Reconstruction of Large Lateral Facial Defects Utilizing Variations of the Cervicopectoral Rotation Flap

Abstract

Large lateral facial defects as a result of trauma or head and neck oncologic surgery can present a challenging reconstructive dilemma for the operating surgeon. A number of options currently exist for reconstructing such defects, including skin grafts, myocutaneous flaps, and free vascularized flaps. The decision to utilize one approach versus another depends largely on the nature of the defect, anatomical location, and the experience of the surgeon. This article describes our experience utilizing cervicopectoral rotation flaps with and without myocutaneous flaps to reconstruct large lateral facial defects after head and neck oncologic surgery.

Introduction

The surgical management of lateral facial carcinomas can be divided into two phases: resection and reconstruction. The initial resection often includes a large surface area, which provides a unique challenge for the reconstructive surgeon. Closure of these wounds is problematic due to the magnitude and location of the soft-tissue defect, functional and aesthetic considerations, need for optimal cancer surveillance, and desire for healthy soft-tissue protection and nourishment of deeper vital structures. The ideal type of reconstruction would provide adequate coverage for the surgical defect, good functional and aesthetic results, and the utmost reliability. Many of the current options to solve this problem include grafts or flaps harvested from a second incision site, but they often provide a poor aesthetic match and have a significant risk of flap or graft failure. Primary reconstruction with cervicopectoral rotation flaps can be incorporated within the incision utilized for the resection, thereby eliminating the need for a second incision, optimizing the aesthetic result by using adjacent tissue with similar characteristics, and mitigating the risk of failure by utilizing a regional blood supply. The following schematics illustrate the use of these flaps in the reconstruction of large lateral facial defects (Figures 1 through 3).

Figure 1. Cervicopectoral rotation flap illustrating coverage of a lateral facial defect after primary excision.

Figure 2. Cervicopectoral rotation flap with an underlying pectoralis major myofascial rotation flap.

Figure 3. Cervicopectoral rotation flap with an underlying pectoralis major myocutaneous rotation flap with a skin paddle.

Surgical Technique

The surgical technique involves first creating an incision that encompasses the primary excision as well as the cervicopectoral flap. The inferior border of the excision of the tumor is delineated as the upper border of the flap. The incision is then carried around the earlobe and back to the hairline in the postauricular region, curving inferiorly along the cervical hairline parallel to, and approximately 2 cm behind the anterior border of the trapezius muscle. This incision further descends across the acromioclavicular point of the shoulder and along the lateral edge of the pectoralis muscle. The inferior most portion of the incision is parallel to the clavicle, approximately 3 cm above the nipple.1 Elevation of the flap occurs superior to the parotid fascia in the face, subplatysmal in the neck, and superior to the pectoralis major muscle in the chest. En bloc excision of the carcinoma is carried out and the flap is subsequently rotated to cover the lateral facial defect. The entire incision is closed primarily (Figure 1). If a pectoralis major myofascial flap is necessary for vascular protection after a neck dissection, this is harvested in the standard fashion (Figure 2). If a skin paddle is necessary along with the myocutaneous flap, the skin paddle is incorporated into the inferior portion of the cervicopectoral flap incision and the myocutaneous flap is subsequently harvested in the standard fashion (Figure 3).

Discussion

The reconstruction of head and neck defects is often confounded by different anatomical regions encompassed within one defect. Although there are a number of different alternatives in reconstruction, only a few have the same texture, color, and hair-bearing characteristics of the face and neck.2 The utilization of a cervicopectoral flap to cover such defects has been well described in the English-language literature and has proven advantageous in head and neck reconstruction for a number of reasons.

For example, the blood supply is derived from the anterior thoracic perforators of the internal mammary artery, thereby making this flap reliable for defects of the lower cheek below the line connecting the tragus and oral commisure.2,3 In patients undergoing reconstruction after head and neck oncologic procedures, the cervicopectoral flap is an ideal choice because the plane of elevation of the flap within the neck is identical to that used in neck dissections. An ideal neck incision for a neck dissection requires sufficient exposure, viability of the elevated skin flap, protection for neurovascular structures, and acceptable postoperative cosmetic results. The cervicopectoral flap possesses all of these features (Figures 4 through 6).

Figure 4. Nodular melanoma of the right face. Resection performed with a planned wide excision and neck dissection. Reconstruction performed with a cervicopectoral rotation flap.

