H. LEONHARDT 1 , R. MAI 1 , W. PRADEL 1 , J. MARKWARDT 1 , T. PINZER 2 , A. SPASSOV 3 , G. LAUER 1 FREE DIEP-FLAP RECONSTRUCTION OF TUMOUR RELATED DEFECTS IN HEAD AND NECK 1 Department of Oral and Maxillofacial Surgery University, Hospital Carl Gustav Carus Dresden, Germany; 2 Department of Neurosurgery University Hospital Carl Gustav Carus Dresden, Germany; 3 Department of Orthodontics, Preventive and Pediatric Dentistry, Ernst- Moritz-Arndt University Greifswald, Germany The free deep inferior epigastric perforator flap (DIEP) is a well-established therapy for plastic reconstruction of the breast or defects of the lower extremity without distinct donor site morbidity. Because of its particular qualities we started to apply the DIEP-flap also in reconstruction of defects in the cranio-maxillofacial area. A series of 10 consecutive patients, who received a DIEP-flap for reconstruction of large soft tissue defects after ablative tumour surgery, was reviewed. Nine of the 10 flaps survived and uneventfully healing was observed in 8 of the 10 flaps. Primary layered closure of the abdominal wall was achieved in all cases and no complications at the donor site were observed. In our experience the DIEP may serve as a well considerable alternative to the rectus abdominis flap and the latissimus dorsi flap for bridging extensive reconstructions in the cranio-maxillofacial region. It offers the possibility for flap elevation simultaneously to the surgical procedures in the head and neck area. A special advantage of the DIEP-flap is the very low donor site morbidity. Key words: DIEP-flap, head and neck reconstruction, microsurgery, donor site morbidity INTRODUCTION The use of microvascular-anastomosed flaps has become the gold standard for reconstruction of extended defects after tumour ablation in head and neck area. Mainly applied flaps are the radial forearm flap (rff), the lateral upper arm flap (luaf), the lateral thigh flap (ltf), the latissimus dorsi flap (ldf) and the rectus JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2008, 59, Suppl 5, 59–67 www.jpp.krakow.pl
Transcript
H. LEONHARDT1, R. MAI1, W. PRADEL1, J. MARKWARDT1, T. PINZER2 , A. SPASSOV3, G. LAUER1
FREE DIEP-FLAP RECONSTRUCTION OF TUMOUR RELATED DEFECTS IN HEAD AND NECK
1Department of Oral and Maxillofacial Surgery University, Hospital Carl Gustav CarusDresden, Germany; 2Department of Neurosurgery University Hospital Carl Gustav Carus
Dresden, Germany; 3Department of Orthodontics, Preventive and Pediatric Dentistry, Ernst-Moritz-Arndt University Greifswald, Germany
The free deep inferior epigastric perforator flap (DIEP) is a well-established therapyfor plastic reconstruction of the breast or defects of the lower extremity withoutdistinct donor site morbidity. Because of its particular qualities we started to apply theDIEP-flap also in reconstruction of defects in the cranio-maxillofacial area. A seriesof 10 consecutive patients, who received a DIEP-flap for reconstruction of large softtissue defects after ablative tumour surgery, was reviewed. Nine of the 10 flapssurvived and uneventfully healing was observed in 8 of the 10 flaps. Primary layeredclosure of the abdominal wall was achieved in all cases and no complications at thedonor site were observed. In our experience the DIEP may serve as a wellconsiderable alternative to the rectus abdominis flap and the latissimus dorsi flap forbridging extensive reconstructions in the cranio-maxillofacial region. It offers thepossibility for flap elevation simultaneously to the surgical procedures in the head andneck area. A special advantage of the DIEP-flap is the very low donor site morbidity.
