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A small group of patients with complex head and neck cancer present with problems of wound healing following radiotherapy and reconstructive surgery. Provision of skin cover to the neck in these cases is often required and presents a challenge to the reconstructive surgeon. We present the use of a pedicled scalp flap based on the occipital artery for such defects. This flap is an axial patterned scalp flap incorporating hair-bearing skin. It may be up to 15 cm wide and can reach beyond the midline of the chin. The anatomy of the flap is described and its use illustrated in three cases. This flap is a useful addition to the options for reconstruction of neck defects in patients with head and neck cancer.
The need to provide skin cover for defects of the neck is common in patients with head and neck cancer. This may be the result of nodal disease requiring skin resection as part of a therapeutic neck dissection or wound breakdown following postoperative radiotherapy. Reconstructive options include regional pedicled flaps or free tissue transfer. There are many pedicled flaps, which have been described for use in head and neck surgery.
Versatility of the delto-pectoral flap in reconstruction following head and neck cancer surgery. Transactions of the Fourth International Congress of International Plastic and Reconstructive Surgeons 1967. Amsterdam,
Excerpta Medica1969
Of these, the most common are the delto-pectoral flap, the pectoralis major flap and the latissimus dorsi flap.
A small number of patients, who have had primary surgery and reconstruction with one or more of the above flaps followed by radiotherapy to the neck, present with recurrent disease which usually requires further reconstructive surgery. These patients may be unfit for a further major procedure. In addition, the common regional pedicled flaps, as well as potential recipient vessels for free tissue transfer, may already be compromised by previous surgery and/or radiotherapy. For these difficult cases with limited reconstructive options, we report the successful use of a pedicled scalp flap based on the occipital artery to reconstruct defects of the neck.
1. Anatomy
The occipital artery arises from the external carotid artery in the neck. It passes deep to the posterior belly of digastric and enters the occipital groove behind the mastoid process. It runs deep to splenius capitis and sternocleidomastoid before turning to become more superficial at the posterior border of these muscles. Here, the occipital artery pierces the deep cervical fascia to enter the scalp. This point, located at the junction of the middle and medial third of the superior nuchal line (joining the tip of the mastoid process to the external occipital protuberance) forms the base of the occipital scalp flap
(Fig. 1) . From 12 cadaver dissections and Doppler studies performed in 10 healthy volunteers, we can confirm that the occipital artery was located within 1 cm either side of this point in all cases. The galea, which arises from the superior nuchal line, lies immediately below the occipital artery and its branches within the subcutaneous tissue.
The occipital artery has three main branches: the vertical branch, which anastomoses with the postauricular, superficial temporal and supraorbital vessels, a horizontal branch, which anastomoses with the contralateral vessel and a descending cutaneous branch. Venous drainage occurs via the occipital vein, which travels with the artery to the neck, where it enters the venous plexus around semispinalis capitis.
Fig. 1Anatomy of the occipital artery. The occipital artery enters the scalp at a point between the middle and medial thirds of the line joining the mastoid process and the external occipital protuberance before dividing into its three main branches.
The occipital scalp flap is based on the occipital artery. It includes hair-bearing skin from the scalp and can reach the midline of the chin with a width of 15 cm or more. The base must include the scalp at the junction of the middle and medial thirds of the superior nuchal line to ensure the occipital artery is present in the base of the flap. Preoperative Doppler studies should be performed to confirm patency of the occipital artery. The width of the flap may extend from just beyond the midline to the edge of the hair-bearing scalp above the pinna. The anterior margin may be extended on to the forehead if necessary to provide adequate flap length, however, the cosmetic result is improved if the anterior limit of the flap is within the anterior hairline (Fig. 2(B)) . The flap is raised in the subgaleal plane from the anterior border, in order to protect the artery and vein. The flap may then be turned down to pass below the pinna, adjusted to suit the defect and inset into the neck without tension (Fig. 2(C) and (D)). The donor defect is covered with a split thickness skin graft. Although the pedicle creates a sizeable dog-ear, this diminishes with time. If necessary, the pedicle may be divided and inset after a suitable time period.
Fig. 2Case 1. (A) At presentation to our unit, showing exposed mandible. (B) The flap is marked on the scalp showing the anterior limit within the anterior hairline. (C) The defect following debridement and the flap, which has been raised prior to insetting. (D) The immediate postoperative result following insetting of the flap.
The use of this flap is illustrated in the following case reports of three patients. All patients had received initial surgical treatment of their primary condition under the care of other specialties before being referred for further reconstruction at a later date.
3.1 Case 1
A 40-year-old merchant seaman initially presented with a well-differentiated squamous cell carcinoma of the floor of the mouth and bilateral cervical lymphnode involvement (stage T2N2). He was treated with chemoradiotherapy to the floor of the mouth and neck. Six months later, due to persistent disease, he underwent a right marginal mandibular resection, bilateral neck dissection and a right pectoralis major flap for reconstruction of the floor of the mouth. Two years later, he presented with osseo-radionecrosis and a persistent sinus over the right mandible (Fig. 2(A)). He was referred to our unit for reconstruction and underwent a right hemi-mandibulectomy and free fibulo-osseo-cutaneous flap reconstruction. The skin paddle failed and was subsequently resected. An occipital scalp flap was used to cover the neck defect (Fig. 2(B)–(D)). Three years later, his appearance is satisfactory (Fig. 3) .
