The short head of the biceps femoris as a monitor for the free lateral thigh flap in pharyngoesophageal reconstruction

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1 British Journal of Plastic Surgery (2001), 54, O 2001 The British Association of Plastic Surgeons doi: 10,1054/bjps PLASTIC SURGERY POINT OF TECHNIQUE The short head of the biceps femoris as a monitor for the free lateral thigh flap in pharyngoesophageal reconstruction H. G. Kim, B. Ha, C.-H. Back*, Y. J. Park, W. S. Hyon, J. J. Kim and M. S. Shin Departments of Plastic and Reconstructive Surgery, and *Otorhinolaryngology - Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Centre, Seoul, South Korea SUMMARY Free flaps are frequently used to reconstruct the defect following radical resection of pharyngoesophageal malignancy but postoperative monitoring of buried flaps is difficult. We have designed a monitoring-muscle flap using the short head of the biceps femoris muscle when using a free lateral thigh flap. The and fourth perforators of the profunda femoris artery, the main vascular pedicle of the lateral thigh flap, pass through the short head of the biceps femoris. Partial excision of the short head of the biceps femoris muscle does not result in any functional disturbance of the leg, and the viability of the buried lateral thigh flap can be monitored by observing the exposed muscle through a small window in the neck. Between April and October 1998 five patients undel~ent pharyngoesophageal reconstruction by this method. The short head of the biceps femoris was used to monitor the main flap in three patients and to obliterate the dead space after neck dissection in two patients. There were no recipient-site complications such as fistula or infection and no disturbance of thigh function The British Association of Plastic Surgeons Keywords: free tissue transfer, monitoring, lateral thigh flap, biceps fem oris. Various ising methods have been devised to monitor internally placed flaps. In 1985, Katsaros et al used the minor segment based on the superior mesenteric artery, the vascular pedicle of the jejunum, as a monitor flap by ising itj In 1994, A1 Qattan and Boyd used a small skin paddle attached to a free fibular flap to monitor the viability of the flap. 2 In a radial forearm free flap, a small island skin flap 3 or insignificant small muscles (palmaris longus and brachioradialis) 4 have been used to monitor the flap. There have been no reports on monitoring flaps for the free lateral thigh flap to date. The aim of this report is to introduce the usefulness of the short head of the biceps femoris muscle as a monitor for a free lateral thigh flap, which can be used in pharyngoesophageal reconstruction. the iliotibial tract. The flap is elevated from the fascia as far as the beginning of the intermuscular septum. On reaching the intermuscular septum, the perforators are seen running along it. The second perforator is located superiorly, separate from the short head of the biceps femoris. 5 The and fourth perforators run on, through or under the short head of the biceps femoris 6,7 and have consistent numerous branches to the short head of the biceps femoris, 6,8 which means that the and fourth perforators are always in contact with the short head of the biceps femoris (Fig. 1). Patients and methods Operative technique In the supine position with hip flexed, the lateral condyle of the femur and the greater trochanter are marked and the intermuscular septum identified along the posterior border of the vastus lateralis. Ultrasound Doppler examination of the thigh is used to identify the perforators of the profunda femoris artery within the intermuscular septurn. Flaps have been routinely designed with the long axis on the intermuscular septum, including as many perforators as possible. The anterior and posterior incisions are made through the skin and subcutaneous tissue overlying the fascia of Figure 1--The relationship between the perforators and the short head of the biceps femoris, The and fourth perforators pass through the short head of the biceps femoris, but the second perforator does not. 62