K e y w o r d s : DIEP-flap, head and neck reconstruction, microsurgery, donor site morbidity
INTRODUCTION
The use of microvascular-anastomosed flaps has become the gold standard forreconstruction of extended defects after tumour ablation in head and neck area.Mainly applied flaps are the radial forearm flap (rff), the lateral upper arm flap(luaf), the lateral thigh flap (ltf), the latissimus dorsi flap (ldf) and the rectus
JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2008, 59, Suppl 5, 59–67www.jpp.krakow.pl
abdominis flap (raf) (1- 4). The advantage of the raf is that an extended tissuevolume consisting of muscle, subcutaneous fat and a variable big skin area with areliable pedicle is available. The skin area including the fat is nutrified via separateperforator vessels. These perforators are branches of the deep inferior epigastricartery and vein. Therefore, the harvest of the deep inferior epigastric perforator(DIEP) flap with extended skin-areas without sacrificing the rectus abdominismuscle is possible (5). High rates of successful reconstruction and little donor sitemorbidity were pointed out in breast reconstruction with the DIEP (6, 7). Howeverthere is very little experience with the DIEP in head and neck reconstruction (8).We describe the technique of the DIEP for reconstruction of extensive voluminousfacial defects after ablative tumour surgery and its outcome in 10 cases.
PATIENTS AND METHODSDIEP flap reconstruction for primary and secondary repair of large defects after ablative tumour
surgery was performed in 10 cases between 2001 and 2004 (follow up between 12 and 47 month).The defect-locations, diagnoses of the tumours and recipient vessels are specified in Table 1 and 2.The resected skin surface ranged between 40 and 180 cm2. The Ethic Committe of DresdenUniversity approved this study and informed consent was obtained from each patient.
Operation TechniquePreoperatively a Doppler flow imaging of the epigastric vessels was performed. Hereby, the
location and the calibre of the perforator vessels were assessed and marked on the skin (Fig. 1). Skin
incision will then start at the lateral part of the abdominal wall cutting through subcutaneous fatstaying on the fascia of the abdominal muscles. Without resecting any fascia the dissection moves
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Case Flap Size PerforatorVessels Recipient Vessels
1 7 x 9 cm 3 A. carotis ext., V. jugularis int.
2 5 x 8 cm 4 A. & V. thyroidea sup.
3 5 x 8 cm 4 A. & V. facialis
4 8 x 10 cm 4 A. & V. facialis
5 9 x 9 cm 4 A. facialis, V. jugularis int.
6 10 x 17 cm 3 A. & V. facialis
7 8 x 10 cm 3 A. facialis, V. jugularis int.
8 6 x 15 cm 2 A. thyroidea sup., V. jugularis int.
9 8 x 14 cm 2 A. facialis, V. jugularis int.
10 12 x 12 cm 1 A. thyroidea sup., V. jugularis ext.
Table. 2.
Fig. 1. Flap design and DIEP vessels outlined after Doppler-flow ultrasound investigation.
towards the midline. Once the selected periumbilical perforators are identified (Fig. 2), the anteriorrectus fascia is incised to form separate collars around the tiny gaps to protect the perforatingvessels. The incision is then extended towards the groin to dissect the main stem of the inferiorepigastric vessels and to follow it to the level of the lateral border of the rectus abdominis muscle.Then the branches leading from the inferior epigastric stem to the perforator vessels are exposed byblunt dissection along the muscle-fibres towards the tiny gaps in the fascia (Fig. 3). Thereby themotor-nerves are identified and because the pedicle is dissected deep to motor nerves they can bemostly preserved. If this is not possible divided branches are to suture. Thus, after completelydeveloping the flap consisting of ligated vessel pedicle, subcutaneous fat and skin, it is raised andtransferred to the recipient site. After the flap is sutured into the defect, the A. and V. epigasticainferior are connected to the recipient vessels by microsurgery. Before wound closure at the donor-site the rectus abdominis muscle and the anterior rectus sheath are inspected and potential surgicaldamages to the structures is repaired by coaptation.
RESULTS
Nine of the 10 DIEP survived completely, 8 flaps healed uneventfully andwithout any complication. A sufficient wound closure and aesthetically pleasingcoverage of the large facial defects could be achieved (Fig. 4). A sufficienthealing also occurred in the 2 cases of secondary mandibular reconstruction.Metal plates and free iliac bone grafts restored the continuities of the mandiblesand the DIEPs filled the extraoral soft tissue defects without complications (Fig.
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Fig. 2. Dissection of one large periumbilical perforator vessel embedded in a collar of the anteriorrectus fascia.
