The blood supply of the sternocleidomastoid muscle and its clinical implications

Radial Forearm Flap for Esophageal Perforation After Anterior Cervical Hardware Removal: Surgical Technique and Case Report

CASE

A 51-year-old woman, who had previously undergone C5-C7 anterior cervical discectomy and fusion, presented with symptomatic hardware failure and subsequently underwent instrumentation removal. Her postoperative course was complicated by an esophageal perforation. Despite initial repair using a rotational flap, the leak persisted, prompting esophageal reconstruction with a radial forearm free flap (RFFF).

CONCLUSION

Persistent esophageal perforation is exceedingly rare and difficult to treat. This report discusses the surgical technique for RFFF, an excellent option for revising failed sternocleidomastoid rotational flaps. The decision between rotational repair and free flap reconstruction depends on factors such as defect size, vascularization, wound condition, and donor site morbidity.

Features of the use of ladder myoplasty of a gunshot wound to the laryngopharynx: Case report

INTRODUCTION AND IMPORTANCE

The laryngopharynx wound is considered to be one of the most severe wounds of neck both in war and in peace, as it may cause life threatening changes in the whole body (asphyxia, bleeding, shock). Important aspects of surgical treatment are to ensure full breathing, acceptable ways of feeding, and the use of reliable wound closure techniques aimed to prevent digestive tract failure and to maintain the framework and aerostasis of the laryngotracheal region.

CASE PRESENTATION

A case of unilateral multiple wounds of the laryngopharynx was described in the article. The features of diagnostics, surgical treatment and conservative therapy in the postoperative period with this injury were presented. The wounded man was urgently operated. During surgery the pharynx was mobilized. The metal fragment was removed. The wound of the pharynx was sutured with a two-row suture. The next stage of the surgical treatment was myoplasty. In the case of the patient, the purpose of myoplasty was additional sealing of the pharyngeal suture and myoplasty of the thyroid cartilage injury zone for the purpose of aerostasis. Because of the size of the wounds and their anatomical localization, we used the mobilized lower edge of the Musculus sternocleidomastoideus for myoplasty and proposed the method of ladder myoplasty developed by us.

CLINICAL DISCUSSION

In myoplasty method the following criteria must be followed: the muscle flap must be of sufficient length and width, so as not to cause excessive tension in the myoplasty area; the flap must be thick enough to avoid necrosis that may cause subsequent infectious complications; when taking the flap, the most sparing operative access should be used to avoid functional and anatomical disorders; the volume of the taken muscle flap must not lead to functional and anatomical disorders.

CONCLUSION

The proposed method of ladder myoplasty using Musculus sternocleidomastoideus is unique, and proves its high efficiency in unilateral multiple laryngopharyngeal injuries, and can be recommended for wide clinical implementation in such clinical situations.

An alternative surgical technique for advanced tongue/tongue base cancer without free flap reconstruction

BACKGROUND/PURPOSE

Locally advanced tongue or tongue base cancer is recommended to be treated by radical resection that is usually detrimental to physiological functions. This study reports the efficacy and treatment outcome of the patients who had received total glossectomy and laryngeal suspension without lip-split mandibulotomy and free flap reconstruction to preserve laryngopharyngeal function.

METHODS

From 2010 to 2018, 37 consecutive patients who had received the surgery were retrospectively recruited.

RESULTS

The overall five-year survival is 72%. The postoperative dependent rate of feeding tube and tracheostomy largely decreases within 1-year follow-up. Treated by this surgical method, these patients are free from facial disfiguration, donor site morbidity, and destructive mastication and occlusion. It is also feasible to perform this surgical technique in the recurrent cases previously treated by chemoradiation.

CONCLUSION

Total glossectomy with laryngeal suspension can be successfully applied to locally advanced tongue or tongue base cancer, and benefits the patients with improved survival and preserved physiological function. Especially surgeons for free flap reconstruction are understaffed at some regional or district hospitals.

Factors in the occurrence and restoration of hypoparathyroidism after total thyroidectomy for thyroid cancer patients with intraoperative parathyroid autotransplantation

INTRODUCTION

Postoperative hypoparathyroidism (POH) is the most common and important complication for thyroid cancer patients who undergo total thyroidectomy. Intraoperative parathyroid autotransplantation has been demonstrated to be essential in maintaining functional parathyroid tissue, and it has clinical significance in identifying essential factors of serum parathyroid hormone (PTH) levels for patients with parathyroid autotransplantation. This retrospective cohort study aimed to comprehensively investigate influential factors in the occurrence and restoration of POH for patients who underwent total thyroidectomy with intraoperative parathyroid autotransplantation (TTIPA).

METHOD

This study was conducted in a tertiary referral hospital, with a total of 525 patients who underwent TTIPA. The postoperative serum PTH levels were collected after six months, and demographic characteristics, clinical features and associated operative information were analyzed.

