Use of the versatile sternocleidomastoid flap in oral and maxillofacial surgery: our experience

Clinical comparison of superior thyroid artery perforator flap and sternocleidomastoid myocutaneous flap for intraoral reconstruction

The aim was to evaluate the techniques and outcomes of superior thyroid artery perforator flaps (STAPF) for intraoral reconstruction and to compare them with those of the sternocleidomastoid myocutaneous flap (SCMMF). The cases of 43 patients who underwent reconstruction with either a SCMMF or STAPF for the repair of a medium-sized intraoral defect, between January 2013 and December 2020, were reviewed retrospectively. Although both flaps are based on the superior thyroid artery, their specific harvesting techniques largely differ. All SCMMF (n = 23) were superiorly-based rotational flaps with myocutaneous designs. The STAPF cases (n = 20) included 18 septocutaneous flaps and two chimeric flaps. The flap size was larger in the STAPF group (P = 0.008), while incomplete level IIB dissection (oncological safety) was more frequent in the SCMMF group (P = 0.002). The flap necrosis rate was lower in the STAPF group (STAPF 15% vs SCMMF 34.8%, though this was not statistically significant). Cox multivariate analysis showed that the postoperative flap outcome (total flap necrosis vs flap survival; hazard ratio 27, 95% confidence interval 2.149-336.05; P = 0.001) and complications (excluding fistula) (hazard ratio 14, 95% confidence interval 1.314-142.767; P = 0.029) were associated with overall patient survival. Both speech (P < 0.001) and neck mobility (P < 0.001) functions were superior with STAPF reconstruction. Compared with the traditional SCMMF, the STAPF was found to have a lower necrosis rate with uncompromised oncological safety during harvesting. The STAPF is a good alternative for the repair of medium-sized head and neck defects.

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.

Periosteal Flaps Enhance Prefabricated Engineered Bone Reparative Potential

The clinical translation of bone tissue engineering for reconstructing large bone defects has not advanced without hurdles. The in vivo bioreactor (IVB) concept may therefore bridge between bone tissue engineering and reconstructive surgery by employing the patient body for prefabricating new prevascularized tissues. Ideally, IVB should minimize the need for exogenous growth factors/cells. Periosteal tissues are promising for IVB approaches to prefabricate tissue-engineered bone (TEB) flaps. However, the significance of preserving the periosteal vascular supply has not been adequately investigated. This study assessed muscle IVB with and without periosteal/pericranial grafts and flaps for prefabricating TEB flaps to reconstruct mandibular defects in sheep. The sheep (n = 14) were allocated into 4 groups: muscle IVB (M group; n_M = 3), muscle + periosteal graft (MP group; n_MP = 4), muscle + periosteal flap (MVP group; n_MVP = 4), and control group (n_Control = 3). In the first surgery, alloplastic bone blocks were implanted in the brachiocephalic muscle (M) with a periosteal graft (MP) or with a vascularized periosteal flap (MVP). After 9 wk, the prefabricated TEB flaps were transplanted to reconstruct a mandibular angle defect. In the control group, the defects were reconstructed by non-prevascularized bone blocks. Computed tomography (CT) scans were performed after 13 wk and after 23 wk at termination, followed by micro-CT (µCT) and histological analyses. Both CT and µCT analysis revealed enhanced new bone formation and decreased residual biomaterial volume in the MVP group compared with control and MP groups, while the M group showed less new bone formation and more residual biomaterial. The histological analysis showed that most of the newly formed bone emerged from defect edges, but larger areas of new bone islands were found in MP and MVP groups. The MVP group showed enhanced vascularization and higher biomaterial remodeling rates. The periosteal flaps boosted the reconstructive potential of the prefabricated TEB flaps. The regenerative potential of the periosteum was manifested after the transplantation into the mechanically stimulated bony defect microenvironment.

Sternocleidomastoid myocutaneous flap or free flap: Long-term follow-up of soft tissue defect repair in oral cancer

OBJECTIVE

To evaluate the reliability and long-term efficacy of the sternocleidomastoid (SCM) flap in reconstructing and repairing soft tissue defects after oral cancer surgeries.

STUDY DESIGN

A total of 102 patients who underwent soft tissue defect reconstruction with the SCM flap after oral cancer surgery (from 2012 to 2019) were assessed. Relevant clinical indicators were analyzed. They were also grouped according to pathologic cervical lymph node staging. Postoperative recurrence and metastases were compared with radial forearm free flap (RFFF).