2 Monitor muscle for free lateral thigh flap 63 Figure 2~The harvested free lateral thigh flap: a part of the short head of the biceps femorisis attached to the vascularpedicle. (A) Flap based on the perforatorand (B) the fourth perforator. Figure 3--Brisk bleeding through the window in the lower portion of the neck on postoperativemonitoring. With retraction of the vastus lateralis anteriorly, the perforator can be followed toward the linea aspera. The muscular branches of the perforator to the vastus lateralis must be identified and ligated before dissection proceeds proximally. We could easily see the relationship between the perforator and the short head of the biceps femoris. Generally, in conventional flap elevation, the short head of the biceps femoris is separated from the perforator by dissection of the vascular pedicle. However, at this point, the short head of the biceps femoris is harvested, attached to the perforator. Further dissection of the vascular pedicle, away from the muscle, provides sufficient length and an adequate diameter pedicle for anastomosis (Fig. 2). If the perforator is divided at its origin from the profunda femoris artery, it is 6-8 cm long and its diameter is 2-3 mm. 9 Once raised, the flap is usually placed back into position on the thigh to wait for transfer to the pharyngoesophageal defect. Once the defect is established, the flap may be contoured and then transferred in the usual manner. At the end of the operation, the short head of the biceps femoris, attached to the vascular pedicle, is ised through a small window in the lower side of the neck (Fig. 3). This exposed muscle reflects the viability of the internal main flap. Patients Between April and October 1998, free lateral thigh flaps with the short head of the biceps femoris were harvested in five patients for pharyngoesophageal reconstruction. Immediate reconstruction was performed in all patients following resection by the otorhinolaryngology team. All patients were males with squamous cell carcinoma. The mean age at the time of surgery was 63.8 years (range: years) and the mean follow-up period was 5.8 (range: 4-8 ). Four patients received postoperative radiotherapy; received preoperative radiotherapy. Only one patient required reconstruction of a circular defect owing to total laryngopharyngectomy. The short head of the biceps femoris was used to monitor the buried flap in three patients and it was also used to obliterate the dead space and to protect the major neck vessels exposed after neck dissection in two patients (Table 1). In the monitoring cases, additional muscle attached to the main flap was ised through a small window in the lower side of the neck at the end of the operation. The status of the exposed muscle was checked by observing the colour and bleeding pattern until the postoperative day. Simultaneously, we checked the status of the buried flap by endoscopic examination. On the day, monitoring was terminated and the open wound was sutured with 4-0 nylon at the bedside. To evaluate the patency of the neo-pharyngoesophagus, an oesophagograph was performed on the tenth postoperative day. Two postoperatively, the function of the leg was evaluated by observing the patient's gait and repeated standing from a sitting position. Patients were asked about weakness, and ability to walk, run and climb stairs. Results The skin paddle measured cm on average (range of width: 5-10cm; range of length: 7-12 cm). All flaps were vascularised by a single perforator. The perforator was used for the main vascular pedicle in four patients, and the fourth perforator was used in one patient. After neck dissection, several arteries could be selected for anastomosis. We selected the artery in three patients, the superior thyroid artery in one patient and the lingual artery in one patient. The veins were used as recipient veins in all patients. All flaps were well vascularised after anastomosis. Only one patient, with a 7 x 10cm skin paddle, required split-thickness skin graft to repair the donor site.

3 Outcome, Follow-up period death at 5 death at 4 survival for 13 death at 4 survival for 14 Complications (donor and recipient sites) 4~ g g. Table 1 Patient summary Sex~age Diagnos& Defect (years) Neck Radiotherapy dissection Diet Flap size (cm) Donor site repair Pedicle Recipient artery Recipient vein T3NoMx M/61 SCC, pyriform circular sinus, TnNoM 0 T1N2bMo M/63 SCC, partial T4N2Mo T2N1M0 left LND, postoperative left MRND (type II), left LND, postoperative left LND, postoperative right MRND (type II) left LND, postoperative fight MRND (type lid 12x9 12 x 10 5x7 7xlO 6xlO split thickness skin graft fourth lingual superior thyroid SCC: squamous cell carcinoma; LND: lateral neck dissection; MRND: modified radical neck dissection.