RESULTS

A total of 66.48% (349/525) of patients who underwent TTIPA were diagnosed with POH. Multivariate logistic regression indicated that Hashimoto's thyroiditis (OR=1.93, 95% CI: 1.09-3.42), P=0.024), the number of transplanted parathyroid glands (OR=2.70, 95% CI: 1.91-3.83, P<0.001) and postoperative blood glucose levels (OR=1.36, 95% CI: 1.06-1.74, P=0.016) were risk factors for POH, and endoscopic surgery (OR=0.39, 95% CI: 0.22-0.68, P=0.001) was a protective factor for POH. Multivariate Cox regression indicated that PTG autotransplantation patients with same-side central lymph node dissection (CLND) (HR=0.50; 95% CI: 0.34-0.73, P<0.001) demonstrated a longer time for increases PTH, and female patients (HR=1.35, 95% CI: 1.00-1.81, P=0.047) were more prone to PTH increases. Additionally, PTG autotransplantation with same-side CLND (HR=0.56, 95% CI: 0.38-0.82, P=0.003) patients had a longer time to PTH restoration, and patients with endoscopic surgery (HR=1.54, 95% CI: 1.04-2.28, P=0.029) were more likely to recover within six months.

CONCLUSION

High postoperative fasting blood glucose levels, a large number of transplanted PTGs, open surgery and Hashimoto's thyroiditis are risk factors for postoperative POH in TTIPA patients. Elevated PTH levels occur earlier in female patients and patients without CLND on the transplant side. PTH returns to normal earlier in patients without CLND and endoscopic surgery on the transplant side.

Segmental mandibular reconstruction in patients with poor lower extremity perfusion, vessel-depleted necks and/or profound medical frailty

PURPOSE OF REVIEW

Options for segmental mandibular reconstruction in patients poorly suited to undergo fibula free flap (FFF).

RECENT FINDINGS

Although FFF is the current 'gold standard' for segmental mandibular reconstruction, other reconstructive options must be considered when FFF is contraindicated or disfavoured and/or patient frailty precludes a lengthy anaesthetic. In addition to various nonvascularized and soft tissue only reconstructions, excellent osseous free flap alternatives for functional segmental mandibular reconstruction may be employed. The subscapular system free flaps (SSSFF) may be ideal in frail and/or elderly patients, as SSSFF allows for early mobility and does not alter gait. In extensive and/or symphyseal defects, functional mandibular reconstruction in lieu of a free flap is extremely limited. Pedicled segmental mandibular reconstructions remain reasonable options, but limited contemporary literature highlights unpredictable bone graft perfusion and poor long-term functional outcomes.

SUMMARY

There are several excellent free flap alternatives to FFF in segmental mandibular reconstruction, assuming adequate cervical recipient vessels are present. On the basis of the current literature, the optimal mandibular reconstruction for the medically frail, elderly and/or patients with extreme vessel-depleted necks is limited and debatable. In qualifying (i.e. limited, lateral) defects, soft tissue only reconstructions should be strongly considered when osseous free flaps are unavailable.

Recurrent cervical stitch sinus arising from the deep neck space after thyroidectomy: case study and review

OBJECTIVE

We describe a one-stage surgical technique for the management of recurrent cervical stitch sinus after thyroidectomy.

METHOD

A retrospective, single-centre study of all patients who were operated on because of cervical neck sinus after thyroidectomy. We provide a detailed description of our surgical approach, based on guided sinus removal after prior tract staining with methylene blue and subsequent obliteration using local strap muscle flap.

RESULTS

A total of seven patients with a mean age of 46 years were included in the study. All patients had a past history of thyroidectomy because of goitre (n=5) or thyroid cancer (n=2) which had previously been unsuccessfully debrided two or three times. Surgical sinus removal was successful in all cases and no recurrence was observed during the follow-up time.

CONCLUSIONS

We conclude that a comprehensive en bloc resection down to the suture granuloma is essential in order to provide surgical cure and prevent recurrence.

Free Tissue Transfer for Repair of Chronic Esophageal Perforations

Objective

Anterior cervical discectomy and fusion have become a common intervention for cervical spine stabilization. However, complications can cause life-threatening morbidity. Among them, esophageal perforation is associated with severe morbidity, including dysphagia, malnutrition, and infection with the potential development of mediastinitis. Presentation is variable but often results in chronic morbidity. Herein we examine our experiences in the management of esophageal perforation with microvascular free tissue transfer.

Study Design

Retrospective review from January 2013 to September 2020.

Setting

Single academic tertiary care center.

Methods

This study comprised all patients (age, 41-73 years) undergoing free tissue transfer for the repair of chronic esophageal perforation secondary to anterior cervical discectomy and fusion at an academic tertiary care center. Four patients underwent repair via vastus lateralis myofascial onlay grafting for defects ≤2 cm in greatest dimension, while 1 patient underwent a fasciocutaneous radial forearm free flap repair of an 11 × 5-cm defect.

Results

Defect location ranged from hypopharynx to cervical esophagus. Mean operative time was 6.2 hours; the average length of stay for all patients was 6.6 days. Of 5 patients, 1 required additional hardware placement for spine stabilization. All patients underwent gastrostomy tube placement to bypass the surgical site during healing, and all eventually resumed an oral diet postoperatively. Recurrent fistula occurred in 1 of 5 patients. No flap failures were encountered in the study population.

Conclusion

Vastus lateralis myofascial onlay grafting and fasciocutaneous radial forearm free flap are robust, relatively low-morbidity interventions with a high success rate for definitive repair of chronic esophageal perforation. Repair should be undertaken in concert with a spine surgeon for management of the cervical spine.

