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

Facial Reconstruction Using Sternocleidomastoid (SCM) Flap: A Review of the Literature

The sternocleidomastoid (SCM) flap has been used for a long time in protective coverage of major vessels, reconstruction of intraoral pharyngeal, closure of pharyngo-cutaneous fistulas, and augmentation of soft tissue defects in the oral and maxillofacial region. However, this flap is not yet commonly used due to doubtful blood supply to the flap. This flap offers favorable esthetic results, combined flap, rich vascularization, and the possibility of shifting the two heads of the muscle. Thus, this flap has been used broadly in the maxillofacial region to reconstruct the defects of the post-parotidectomy, mandible, pharynx, and floor of the mouth defects. Previous studies discussed the use of a SCM flap following parotidectomy. However, few studies explained the use of SCMs in facial reconstruction. This study aims to review published articles discussing the use of SCMs for facial reconstruction.

Sternocleidomastoid flap for pedicled reconstruction in head & neck surgery- revisiting the anatomy and technique

Background

Previous studies on sternocleidomastoid flaps, have defined the importance of preserving sternocleidomastoid (SCM) branch of superior thyroid artery (STA). This theory drew criticism, as this muscle is known to be a type II muscle, i.e., the muscle has one dominant pedicle (branches from the occipital artery at the superior pole) and smaller vascular pedicles entering the belly of muscle (branches from STA and thyrocervical trunk) at the middle and lower pole respectively. It was unlikely for the SCM branch of STA to supply the upper and lower thirds of the muscle. We undertook a cadaveric angiographic study to investigate distribution of STA supply to SCM muscle.

Methods

It is a cross-sectional descriptive study on 10 cadaveric SCM muscles along with ipsilateral STA which were evaluated with angiography using diatrizoate (urograffin) dye. Radiographic films were interpreted looking at the opacification of the muscle. Results were analyzed using frequency distribution and percentage.

Results

Out of ten specimens, near complete opacification was observed in eight SCM muscle specimens. While one showed poor uptake in the lower third of the muscle, the other showed poor uptake in the upper third segment of muscle.

Conclusion

Based on the above findings we suggest to further investigate sternocleidomastoid muscle as a type III flap, as the STA branch also supplies the whole muscle along with previously described pedicle from occipital artery. However, this needs to be further corroborated intra-operatively using scanning laser doppler. This also explains better survival rates of superior thyroid artery based sternomastoid flaps.

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.

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.