Fig. 3Case 1. At 3 years follow-up. The view from the front (A) shows an excellent cosmetic appearance. In (B), the donor site and resultant dog-ear can be seen.
A 66-year-old lady presented with a moderately differentiated squamous cell carcinoma of the supraglottis and right cervical lymphadenopathy (stage T2N1). She was treated with radiotherapy to the supraglottis and neck, but the tumour recurred 1 year later. She required a total laryngectomy and right radical neck dissection using a delto-pectoral flap to reconstruct the neck defect. The flap failed and was replaced by a pectoralis major flap. This too failed (Fig. 4(A)) and she was subsequently referred to our unit for further management. Following debridement of the necrotic tissue, a right occipital scalp flap was used to provide skin cover. Two years later, she remained well (Fig. 4(B)).
Fig. 4Case 2. The patient at presentation, (A), in which the necrotic pectoralis major and delto-pectoral flaps can be clearly seen and (B) at 2 years after reconstruction with an occipital scalp flap.
A 73-year-old retired postman had initially been diagnosed, at the age of 50, with a well-differentiated squamous cell carcinoma of the left tonsil. He had had radiotherapy to the lower face and neck, followed by hemi-mandibulectomy and left radical neck dissection. He remained disease-free for 23 years. At the time of presentation, he was still disease free. However, as a result of soft tissue contracture, his right hemi-mandible had shifted across the midline, resulting in the inability to tolerate dentures (Fig. 5(A)) . He was therefore referred to our unit for mandibular reconstruction. A free fibulo-osseo-cutaneous flap was used to reconstruct the mandible and provide the mucosal lining. An occipital scalp flap was then used to reconstruct the neck defect. His appearance at 6 weeks is satisfactory (Fig. 5(B)–(D)).
Fig. 5Case 3. At presentation (A), the right hemi-mandible is shifted across the midline, with the resulting deformity leading to inability to tolerate dentures. (B)–(D) The results at 6 weeks after mandibular reconstruction and reconstruction of the neck defect with an occipital scalp flap. The area covered by the flap can be seen to extend from the mid-cheek area to the midline of the neck. The dog-ear is shown in (D).
The three patients described all achieved stable coverage with no flap failure. All three declined further surgery to correct the dog-ear deformity, as with time, it did not cause significant problems. In Case 2, despite the offer of further treatment to the hair on the flap, the patient chose to trim the hair herself at regular intervals. Both patients described in Cases 1 and 2 remained disease-free over the follow-up period of 3 and 2 years, respectively.
4. Discussion
Reconstructive surgery in complicated head and neck cancer requires careful planning. Free tissue transfer is an attractive option, however, the condition of the patient and the state or absence of potential recipient vessels may render this an inappropriate option. A proportion of these patients require a safe, reliable and quick salvage procedure.
The occipital artery scalp flap has several advantages. Neither the occipital vessels nor the territory of this flap itself is likely to have been compromised by primary surgery, radiotherapy, or the previous use of other pedicled flaps. Furthermore, the axial pedicle lies superficial to the galea, which serves to support and protect the vessels, preventing undue tension or kinking at the flap base. Sharma et al. recommended that, if the flap was to extend beyond the vertex, the posterior auricular vessels should also be included in the flap. In our study, however, the occipital vessels alone were used for the vascular pedicle without any adverse effect on flap survival or limitation of flap dimensions. Finally, the occipital artery scalp flap may be raised and inset as a single stage procedure.
The disadvantages of this flap are mainly cosmetic. It results in a large dog-ear in the occipital region, an area of alopecia on the scalp and, in women, the transfer of hair-bearing skin to the neck. Whilst the dog-ear can be divided and inset at a later stage, this is often unnecessary as it does shrink significantly over time. The area of alopecia can be camouflaged by retaining the anterior hairline if the flap design allows. Alternatively, a wig may be used. The hair at the recipient site, which may be easily camouflaged within the beard area in men, may be prominent in female patients. Possible treatments include laser, electrolysis or further surgery, although this is not always required as demonstrated in Case 2.
Other flaps for use in head and neck reconstruction based on the occipital artery and its branches have been described, including the parietal occipital nape of neck flap.
The advantage of this flap is that non-hair bearing skin is transposed. The flap is based on the descending cutaneous branch of the occipital artery together with perforators from the trapezius.
The distal tip of the flap, however, has a more random blood supply and is therefore less reliable. Furthermore, a second procedure is usually necessary to re-inset the long pedicle. Free flaps based on the occipital artery have also been described for reconstruction of the upper lip
The occipital artery scalp flap is a reliable axial pattern flap based on the occipital vessels that may be raised without delay as a single stage reconstructive procedure for defects of the neck. It can measure up to 15 cm in width and is long enough to reach beyond the midline of the anterior neck. It is particularly useful in the male patient, where the use of hair-bearing skin for a neck defect can provide an excellent cosmetic result. Although the flap may theoretically be divided at a second stage, this is usually unnecessary. The occipital artery scalp flap should be remembered as a useful addition to the reconstructive options for defects of the neck.
Acknowledgements
We thank Department of Anatomy, University College London Medical School for providing cadaveric specimens.
References
Bakamjian V.Y.
Culf N.K.
Bales H.W.
Versatility of the delto-pectoral flap in reconstruction following head and neck cancer surgery. Transactions of the Fourth International Congress of International Plastic and Reconstructive Surgeons 1967. Amsterdam,
Excerpta Medica1969 (pp. 808–15)
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