Island sternocleidomastoid myocutaneous flap for posterior pharyngeal wall defect repair after anterior cervical spine surgery

Injuries and tumours of the cervical spine represent therapeutic challenges to the treating surgeon due to the complex anatomical relationships and biomechanical features. The anterior cervical midline (ACM) and anterior cervical retropharyngeal (ACR) approaches are effective and safe surgical approaches for certain cervical spine lesions, such as cervical spine neoplasms, atlantoaxial subluxation, and certain odontoid fractures. Posterior pharyngeal wall defects (PPWDs) is one of the most frequently encountered surgical morbidities after anterior cervical spine surgery (ACSS). However, limited information has been published concerning effective approaches for PPWD reconstruction after ACSS. The manuscript aimed to describe a novel application of the island sternocleidomastoid myocutaneous flap (ISMF) in the management of PPWDs after ACSS, including surgery with the ACM approach and ACR approach. From April 2015 to November 2019, the clinical data of three patients with PPWDs repaired using the ISMF in Peking university third hospital were retrospectively analysed. The observational indexes are as follows: postoperative survival of the flap, wound healing 2 weeks after surgery, eating and pronunciation function 2 months after surgery. The above indexes of these three cases recovered well. Three patients did not have any persistent PPWD after repair with the ISMF and did not require any further surgical procedures related to the cervical spine.

The effect of external jugular vein's preservation on the prognosis of sternocleidomastoid myocutaneous flap

OBJECTIVE

As a supplementary and significant pedicle flap,the sternocleidomastoid (SCM) myocutaneous flap has been be flexiblely used in the reconstruction of oral soft tissue defect. The problem of venous stagnation after its transposition limited its clinical application.To improve its application, we raised a modified SCM flap for oral softtissue defect reconstruction.

METHOD

We carried out a continuous retrospective study of 43 patients who had tissue defects because of oral carcinomas resection and underwent reconstruction with modified SCM flap from April 2014 to January 2017.

RESULTS

3 of 43 cases had partial flap necrosis and there were primary healing in the rest 40 cases. During the follow-up,4 patients were lost, 2 patients recurred in situ and 2 patients had neck recurrence. The remaining patients were satisfied with their appearance, and had normal oral function.

CONCLUSION

Modified SCM flap is simple to harvest. It can improve the venous return and has a high survival rate. It has active effect in the recovery of the function of oral and maxillofacial region and elevates quality of life of patients.

A novel application of superior thyroid artery perforator flaps for medium-sized intraoral reconstructions: Retrospective analysis of 12 cases

BACKGROUND

To describe the indications, technique, and preliminary experience in the application of the superior thyroid artery perforator flap (STAPF) for the reconstruction of various medium-sized intraoral defects.

METHODS

From September 2018 to September 2019, 12 consecutive cases of oral squamous cell carcinoma underwent reconstruction with a STAPF. Clinical details were collected, and postoperative function was analyzed.

RESULTS

The venous drainage of the STAPF is variable with drainage into the internal jugular vein in six cases, into both the internal and external jugular veins in four cases, and into the external jugular vein in two cases. Ten cases were harvested as pedicled flaps, while two cases required a venous anastomosis due to inadequate length of the venous pedicle. Ten flaps survived completely, whereas two flaps had partial necrosis that ultimately resolved with secondary healing.

CONCLUSIONS

STAPF is a reliable method for the reconstruction of medium-sized intraoral defects.

Method to prevent cheek depression using an island sternocleidomastoid muscle flap with the middle pedicle as a feeding vessel in immediate reconstruction of the facial nerve with the sural nerve following resection of a parotid gland tumor

Many surgeons have demonstrated the validity of sternocleidomastoid muscle flaps for the reconstruction of head and neck tumors. We present a case in which we used an island sternocleidomastoid muscle flap to reconstruct a cheek depression after excision of a malignant parotid tumor. A 44-year-old woman presented with a right malignant parotid tumor. We performed total resection of the parotid gland and facial nerve with the sural nerve and reconstructed the facial nerve and cheek depression with an island sternocleidomastoid muscle flap. The sternal head of the right sternocleidomastoid muscle was cut at the cranial and caudal segments to elevate it as an island flap. We used the superior thyroid artery as the sole pedicle for the island muscle flap. At 1 year and 3 months after the operation, the mimic muscles had gradually recovered and progressed without complications such as Frey syndrome, cervical motor dysfunction, or concave deformation of the neck and cheeks.

From the clavicle to the windpipe: Tracheal window resections reconstructed with calcifying periosteum in thyroid cancer

OBJECTIVES

We aimed to evaluate the outcomes of tracheal window resection and reconstruction using a vascularized periosteal flap (intended for calcification) harvested from the medial clavicle. This is one of several surgical techniques for tracheal resection and reconstruction used for patients with thyroid carcinoma invading the trachea. Importantly, in partial tracheal resection postoperative dynamic airway collapse must be prevented. Reconstruction of the tracheal defect with a vascularized periosteal flap is one method of achieving a stable airway.

METHODS

Twelve patients with locally advanced thyroid carcinoma who underwent tracheal resection and reconstruction at Oslo University Hospital from 2004 to 2017 were studied retrospectively. The primary outcome was a stable airway not requiring airway stenting. The secondary outcomes were the time to decannulation, morbidity, and survival.