Figure 5. Elevation of the cervicopectoral flap occurs superior to parotid fascia in the face, subplatysmal in the neck, and superior to the pectoralis major muscle in chest. This is the same patient from Figure 4.

Figure 6. Primary closure of a cervicopectoral rotation flap. This is the same patient from Figures 4 and 5.

Certain types of lateral facial defects are too extensive for a simple cervicopectoral flap to reconstruct. If additional bulk is needed in the neck for cosmesis or carotid artery coverage, the cervicopectoral flap may be utilized with an underlying pectoralis major myofascial flap without the skin paddle (Figure 2).

If full thickness cheek defects are created by the oncologic resection, epithelial lining is necessary to provide an effective barrier to prevent salivary fistulas. The dissection of the cervicopectoral flap superficial to the parotid fascia in the face and subplatysmal in the neck does not provide the lining necessary to reconstruct full thickness cheek defects. In these cases a myocutaneous pectoralis major flap with a skin paddle can be utilized in conjunction with a cervicopectoral rotation flap (Figures 7 through 9).

Figure 7. Squamous cell carcinoma of the lower face and lip eroding intraorally. Resection was performed with a planned wide resection with neck dissection. Reconstruction was performed intraorally with a skin paddle attached to a pectoralis major flap rotated under a cervicopectoral rotation flap.

Figure 8. Rotation of a pectoralis major myocutaneous flap under a cervicopectoral rotation flap into the surgical defect. The attached skin paddle is utilized for intraoral lining. This is the same patient from Figure 7.

Figure 9. Primary closure of a cervicopectoral rotation flap. This is the same patient from Figures 7 and 8.

First documented in 1983 by Skow, a standard pectoralis major myocutaneous flap with a skin paddle sized to fit the intraoral defect is created.4 The paddle is fashioned from the inferior aspect of the cervicopectoral incision and rotated superiorly with the pectoralis myocutaneous flap to fill the intraoral defect. The medially based cervicopectoral flap is then rotated to provide external defect coverage.

The advantages of utilizing these variations of the cervicopectoral rotation flap for reconstructing lateral facial defects lie in their incorporation with the incision for the primary resection. The plane of dissection and elevation for a cervicopectoral flap is identical to that required for a parotidectomy in the face and a neck dissection in the cervical region. This allows both resection and reconstruction to be performed in a single stage, thereby providing a shorter operative time. Many head and neck cancer patients have significant coexisting pulmonary disease secondary to smoking, and as a result longer operative periods may be associated with more morbidity under general anesthesia. In fact, for procedures lasting less than 8 hours, the risk of complications was less than that for prolonged operations.2 Furthermore, oncologic principles are not violated in the creation of a cervicopectoral flap since the excision margins of the primary are not compromised for fear of creating too large a surgical defect to reconstruct.

The aesthetic value of a cervicopectoral flap for the head and neck region is also a great advantage. These flaps rotate tissue that is similar in both color and texture to cheek skin. Furthermore, when combined with a pectoralis major myocutaneous flap, bulk is provided to the full thickness cheek defect, yielding a more symmetric appearance with the contralateral side (Figure 10).

Figure 10. Postoperative photograph demonstrating the excellent skin tone and texture match provided by a cervicopectoral rotation flap with a pectoralis major rotation flap with a skin paddle for intraoral reconstruction. This is the same patient from Figures 7, 8, and 9.

The cervicopectoral flap, like most other surgical alternatives, is not without its drawbacks. The vascular supply of both the cervicopectoral flap and pectoralis major myocutaneous flap are susceptible to linear tension. Excessive tension on either can compromise healing and cause breakdown. Also, case reports have shown scenarios in which skin grafting was required to repair areas of skin necrosis from prior radiation.5

Skin grafts may also be necessary if primary closure is not possible. It is important to keep in mind that this is a rare occurrence, given that primary closure of this flap is one of its advantages. Furthermore, utilization of this flap in women may pose a problem with resulting breast asymmetry.

Conclusion

The cervicopectoral rotation flap and its variations are acceptable treatment options for reconstructing large lateral facial defects. The decreased operative time, single stage resection and reconstruction, and functional and aesthetic results achieved with these flaps make them a welcome addition to the armamentarium for head and neck surgeons.