Transaxillary-Subclavian Transfer of Pedicled Latissimus Dorsi Musculocutaneous Flap to Head and Neck Region

Abstract

Free-tissue transfer is the reconstruction of choice for most head and neck defects. However, pedicled flaps are also used, especially in high-risk patients and after failure of a free flap. The aim of this study was to compare transaxillary-subclavian pedicled latissimus dorsi musculocutaneous (PLDMC) flap, pectoralis major musculocutaneous flap, and free-tissue transfer for head and neck reconstruction in American Society of Anesthesiologists grades II and III patients. During the last 4 years, PLDMC flap with a modified transaxillary-subclavian route for transfer to the neck was used in 8 patients, pectoralis major musculocutaneous flap was used in 7 patients, and free flaps were used in 12 patients for head and neck reconstructions. These 3 methods were compared regarding the flap dimensions, complications, flap outcome scores, hospitalization time, and cost of the treatment. Mean age of the patients, mean American Society of Anesthesiologists scores, mean dimensions of the flaps, and mean hospitalization time did not differ significantly among the 3 groups. Regarding the operation time, flap complications, outcomes, and cost of total treatment, although statistically not significant, PLDMC group offered the fastest reconstruction with highest flap outcome scores and minimum cost. Free-tissue transfer is the procedure of choice especially for functional reconstruction of head and neck region. Occasionally, there exist cases in whom a pedicled flap could offer a safer option. The PLDMC flap transferred via the transaxillary-subclavian route may be preferred than, with advantages including increased arc of rotation, safer pedicle location, shorter duration of the procedure, and reduced complication rates and costs.

Latissimus dorsi (LD) free flap and reconstruction plate used for extensive maxillo-mandibular reconstruction after tumour ablation

“…There are many reports of microvascular reconstructions in the head and neck region replacing alloplastic devices, locoregional flaps and autologous bone grafts with high success rates (90e95%) (Suga et al, 2007;Brown et al, 2008;Demirtas et al, 2010). Reconstruction with free LD flaps and R-plates has the major advantage of simultaneous reconstruction of muscular, bony and skin defects with a single free flap (Danino et al, 2003;Bhatt et al, 2009;Achal et al, 2011).…”

Pedicled latissimus dorsi myocutaneous flap in the reconstruction of the head and neck region: Experience with 17 patients

“…Rates of complication seem to increase after free flap transfer in elderly patients (7). The number and severity of complications tend to be higher in advanced age.…”

“…Osteotomy of the clavicle may be required for subclavian passage, and injury to the major vessels and brachial plexus is possible (7). Therefore, the subclavian transfer method is dependent on the experience and skill of a surgeon, therefore calling for a challenging and long learning curve.…”

“…The transfer of a pedicled LDMF to the head and neck region can be achieved via pectoral tunnel, subscapular, or subcutaneous routes (7). If a flap is completely released from humeral insertion together with the dissection of the pedicle, it can be successfully transferred to distal regions such as the vertex of the cranium (8).…”

“…Owing to the popularity of and advancement in microsurgical techniques, LDMFs have been frequently used as free flaps (1,4,5). However, they can also be used as pedicled flaps, particularly in elderly patients, in the presence of comorbidities and in patients with compromise of vasculature in the recipient tissue or with a history of loss of a free flap (6,7).…”