RESULTS

Eleven of 12 patients did not require airway stenting postoperatively after a median of 111 days. Seven patients developed postoperative complications. The median observation time was 74.8 months (range 10.5-153.5) for all patients. The median disease-free survival was 40 months (range 0-147). By February 1, 2020, seven patients were alive, of whom five showed no evidence of disease.

CONCLUSIONS

Tracheal reconstruction with a vascularized periosteal flap yielded good results in terms of establishing a stable airway. This procedure is a viable reconstructive option that allows for decannulation by preventing airway collapse, thereby potentially mitigating the need for end-to-end (ETE) anastomosis or sleeve resections. For selected patients, this procedure may prevent local fatal complications from thyroid cancer invading the trachea.

LEVEL OF EVIDENCE

Level 4.

Stapled Repair of Benign Acquired Tracheoesophageal Fistula: Description of Novel Technique and Assessment of Outcomes

Compared to less invasive measures, surgical repair is the most effective modality for managing benign acquired tracheoesophageal fistula (TEF). Traditionally, this involves dismantling of the fistula and suture repair of tracheal and esophageal defects using a lateral or direct approach. However, the best approach remains a subject of debate. We describe a novel and simple technique for dismantling a benign acquired TEF with the use of an endo-stapler and interposition with sternocleidomastoid (SCM) muscle flap. Eleven TEF patients underwent repair using this stapled repair technique. Retrospectively, the perioperative and long-term outcomes were assessed in these patients. There were no cases of procedure-related mortality or airway-related complications. Two patients developed transient vocal cord palsy and one developed esophageal leak. At a mean follow-up of 21.4 months, no fistula recurrence, dysphagia, or tracheal stenosis was observed. Hence stapled dismantling and SCM muscle interposition is a simple and safe technique for repair of benign acquired TEF.

Case of Esophageal Perforation and Repair with a Supraclavicular Artery Island Fascial Flap 15 Years After Anterior Spine Surgery

BACKGROUND

Esophageal perforation represents a rare but potentially life-threatening complication of an anterior cervical diskectomy and fusion (ACDF). Delayed presentations of esophageal perforation more than 10 years following surgery are exceedingly rare and difficult to diagnose. Here, we discuss the case of an 80-year-old man who presented to the emergency department with progressive dysphagia 15 years after his ACDF.

CASE DESCRIPTION

While prior outpatient workup was suggestive of a diverticulum, there was no evidence of esophageal perforation. Progressive symptoms and repeat imaging on admission were suggestive of retropharyngeal phlegmon. Operative esophagoscopy revealed that the spinal hardware had eroded through the posterior wall of the esophagus, creating a traction diverticulum. The hardware was removed, and the esophageal perforation was closed primarily and buttressed with vascularized tissue from a supraclavicular artery island fascial flap.

CONCLUSIONS

This case emphasizes the importance of considering an esophageal perforation in patients who present with dysphagia at any interval following an ACDF, even in the extremely delayed setting. Furthermore, this is the first report, to the best of our knowledge, using a supraclavicular artery island fascial flap to reconstruct an esophageal perforation following an ACDF, and we introduce a novel strategy for managing these complicated injuries.

Smart flap of sternocleidomastoid muscle in anterior cervical spine surgery: Surgical anatomical dissection technique

The use of sternocleidomastoid muscle flap has firstly been described in 1909. In spine surgery, it is usually reserved in the cases of revision after anterior cervical spine procedures. The aim of this article is to introduce its usage as prophylactic measure in cases at high risk of iatrogenic fistula formation. The procedure consists of three main steps: sternocleidomastoid isolation, flap design and harvesting, and flap fixation. The use of a surgical anchor allows a better adherence to the plate preventing hematoma formation. The use of SCM smart flap in primary anterior cervical spine surgery as a prophylactic method could be considered a safe and feasible procedure in patients with a high risk of iatrogenic fistulas.

Revisiting the sternocleidomastoid flap as a reconstructive option in head and neck surgery

Background

The sternocleidomastoid can be used as a pedicled flap in head and neck reconstruction. It has previously been associated with high complication rates, likely due in part to the variable nature of its blood supply.

Objective

To provide clinicians with an up-to-date review of clinical outcomes of sternocleidomastoid flap surgery in head and neck reconstruction, integrated with a review of vascular anatomical studies of the sternocleidomastoid.

Methods

A literature search of the Medline and Web of Science databases was conducted. Complications were analysed for each study. The trend in success rates was analysed by date of the study.

Results

Reported complication rates have improved over time. The preservation of two vascular pedicles rather than one may have contributed to improved outcomes.

Conclusion

The sternocleidomastoid flap is a versatile option for patients where prolonged free flap surgery is inappropriate. Modern vascular imaging techniques could optimise pre-operative planning.

Sternocleidomastoid Encephalomyosynangiosis for Treatment-Resistant Moyamoya Disease

BACKGROUND AND IMPORTANCE

Refractory ischemic symptoms in moyamoya disease are a challenging problem, particularly in situations in which multiple direct and indirect revascularization techniques have already been employed. In addition, revascularization of the parietal lobes is difficult, as this area is a watershed between the middle cerebral artery and posterior cerebral artery distributions.