5). In the patient who underwent a subtotal glossectomy a total flap loss wasencountered after thrombosis of the venous pedicle. It had occurred afterreintubation, necessitated by the threat of suffocation after pharyngeal swelling.In one other patient primary skin closure of the tumour defect with the flap couldnot be achieved due to bulky subcutaneous fatty tissue. The risk to compress thevessel pedicle was avoided by temporarily covering a part of the subcutaneousfatty tissue with Syspurderm® as artificial surface. After healing of the flap for 3weeks, the adipose subcutaneous tissue was reduced by liposuction and thedefect area was closed completely. Primary layered closure of the abdominalwall led in all cases to functional and good aesthetic results of the donor sites.Abdominal wall complications like bulking, herniation or functional deficitswere not observed.
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Fig. 3. Recipient sites ofDIEP-reconstruction(Patient 1 to 10).
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Fig. 4. Operation situs showing the vessel pedicle and a perforator leading into the flap.
Fig. 5. Primary DIEP-flap reconstruction after resection of a myxofibrosarcoma in the lefttemporal region
DISCUSSION
Although the muscle-sparing DIEP-flap is widely used in breastreconstruction surgery this report is one of the few of its application for largefacial or head and neck defect reconstruction (8-10). In general DIEP-flaps arevery suitable for the rehabilitation of large volume defects due to their pliablecharacter with a certain amount off subcutaneous tissue (9). The perforatorsprovide a good nutrition as a precondition for uneventful wound healing aftersuccessful microvascular anastomosis at the recipient site. The importance of theperforators blood supply is clearly demonstrated by the DIEP failure in this study,which was encountered in the early postoperative interval. However,Moolenburgh et al. even described a DIEP failure 3 years after transplantationdue to pedicle diversion (11). In contrast to total flap loss Nahabedian et al.reported a rate of about 10% of fat necrosis related to breast reconstruction withDIEP-flaps (12) and Kroll et al. described a close relation between the size of theperforators and fat necrosis (13). These facts relate to our experience with thecase of delayed primary defect closure after the liposuction. It suggests thatextensive subcutaneous fatty tissue due to adipositas should be encountered as arisk factor for flap survival even when large perforators exist that guaranteed wellnutrified DIEP-flaps. All patients were satisfied with the aesthetic results of thereconstruction and none of the patients showed functional disturbances of theabdominal wall. The low donor site morbidity of the DIEP-flap except the skinscar matches with the results of Blondeel et al. who assessed the function of the
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Fig. 6. DIEP-flap for soft tissue cover of free iliac bone graft in secondary reconstruction of themandible after resection and radiation of a fibrosarcoma.
abdominal wall by clinical examinations, physical exercises and a questionnaireafter DIEP-and TRAM-flap elevation (14). However, the low donor-sitemorbidity of the DIEP-flap is associated with a longer operation time, due to thedelicate dissection of the perforators to the stem of the deep inferior epigastricvessels. This slight disadvantage is matched by the simultaneous two-teamapproach for parallel flap harvesting and tumour-surgery as no patientrepositioning is required (15). Taken all this into account, we advocate the DIEPas a reliable and save transplant for head and neck reconstruction.
The application of the DIEP-flap is in particular an alternative for primary andsecondary reconstruction of large tumour associated defects in the head and neckarea. Especially the pliability together with a certain volume, the long and reliablevascular pedicle and the texture of the flap make the DIEP suitable for theaesthetically challenging reconstruction of large facial defects after ablativetumour surgery. The preservation of the rectus abdominis muscle and the fasciaguarantees a very little donor site morbidity. The simultaneous two-teamapproach for tumour surgery and flap harvesting makes the application of theDIEP very comfortable also for craniomaxillofacial or head and neck surgery.
Conflicts of interest statement: None declared.
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R e c e i v e d : July 24, 2008A c c e p t e d : October 15, 2008
Author’s address: Dr. Henry Leonhardt, Department of Oral and Maxillofacial Surgery,University Hospital Carl Gustav Carus, Fetscherstraße 74, Dresden, D - 01307, Germany; phone:+49 351 458 5205; fax: +49 351 458 5382; e-mail: [email protected]