4 Monitor muscle for free lateral thigh flap 65 This patient needed the graft because he had bulky thigh muscle with limited skin laxity. In another patient, a defect of 12 10cm could be closed directly, owing to sufficient skin laxity (Table 1). No flap was lost. We observed brisk bright red bleeding from the exposed monitor flap postoperatively (Fig. 3). On simultaneous endoscopic examination, no significant change in skin colour of the neo-pharyngoesophagus was seen. L-tube feeding started on the second postoperative day. On the tenth postoperative day, oesophagography showed a patent neo-pharyngoesophagus without leakage in all patients. Thereafter, the patients were encouraged to take jelly food instead of the L-tube feeding. All patients were allowed a soft diet at around the time of discharge from hospital. The mean hospital stay was 39.4 days (range: days). No marked complications, such as leakage or stricture, were observed during the hospital stay. Unfortunately, three patients with advanced cancer died of multiple recurrence within 5. However, those patients could eat gruel without aspiration and had no wound problems after discharge from hospital. The newly formed flap was able to maintain the neo-pharyngoesophagus without stricture or leakage. Two postoperatively, the status of the patients was evaluated using tests and questionnaires. No patients demonstrated gait disturbance. They were able to stand from sitting and sit down again without signs of weakness. None had a subjective feeling of weakness in the thigh. The patients were able to perform the same physical tasks as before surgery. In surviving patients, final interview by telephone at eight postoperatively revealed that of their activities of daily life were affected by the surgery. Discussion The free lateral thigh flap has been considered as an alternative to the free radial forearm flap in pharyngoesophageal reconstruction. 5'6 Due to the wide cutaneous territory of the lateral thigh, the skin island can be designed without any serious complications at the donor site. A two-team approach is possible without changing the position of the patient during the operation. Additionally it is a thin pliable fasciocutaneous flap, which is suitable for circular defects. Direct inspection of the flap is the most reliable way of monitoring a free flap. In 1999, Disa et al reported that the loss rate for non-buried flaps was significantly lower than that for buried flaps if all flaps were monitored by a conventional method. 1~ Also, the overall salvage rate of non-buried flaps was significantly higher than that of buried flaps. In 1995, Miller et al reported that the perforator courses through the short head of the biceps femoris (in 57 out of 61 cases) and has large consistent muscular branches (in 61 out of 61 cases). 8 In 1998, Truelson and Leach observed that the and fourth perforators pass through the short head of the biceps femoris but the second perforator does not. 5 The anatomical relationship between the perforators and the short head of the biceps femoris can easily be seen during the dissection of the lateral thigh. Part of the short head of the biceps femoris can be safely included on the principal vascular pedicle without prolonging the operating time or requiring difficult extra dissection (Fig. 1). Observing the status of a muscle exposed ly is easy and accurate. During the period of observation, we observed brisk bright red bleeding from the muscle and were able to confirm the survival of the main flap by simultaneous endoscopic examination. As the exposed muscle shares the vascular pedicle with the main flap it reflects the condition of the inner flap. An additional role for the muscle is to obliterate dead space. We did not use the short head of the biceps femoris for monitoring in two patients who underwent Type II modified radical neck dissection but, rather, to obliterate the dead space and protect the major vessels. Partial excision of the biceps femoris muscle did not produce any serious complications. We conducted musclefunction assessments to evaluate the capacity of the postoperative biceps femoris at outpatient clinic visits. The short head of the biceps femoris is one of the hamstring muscles, arising from the distal half of the lateral lip of the linea aspera and gaining insertion to the head of the fibula and the lateral condyle of the tibia, acting in flexion and lateral rotation of the leg. The long head of the biceps femoris, the semitendinosus and the semimembranosus constitute the hamstring muscle group, and the short head of the biceps femoris has less influence on leg movement than the remaining hamstring muscles. 11 As noted earlier, the and fourth perforators pass through the short head of the biceps femoris but the second perforator does not since it is situated cephalad of the short head of the biceps femoris. 5-s Most lateral thigh flaps are based on the perforator but there are rare cases of a variation where the second perforator is used as the main vascular pedicle. 12 In such cases, an operator may not be able to use this technique since elevation along with the short head of the biceps femoris will not be possible. In summary, the free lateral thigh flap is useful in pharyngoesophageal reconstruction and the exposed short head of the biceps femoris muscle can be used as a buried-flap monitor. In addition, the muscle can be used to protect the major neck vessels and to obliterate dead space. References 1. Katsaros J, Banis JC, Acland RD, Tan E. Monitoring free vascularised jejunum grafts. Br J Plast Surg 1985; 38: A1 Qattan MM, Boyd JB. 'Mini paddle' for monitoring the fibular free flap in mandibular reconstruction. Microsurgery 1994; 15: Furuta S, Hataya Y, Ishigaki Y, Watanabe T. Monitoring the free radial forearm flap in pharyngo-oesophageal reconstruction. Br J Plast Surg 1997; 50: Iwasawa M, Furuta S, Hayasi M, Ohtsuka Y, Kushima H. Use of a monitor muscle flap in buried free forearm flap transfer. Ann Plast Surg 1996; 37: Truelson JM, Leach JL. Lateral thigh flap reconstruction in the head and neck. Otolaryngol Head Neck Surg 1998; 118: Hayden RE. Lateral thigh flap. Otolaryngol Clin North Am 1994; 27: Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37:

5 66 British Journal of Plastic Surgery 8. Miller MJ, Reece GP, Marchi M, Baldwin BJ. Lateral thigh free flap in head and neck reconstruction. Plast Reconstr Surg 1995; 96: Ha B, Baek C-H. Head and neck reconstruction using lateral thigh free flap: flap design. Microsurgery 1999; 19: Disa JJ, Cordeiro PG, Hidalgo DA. Efficacy of conventional monitoring techniques in free tissue transfer: an 11-year experience in 750 consecutive cases. Plast Reconstr Snrg 1999; 104: Clemente CD, ed. Gray's Anatomy. 30th American edition. Philadelphia: Lea and Febiger, 1985: Baek S-M. Two new cutaneous free flaps: the medial and lateral thigh flaps. Plast Reconstr Surg 1983; 71: The Authors Hun Gon Kim MD, Resident Bomjoon Ha MD, PhD, Assistant Professor Young Jin Park MD, Clinical Fellow Won Sok Hyon MD, Clinical Fellow Jae Joong Kim MD, Assistant Professor Myoung Soo Shin MD, PhD, Associate Professor and Chairman Department of Plastic and Reconstructive Surgery, Chung-Hwan Back MD, PhD, Associate Professor Department of Otorhinolaryngology - Head and Neck Surgery, Samsung Medical Centre, 50 I1 Won Dong, Kang Nam Ku, Seoul , South Korea. Correspondence to Bomjoon Ha. Paper received 30 November Accepted 11 September 2000, after revision. Published online 9 November 2000.