CLINICAL PRESENTATION

This is the case of a 50-yr-old woman with hemibody sensorimotor deficits, who had previously undergone bilateral arterial bypass and temporalis myosynangiosis. A method for indirect surgical cerebral revascularization is described, utilizing a rotated and tunneled sternocleidomastoid flap. The perfused muscle is approximated to the cortical surface, with adjacent sulci dissected to expose the underlying vasculature. After sternocleidomastoid encephalomyosynangiosis, the patient experienced symptomatic improvement, along with the appearance of new pial collateral vasculature on diagnostic cerebral angiography. Pre- and postoperative dynamic perfusion computed tomography with acetazolamide challenge demonstrate an increase in cerebral blood flow and decrease in mean transit time, as well as improved cerebrovascular reserve.

CONCLUSION

Sternocleidomastoid encephalomyosynangiosis using a tunneled muscle flap is a useful method for revascularization of the parietal and occipital lobes, particularly for refractory moyamoya in cases where a variety of other options have been exhausted.

Esophageal Perforation due to Anterior Cervical Spine Hardware Placement: Case Series

Context. This case series discusses surgical management of esophageal perforations that occurred following cervical spine hardware placement. Purpose. (1) Determine presenting symptoms of esophageal perforation after anterior cervical spine hardware placement. (2) Discuss surgical management of these resulting esophageal perforation complications. Design/Setting. Case series of six patients at a tertiary-care, academic medical center. Patient Sample. Six patients with pharyngoesophageal perforations following anterior cervical spine surgery (ACSS). Outcome Measures. Date of ACSS, indication for ACSS, level of hardware, location of esophageal or pharyngeal injury, symptoms at presentation, surgical intervention, type of reconstruction flap, wound culture flora, and antibiotic choice. Methods. A retrospective review of patients with an esophageal or hypopharyngeal injury in the setting of prior ACSS managed by the otolaryngology service at a tertiary, academic center between January 2015 and January 2019. Results. Six patients who experienced pharyngoesophageal perforation following ACSS are included in this study. Range of presentation was two weeks to eight years following initial hardware placement. Five patients presented with an abscess and all had evidence of perforation on initial CT or esophagram. All patients underwent repair with a sternocleidomastoid flap with two patients eventually requiring an additional pectoralis myofascial flap for a persistent esophageal leak. Five patients eventually attained ability to tolerate oral nutrition. An algorithm detailing surgical reconstructive management is proposed. Conclusions. Esophageal perforations in the setting of prior ACSS are challenging clinical problems faced by otolaryngologists. Consideration should be given to early drainage of abscesses and spine surgery evaluation. Spinal hardware removal is recommended whenever possible. Utilization of a pedicled muscle flap reinforces primary closure and allows coverage of the vertebral bony defect. Nutrition, thyroid repletion, and culture-directed IV antibiotics are necessary to optimize esophageal perforation repair.

Using a Sternocleidomastoid Muscle Flap to Close an Iatrogenic Tracheoesophageal Fistula in a Patient With Advanced Laryngeal Cancer: A Case Report and Literature Review

BACKGROUND

An iatrogenic tracheoesophageal (TE) fistula is one possible complication after total laryngectomy with flap reconstruction. We used sternocleidomastoid (SCM) rotation flap to close a TE fistula.

METHODS AND RESULTS

A 69-year-old man with laryngeal cancer underwent total laryngectomy with radial forearm free flap reconstruction. A tracheostoma stenosis was noticed 7 months after the tracheostomy tube was removed. The patient underwent tracheostoma dilatation; the iatrogenic TE fistula was noticed 1 month later. We used SCM rotation flap to close the TE fistula. The postoperative course was uneventful. A barium esophagogram showed no leakage in the esophagus.

CONCLUSIONS

Tracheoesophageal fistula can be reconstructed with an SCM rotation flap. If the TE fistula is of a suitable size, this reconstructive strategy is effective and simple to close persistent TE fistula and avoid further airway complications.

A Novel Approach to Identifying the Spinal Accessory Nerve in Surgical Neck Dissection

Intraoperative identification of the spinal accessory nerve (SAN) is key in reducing nerve injury. This study aims to explore the surgical anatomy of the SAN and 2 landmarks for its identification-the sternocleidomastoid branch of the occipital artery (SBOA) and superior sternocleidomastoid tendon (SST)-to propose a novel method of identifying the SAN during surgical neck dissections. Twelve cadavers underwent bilateral level II-V neck dissection identifying the SAN, SBOA, and SST. Variation was documented and distance between landmarks and the SAN measured. The most common arrangement had the SST most superficially followed by the SBOA and then the SAN. The SAN was 3.63 ± 4.02 mm from the artery and 2.31 ± 1.72 mm from the tendon. A triangle-bordered by the tendon laterally, artery medially, and digastric muscle superiorly-contained the SAN in 95.8% of cases. This relationship translated into a reliable technique to identify the SAN intraoperatively, which has been used successfully in practice.

Tracheoesophageal fistula after total resection of gastric conduit for gastro-aortic fistula due to gastric ulcer

Background

Tracheoesophageal fistula (TEF) is a rare but life-threatening complication after esophagectomy. It has a high mortality rate and often leads to severe aspiration pneumonia. Various types of surgical repair procedures have been reported, but the optimal management of TEF is challenging and controversial. Treatment should be individualized to each patient.

