FREE DIEP-FLAP RECONSTRUCTION OF TUMOUR RELATED DEFECTS IN HEAD AND NECK

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1 JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2008, 59, Suppl 5, 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

2 60 abdominis flap (raf) (1-4). The advantage of the raf is that an extended tissue volume consisting of muscle, subcutaneous fat and a variable big skin area with a reliable pedicle is available. The skin area including the fat is nutrified via separate perforator vessels. These perforators are branches of the deep inferior epigastric artery and vein. Therefore, the harvest of the deep inferior epigastric perforator (DIEP) flap with extended skin-areas without sacrificing the rectus abdominis muscle is possible (5). High rates of successful reconstruction and little donor site morbidity were pointed out in breast reconstruction with the DIEP (6, 7). However there is very little experience with the DIEP in head and neck reconstruction (8). We describe the technique of the DIEP for reconstruction of extensive voluminous facial defects after ablative tumour surgery and its outcome in 10 cases. PATIENTS AND METHODS DIEP 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 cm 2. The Ethic Committe of Dresden University approved this study and informed consent was obtained from each patient. Operation Technique Preoperatively 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 Table. 1. Case Age Gender Diagnoses Localisation 1 55 M SCC Mandible right 2 60 M ChS Mandible middle 3 48 M SCC Floor of Mouth, Tongue 4 71 M NS Temporal+orbital left 5 74 M SCC Periorbital+nose right 6 58 M SCC Temporal left 7 59 M SCC Orbita left+infraorbital 8 37 F AcC Infraorbital+Nose right 9 60 F FS Temporal right F FS Temporal left Legend: SCC - squamous cell carcinoma, NS - neurosarcoma, ChS - chondrosarcoma, AcC - adenoidcystic carcinoma, FS - myxofibrosarcoma

3 61 Table. 2. Case Flap Size Perforator Vessels 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 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 x 12 cm 1 A. thyroidea sup., V. jugularis ext. Fig. 1. Flap design and DIEP vessels outlined after Doppler-flow ultrasound investigation. incision will then start at the lateral part of the abdominal wall cutting through subcutaneous fat staying on the fascia of the abdominal muscles. Without resecting any fascia the dissection moves

4 62 Fig. 2. Dissection of one large periumbilical perforator vessel embedded in a collar of the anterior rectus fascia. towards the midline. Once the selected periumbilical perforators are identified (Fig. 2), the anterior rectus fascia is incised to form separate collars around the tiny gaps to protect the perforating vessels. The incision is then extended towards the groin to dissect the main stem of the inferior epigastric 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 by blunt dissection along the muscle-fibres towards the tiny gaps in the fascia (Fig. 3). Thereby the motor-nerves are identified and because the pedicle is dissected deep to motor nerves they can be mostly preserved. If this is not possible divided branches are to suture. Thus, after completely developing the flap consisting of ligated vessel pedicle, subcutaneous fat and skin, it is raised and transferred to the recipient site. After the flap is sutured into the defect, the A. and V. epigastica inferior are connected to the recipient vessels by microsurgery. Before wound closure at the donorsite the rectus abdominis muscle and the anterior rectus sheath are inspected and potential surgical damages to the structures is repaired by coaptation. RESULTS Nine of the 10 DIEP survived completely, 8 flaps healed uneventfully and without any complication. A sufficient wound closure and aesthetically pleasing coverage of the large facial defects could be achieved (Fig. 4). A sufficient healing also occurred in the 2 cases of secondary mandibular reconstruction. Metal plates and free iliac bone grafts restored the continuities of the mandibles and the DIEPs filled the extraoral soft tissue defects without complications (Fig.

5 63 Fig. 3. Recipient sites of DIEP-reconstruction (Patient 1 to 10). 5). In the patient who underwent a subtotal glossectomy a total flap loss was encountered after thrombosis of the venous pedicle. It had occurred after reintubation, necessitated by the threat of suffocation after pharyngeal swelling. In one other patient primary skin closure of the tumour defect with the flap could not be achieved due to bulky subcutaneous fatty tissue. The risk to compress the vessel pedicle was avoided by temporarily covering a part of the subcutaneous fatty tissue with Syspurderm as artificial surface. After healing of the flap for 3 weeks, the adipose subcutaneous tissue was reduced by liposuction and the defect area was closed completely. Primary layered closure of the abdominal wall led in all cases to functional and good aesthetic results of the donor sites. Abdominal wall complications like bulking, herniation or functional deficits were not observed.

