol HeadNeck Surg 124:60-66, 1998

8. Psillakis JM, de Jorge FB, Villardo R, et al: Water and electrolytechanges in autogenous skin grafts. Discussion of the So-Called “plas-matic circulation”. Plast Reconstr Surg 43:500-503, 1969

9. Baker SR: Local Flaps in Facial Reconstruction. Edinburgh, ElsevierMosby, 2007

10. Andrews BT, Smith RB, Goldstein DP, et al: Management of compli-cated head and neck wounds with vacuum-assisted closure system.Head Neck 28:974-981, 2006

11. Papel ID: Facial Plastic and Reconstructive Surgery. New York, Thi-eme, 2009

12. Bakamjian VY: A two-stage method for pharyngoesophageal recon-struction with A PRIMARY pectoral SKIN FLAP. Plast Reconstr Surg36:173-184, 1965

13. Daniel RK, Cunningham DM, Taylor GI: The deltopectoral flap: ananatomical and hemodynamic approach. Plast Reconstr Surg 55:275-282, 1975

14. Mathes SJ, Hentz VR: Plastic Surgery. Philadelphia, PA, SaundersElsevier, 2006

15. Rebelo M, Ferreira A, Barbosa R, et al: Deltopectoral flap: an old butcontemporaneous solution for neck reconstruction. J Plast ReconstrAesthet Surg 62:137-138, 2009

16. Becker DW, Jr: A cervicopectoral rotation flap for cheek coverage.Plast Reconstr Surg 61:868-870, 1978

17. Copcu E, Metin K, Aktas A, et al: Cervicopectoral flap in head andneck cancer surgery. World J Surg Oncol 1:29, 2003

18. Shestak KC, Roth AG, Jones NF, et al: The cervicopectoral rotationflap—a valuable technique for facial reconstruction. Br J Plast Surg46:375-377, 1993

19. Puxeddu R, Dennis S, Ferreli C, et al: Platysma myocutaneous flap forreconstruction of skin defects in the head and neck. Br J Oral Maxil-lofac Surg 46:383-386, 2008

20. Ariyan S: Further experience with the sternocleidomastoid myocuta-neous flap. Plast Reconstr Surg 111:381-382, 2003

21. Kakarala K, Emerick KS, Lin DT, et al: Free flap reconstruction in1999 and 2009: changing case characteristics and outcomes. Laryngo-scope 22:2160-2163, 2012; Available at: http://www.ncbi.nlm.nih.gov/pubmed/22674647. Cited June 28, 2012

22. Handschel J, Schultz S, Depprich RA, et al: Tissue expanders for softtissue reconstruction in the head and neck area-requirements andlimitations. Clin Oral Investig (in press); Available at: http://www.ncbi.nlm.nih.gov/pubmed/22562078. Cited June 28, 2012

23. Motamed S, Niazi F, Atarian S, et al: Post-burn head and neckreconstruction using tissue expanders. Burns 34:878-884, 2008

24. Lasheen AE, Saad K, Raslan M: External tissue expansion in headand neck reconstruction. J Plast Reconstr Aesthet Surg 62:e251-

e254, 2009