Case presentation

A 66-year-old female underwent transthoracic esophagectomy with gastric tube reconstruction and an intrathoracic anastomosis for esophageal cancer. Three years later, she had hematemesis and was diagnosed with a gastro-aortic fistula due to a gastric ulcer. She underwent endovascular aortic repair urgently at another hospital. Two days later, she underwent total resection of the gastric tube, during which time an injury to the trachea occurred; it was repaired by patching the stump of the esophagus to the injury site. Two months later, descending aortic replacement was performed due to infection of the stent graft. Six months after the first operation, a TEF developed. The patient was referred to our hospital for further treatment. The fistula was ligated and divided via a cervical approach, and a pectoralis major muscle flap was used to cover the defect. Esophageal reconstruction with the pedunculated jejunum was performed via a subcutaneous route. The postoperative course was uneventful. The patient was discharged after 6 months of physical and dysphagia rehabilitation.

Conclusion

A TEF located near the cervicothoracic border was successfully treated with a pectoralis major muscle flap through a cervical approach. Total resection of a gastric conduit in the posterior mediastinum carries a risk of tracheobronchial injury; however, if such an injury occurs, surgeons should be able to repair the injury using a suitable flap depending on the injury site.

Bilateral Multiple Variations in Carotid Arteries-A Case Report

The common carotid arteries are the largest bilateral arteries of the head and neck. The common carotid arteries may bifurcate higher or lower than the usual levels. A higher bifurcation is more common. Tortuous arteries if present may be asymptomatic if it is mild but may lead to ischaemia of the organs if severe. The cause could be genetic, or may be thickening of the arteries. During routine dissection of an adult male cadaver in the department of Anatomy, BLDEU's Shri BM Patil Medical college, Vijaypur, we found the bilateral multiple variations in the carotid arteries regarding the bifurcation level of common carotid arteries, tortuous external and internal carotid arteries and the number of branches arising from external carotid arteries. The knowledge of such variations of carotid arteries is of great importance in radiological examinations especially per cutaneous carotid angiography. It is necessary to understand the anatomy of these vessels and its variations to carry out surgeries with minimum complications.

Neck muscle atrophy and soft-tissue fibrosis after neck dissection and postoperative radiotherapy for oral cancer

Late complications of head and neck cancer survivors include neck muscle atrophy and soft-tissue fibrosis. We present an autopsy case of neck muscle atrophy and soft-tissue fibrosis (sternocleidomastoid, omohyoid, digastric, sternohyoid, sternothyroid, and platysma muscles) within the radiation field after modified radical neck dissection type I and postoperative radiotherapy for floor of mouth cancer. A 70-year-old man underwent primary tumor resection of the left floor of mouth, left marginal mandibulectomy, left modified radical neck dissection type I, and reconstruction with a radial forearm free flap. The patient received adjuvant radiotherapy. The dose to the primary tumor bed and involved neck nodes was 63 Gy in 35 fractions over 7 weeks. Areas of subclinical disease (left lower neck) received 50 Gy in 25 fractions over 5 weeks. Adjuvant chemotherapy was not administered.

Flap Reconstruction for Esophageal Perforation Complicating Anterior Cervical Spinal Fusion: An 18-year Experience

Background:

Esophageal injury following anterior cervical discectomy and fusion (ACDF) poses a significant reconstructive challenge. Buttressing flap repairs have proven beneficial; however, there remains a paucity of evidence to guide optimal flap selection.

Methods:

A retrospective chart review was performed for patients who presented to the senior author with esophageal perforations after ACDF from 1995 until present. Demographic, clinical, and postoperative details were collected. Outcomes of omental flap reconstructions were compared against other flap reconstructions.

Results:

A total of 13 flap reconstructions were performed in 11 patients with the following distribution: 7 free omental, 1 anterolateral thigh, 1 osteomuscular fibula, 2 radial forearm, and 2 pedicled pectoralis flaps. Patients receiving omental flap reconstructions demonstrated a significantly faster resolution of leak on contrast swallow imaging and earlier return to oral feeding compared with all other flap reconstructions (22.5 versus 268 days, respectively; P < 0.05). This relationship remained evident even when calculations excluded an outlying patient from the nonomental cohort (22.5 versus 111 days, respectively; P < 0.05). Length of hospital stay, complications, and success rates were also more favorable in the omental cohort but failed to reach statistical significance.

Conclusions:

Esophageal perforation after ACDF is an uncommon but devastating complication. The use of free omentum flap reconstruction is associated with a more rapid functional recovery and may prove beneficial in the management of these challenging cases.

Use of a sternocleidomastoid myocutaneous flap based on the sternocleidomastoid branch of the superior thyroid artery to reconstruct extensive cheek defects

INTRODUCTION

Reconstruction of head and neck defects has always been challenging due to functional and cosmetic concerns. Although sternocleidomastoid (SCM) flaps have been used for many head and neck defects, use of an SCM flap to reconstruct a cheek defect based only on the superior thyroid artery has not been reported previously.

CASE REPORT

The case of a 40-year-old farmer with a large full-thickness cheek squamous cell carcinoma is reported. An SCM myocutaneous flap based on the SCM branch of the superior thyroid artery was used.