6 64 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 left temporal region

7 65 Fig. 6. DIEP-flap for soft tissue cover of free iliac bone graft in secondary reconstruction of the mandible after resection and radiation of a fibrosarcoma. DISCUSSION Although the muscle-sparing DIEP-flap is widely used in breast reconstruction surgery this report is one of the few of its application for large facial or head and neck defect reconstruction (8-10). In general DIEP-flaps are very suitable for the rehabilitation of large volume defects due to their pliable character with a certain amount off subcutaneous tissue (9). The perforators provide a good nutrition as a precondition for uneventful wound healing after successful microvascular anastomosis at the recipient site. The importance of the perforators 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 transplantation due 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 with DIEP-flaps (12) and Kroll et al. described a close relation between the size of the perforators and fat necrosis (13). These facts relate to our experience with the case of delayed primary defect closure after the liposuction. It suggests that extensive subcutaneous fatty tissue due to adipositas should be encountered as a risk factor for flap survival even when large perforators exist that guaranteed well nutrified DIEP-flaps. All patients were satisfied with the aesthetic results of the reconstruction and none of the patients showed functional disturbances of the abdominal wall. The low donor site morbidity of the DIEP-flap except the skin scar matches with the results of Blondeel et al. who assessed the function of the

8 66 abdominal wall by clinical examinations, physical exercises and a questionnaire after DIEP-and TRAM-flap elevation (14). However, the low donor-site morbidity of the DIEP-flap is associated with a longer operation time, due to the delicate dissection of the perforators to the stem of the deep inferior epigastric vessels. This slight disadvantage is matched by the simultaneous two-team approach for parallel flap harvesting and tumour-surgery as no patient repositioning is required (15). Taken all this into account, we advocate the DIEP as a reliable and save transplant for head and neck reconstruction. The application of the DIEP-flap is in particular an alternative for primary and secondary reconstruction of large tumour associated defects in the head and neck area. Especially the pliability together with a certain volume, the long and reliable vascular pedicle and the texture of the flap make the DIEP suitable for the aesthetically challenging reconstruction of large facial defects after ablative tumour surgery. The preservation of the rectus abdominis muscle and the fascia guarantees a very little donor site morbidity. The simultaneous two-team approach for tumour surgery and flap harvesting makes the application of the DIEP very comfortable also for craniomaxillofacial or head and neck surgery. Conflicts of interest statement: None declared. REFERENCES 1. Brown JS, Magennis P, Rogers SN, Cawood JI, Howell R, Vaughan ED. Trends in head and neck microvascular reconstructive surgery in Liverpool ( ). Br J Oral Maxillofac Surg 2006; 44: Lyons AJ. Perforator flaps in head and neck surgery. Int J Oral Maxillofac Surg 2006; 35: Yokoo S, Komori T, Furudoi S et al. Indications for vascularized free rectus abdominis musculocutaneous flap in oromandibular region in terms of efficiency of anterior rectus sheath. Microsurgery 2003; 23: Fanghanel J, Gedrange T, Proff P. The face-physiognomic expressiveness and human identity. Ann Anat 2006; 188: Erni D, Harder YD. The dissection of the rectus abdominis myocutaneous flap with complete preservation of the anterior rectus sheath. Br J Plast Surg 2003; 56: Gill PS, Hunt JP, Guerra AB et al. A 10 year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113: Van Landuyt K, Blondeel P, Hamdi M, Tonnard P, Verpaele A, Monstrey S. The versatile DIEP flap: its use in lower extremity reconstruction. Br J Plast Surg 2005; 58: Woodworth BA, Gillespie MB, Day T, Kline RM. Muscle-sparing abdominal free flaps in head and neck reconstruction. Head Neck 2006; 28: Czesnikiewicz-Guzik M, Konturek SJ, Loster B, Wisniewska G, Majewski S. Melatonin and its role in oxidative stress related diseases of oral cavity. J Physiol Pharmacol 2007; 58: Proff P, Weingärtner J, Fanghänel J, Gredes M, Mai R, Gedrange T. Regional changes in the masseter muscle of rats after reduction of blood supply. Ann Anat 2007; 189: Moolenburgh SE, van Huizum MA, Hofer SO. DIEP-flap failure after pedicle division three years following transfer. Br J Plast Surg 2005; 58:

9 Nahabedian MY, Momen B, Galdino G, Manson PN. Reconstruction with the free TRAM or DIEP flap: patient selection, choice of flap, and outcome. Plast Reconstr Surg 2002; 110: Kroll SS, Reece GP, Miller MJ et al. Comparison of cost for DIEP and free TRAM flap breast reconstructions. Plast Reconstr Surg 2001; 107: Blondeel N, Vanderstraeten GG, Monstrey SJ et al. The donor site morbidity of free DIEP flaps and free TRAM flaps for breast reconstruction. Br J Plast Surg 1997; 50: Trzcieniecka-Green A, Bargiel-Matusiewicz K, Borczyk J. Quality of life of patients after laryngectomy. J Physiol Pharmacol 2007; 58: R e c e i v e d : July 24, 2008 A 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 , Germany; phone: ; fax: ; guenter.lauer@uniklinikum-dresden.de