RESULTS

The flap healing rate was 100% in SCM flap, compared with a success rate of 94% in RFFF. SCM flaps would not increase the risk of dysfunction or paresthesia in the neck dissection area. Prognostically, the rate of cervical lymph node metastasis was similar in patients with pathologic cervical lymph node staging N0 and N1 for both flap types, whereas the rate of cervical lymph node metastasis was significantly higher in patients with SCM flaps compared with RFFF in N2 cases.

CONCLUSIONS

The SCM flap is a reliable, cost-effective flap with minimal adverse effects. It is ideal for soft tissue reconstruction of oral cancers if the patients are selected judiciously. N2 cases are not an indication for SCM flaps.

A comparative study on using superior thyroid artery perforator flaps versus traditional sternocleidomastoid myocutaneous flaps for reconstructions after oral cancer ablation: "New tricks for old dogs"?

OBJECTIVES

To introduce new superior thyroid artery perforator flaps (STAPF), and to compare the clinical outcomes with sternocleidomastoid myocutaneous flaps (SCMMF) for their intraoral applications.

MATERIALS AND METHODS

Between January 2013 and December 2020, forty-three oral cancer patients who received post-oncologic reconstructions with one of these two regional flaps were retrospectively collected. Their techniques and outcomes were compared. All the STAPFs were preprepared with radiologic evaluations.

RESULTS

Despite the common arterial origins, the compositions and harvesting procedures of STAPF and SCMMF were different. Though SCMMFs (n = 23) were designed in rotational styles, most STAPFs (n = 20) were septocutaneous perforator flaps, with 2 chimeric ones. In addition, the sizes of STAPFs were generally larger than those of SCMMFs (p = 0.006). Success rate for STAPFs was much higher, with only three partial cutaneous necroses. Radiotherapy delay was more frequently found in those reconstructed with SCMMFs (P = 0.046), mostly due to fistula formations. Besides, incomplete level IIB dissections were also reported in 9 (20.9%) patients in SCMMF group. In our study, the overall survival was affected by both flap conditions (p = 0.014, 1.333-12.881) and postoperative surgical complications (except fistula) (P = 0.005, 2.240-84.134). Functionally speaking, post-reconstructive speech and neck mobility (p < 0.001) were better in the STAPF group.

CONCLUSIONS

With accumulated experiences on the use of locoregional flaps in the neck, STAPF, when well-prepared, can provide superior reconstructive outcomes for various intraoral defects. As a comparison with SCMMF in the same middle region, STAPF is a viable option with higher success rates and oncological safety for oral cancer patients.

Use of a sternocleidomastoid muscle flap to protect the carotid artery during laryngectomy

OBJECTIVES

This paper describes a simple method of securing tissue coverage of the great vessels at the initial surgery by rotating the divided sternal heads of the sternocleidomastoid muscle, a routine step during laryngectomy, and approximating them to the prevertebral fascia. The paper presents an illustrated case example where this technique in a salvage laryngectomy repair resulted in a protected vascular axis following a salivary leak.

RESULTS

Since utilising this technique, there has been a marked reduction in the requirement of subsequent flap procedures to protect vessels, and no episodes of threatened or actual carotid blowout.

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.

Reconstruction of Oromandibular Defect After Tumor Resection by Sternomastoid-clavicular Flap

ABSTRACT

The study aims to evaluate sternocleidomastoid-clavicular osteo-myocutaneous flap (SCM-OMCF) for reconstruction of mandibular defects after tumor resection. In the period between 2010 and 2018, thirteen patients with primary mandibular tumors underwent mandibular resection and reconstruction with SCM-OMCF. Patients were followed up for 10 to 66 months. Hospital was 13 ± 4 days. All patients started fluid in the 2nd day. The mean time to start oral fluid was 7.5 ± 0.8 day. Four (30.8%) patients suffered from complications (infection and salivary leak in 1 case due to partial flap loss, donor wound dehiscence in 1 case, deep venous thrombosis in 1 case and chest infection in 1 case). None of our cases experienced motor disability. Two cases (15.9%) underwent reoperations. The overall aesthetic outcome was found excellent in 5 cases, satisfactory in 5 cases and fair in 3 cases. The functional outcomes were satisfactory. Tumor recurrences were detected in 2 (15.9%) patients. Two patients died during follow up within 2 years after 1st surgery due to local and distant recurrences. SCM-OMCF is a versatile, safe and simple technique for reconstructing mandibular defects less than 11 cm.

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.