CONCLUSION

An SCM myocutaneous flap is a valuable option for head and neck reconstructions with reasonable aesthetic results. For properly selected cases, this flap obviates the need to use the pectoralis major or other more distant flaps.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical repair of long-segment cervical esophageal injury with a sternocleidomastoid myocutaneous flap

We present a useful technique for the surgical management of long-segment cervical esophageal tears using a sternocleidomastoid flap with overlying skin patch. The flap is easily accessible, customizable, and offers the ability to repair long segments of cervical and upper thoracic esophageal injuries.

The unusual origin of the sternocleidomastoid artery from the lingual artery

The sternocleidomastoid (SCM) artery supplying blood to the SCM muscle has different origins according to its anatomical segment. The authors performed cadaveric neck dissection to review the surgical anatomy of neurovascular structures surrounding the carotid artery in the neck. During the dissection, an unusual finding was cited in which the SCM artery supplying the middle part of the SCM muscle originated from the lingual artery (LA); it was also noted that it crossed over the hypoglossal nerve (HN). There have been extremely rare reports citing the SCM artery originated from the LA. Though the elevation of the HN over the internal carotid artery was relatively high, the vascular loop crossing over the HN was very close to the carotid bifurcation. Special anatomical consideration is required to avoid the injury of the HN during carotid artery surgery.

The sternocleidomastoid myocutaneous "patch esophagoplasty" for cervical esophageal stricture

Esophageal strictures may be caused by many etiologies. Patients suffer from dysphagia and many are tube-feed dependent. Cervical esophageal reconstruction is challenging for the plastic surgeon, and although there are reports utilizing chest wall flaps or even free flaps, the use of a sternocleidomastoid (SCM) myocutaneous flap provides an ideal reconstruction in select patients who require noncircumferential "patch" cervical esophagoplasty. We present two cases of esophageal reconstruction in which we demonstrate our technique for harvesting and insetting the SCM flap, with particular emphasis on design of the skin paddle and elucidation of the vascular anatomy. We believe that the SCM flap is simple, reliable, convenient, and technically easy to perform. There is minimal donor site morbidity with no functional loss. The SCM myocutaneous flap is a viable option for reconstructing partial esophageal defects and obviates the need to perform staged procedures or more extensive operations such as free tissue transfer.

Sternocleidomastoid Myofascial Flap for Reconstruction After Composite Resection of Invasive Squamous Cell Carcinoma of the Tonsillar Region: Technique and Outcome

OBJECTIVE

To present the surgical technique and determine the efficacy of sternocleidomastoid myofascial (SCMF) flap reconstruction after composite resection with intent to cure.

STUDY DESIGN

Retrospective review of 73 consecutive patients with a previously isolated and untreated moderately to well-differentiated invasive squamous cell carcinoma of the tonsillar region and a minimum of 3 years follow-up, managed at a tertiary referral care center during the years 1970 to 2002, with an ipsilateral superiorly based SCMF flap after composite resection.

METHODS

The surgical procedure is presented in detail. Potential technical pitfalls are highlighted. Survival, mortality, and morbidity are documented. Univariate analysis for potential correlation between the incidence for postoperative flap complications and various variables is also performed.

RESULTS

The 1, 3, and 5 year Kaplan-Meier actuarial survival estimates were 82.2%, 64.4%, and 49.3%, respectively. Death never appeared to be related to the completion of the SCMF flap. Thirty-three (45.2%) patients had some kind of significant postoperative surgical complication, and nine (12.3%) patients had some kind of significant postoperative medical complication. The most common significant postoperative complication was partial SCMF flap necrosis and pharyngocutaneous fistula noted in 30.1% and 10.9% of patients, respectively. Complete SCMF flap necrosis was never encountered. No patient developed carotid artery rupture or died as a result of the SCMF flap, and none required additional surgery. In univariate analysis, no significant statistical relation was noted between the significant postoperative surgical complications related to the use of the SCMF flap and the variables under analysis.

CONCLUSIONS

The superiorly based SCMF flap appears to be simple to perform and useful for reconstruction of defects after composite resection.

Evidence of significant sternocleidomastoid atrophy following modified radical neck dissection type III

BACKGROUND

Although modified radical neck dissection type III preserves the spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle, the authors believe there is a significant morbidity to retained structures after neck dissection. Although the effects on accessory nerve function and internal jugular vein patency have been documented, there is little information about sternocleidomastoid morphology and function following modified dissection.

METHODS

Using a SonoSite ultrasound machine, the authors assessed sternocleidomastoid muscle morphology, at rest and during contraction, in a cohort of 45 patients who underwent modified radical neck dissection type III with no radiotherapy. All patients had head and neck cancers and received unilateral neck dissection as part of their primary treatment. Static and dynamic measurements were performed at three different levels of the muscle, with the neck in the neutral position. The contralateral neck of the same patient was used as a control. Local muscle asymmetry patterns were calculated using the Absolute Asymmetry Index.

RESULTS

Significant sternocleidomastoid atrophy was noted on the side of modified radical neck dissection type III (p < 0.05). The atrophy was particularly marked in the caudal and middle portions of the sternocleidomastoid muscle and was likely related to damage to the segmental blood supply in the caudal and middle portions of the muscle as well as injury to the innervation.

CONCLUSION

Despite evidence of significant atrophy, the muscle still underwent morphological changes during contraction that were comparable to those on the normal control side.

How Cranial Could the Sternocleidomastoid Muscle Be Split?

The sternocleidomastoid (SCM) muscle, its anatomy, and its possible uses in head and neck reconstruction have been discussed, especially during the last 2 decades. The viability of the muscle and the skin over it depends on the vascular anatomy of the SCM and the anatomical heads-anterior or sternal and posterior or clavicular-that could enable splitting of the SCM muscle or myocutaneous flap. The authors have investigated the nourishment pattern of the SCM muscle to find out whether there was an independent blood supply to the each head of the muscle-anterior or sternal and posterior or clavicular-and whether the anatomical discrimination of the heads was congruent with the vascular pattern of the heads. The distinct vascular pattern of the two heads was determined. The occipital artery supplied all the muscle, and the first minor pedicle of the muscle originating from the superior thyroid artery supplies the clavicular head. Surgically, the heads could be split cranially until the first minor pedicle. The preservation of the first minor pedicle in the split SCM flap in which the clavicular head was harvested could provide a reliable flap. The use of the sternal head till the occipital artery, leaving the minor pedicle and the clavicular head in situ, could enable safe reconstructions with the SCM flap.

Sternocleidomastoid myocutaneous flap for intraoral reconstruction after resection of oral squamous cell carcinoma

PURPOSE

The sternocleidomastoid (SCM) myocutaneous flap remains an important tool in head and neck reconstruction. This article retrospectively reviews 40 consecutive SCM myocutaneous flaps used for the reconstruction after resection of oral squamous cell carcinoma with respect to reliability and complications.

PATIENTS

From 1987 to 1997, 40 patients underwent SCM myocutaneous flap reconstruction of the oral cavity. The age and gender of the patients, site of primary tumor TNM stage, type of associated operation, and clinical course were analyzed.

RESULTS

In 8 cases, partial epithelial loss over the skin paddle occurred with survival of the muscle and at least some of the dermis. Unilateral supraomohyoid neck dissection (SND) was performed in 11 cases, and unilateral functional neck dissection, which preserves SCM and/or internal jugular vein and/or accessory nerve, in 16 cases. Pathologically positive nodes were recognized in 14 of these 27 neck dissection cases; in 11 of these 14 cases, the neck lesion was controlled.

CONCLUSION

The SCM myocutaneous flap appears to be simple to use and useful for reconstruction of the defect after resection of oral carcinoma, and the indications for this flap will be extended in accordance with the recent increases in the number of supraomohyoid and functional neck dissection cases.

The sternocleidomastoid flap--its indications and limitations

HYPOTHESIS

The sternocleidomastoid (SCM) flap seems to be a practicable but underestimated flap for reconstructive and plastic surgery of the head and neck.

OBJECTIVES

To determine in which situations the SCM flap may represent a reliable alternative to other flaps used in head and neck surgery.

STUDY DESIGN

Meta-analysis of the complete literature on the SCM flap.

SETTING

All literature found dealing with the SCM flap was reviewed, with special emphasis placed on the indications and success rates reported. The data presented are compared with our own morphologic findings and their putative clinical implications.

RESULTS

Four types of SCM flap have been described: the muscle flap, the myocutaneous flap, the myoperiosteal flap, and the myosseus or osteomuscular flap. The SCM flap was either superiorly or inferiorly based. The SCM muscle flap was used in a total of 72 patients with only 1 major complication and 7 minor complications. The complication rate, therefore, is 11%. The applications of the muscle flap involved prevention of Frey's syndrome, closure of orocutaneous fistulae and soft tissue deficiencies, closure of pharyngocutaneous and cervical esophageal fistulae, and reconstruction of the tongue. Furthermore, Conley reported on the use of the SCM muscle flap in a group of 30 patients to reanimate the face, reconstruct oral cavity defects, protect the carotid and innominate artery, and even to aid shoulder elevation after poliomyelitis. The SCM myocutaneous flap seems to be the most common application, with a total of 138 patients. All in all, a total of 29 complications (21%) was reported, with partial skin necrosis by far the most frequent. Total failure of the flap has been described in 10 patients (7%). The SCM myocutaneous flap was used for closure of defects of the mouth as well as oro-, pharyngo-, and tracheocutaneous fistulae, facial reconstruction, reconstruction of mastoid defects, and reconstruction of the laryngotracheal complex in children. The SCM myosseus or osteomuscular flap was reported in 23 patients. Flap necrosis is reported in 1 case (4%). The SCM osteomuscular flap was used to reconstruct defects of the lower jaw in all patients. The SCM myoperiosteal flap was used in a total of 49 patients. The complication rate reported is 6% (3 cases). The myoperiosteal flap was used for reconstruction of the laryngotracheal complex in adults and for esophagopharyngeal reconstruction and fistula repair.

CONCLUSIONS

The data presented in previous literature is well correlated with our own morphologic findings. In comparison of the different techniques applied with the assumptions drawn on the basis of our own anatomic findings, it becomes evident that the SCM flap is only a useful tool in limited indications and under certain precautions.