Transcript Diapositive 1

STERNOCLEIDOMASTOID FLAP
FEATURES
Lateral and oblique in the neck
2 bellies
Course from manubrium and clavicle
(head and medial 1/3)
to
occipital bone
(mastoid process and superior nuchal line)
5 X 18 cm
STERNOCLEIDOMASTOID FLAP
MOTOR NERVE
spinal portion of XI and 2sd and 3rd
cervical nerves
enter proximal portion of posterior
muscle belly
FUNCTION
head rotation and bending
expendable if remaining neck muscles are
functionnals
STERNOCLEIDOMASTOID FLAP
VASCULAR ANATOMY
type II of Mathes and Nahai
Dominant pedicle:
branch of occipital artery (D)
enters on deep surface of upper 1/3
of muscle belly
(3 cm x 1 mm)
m1
D
m2
m3
STERNOCLEIDOMASTOID FLAP
VASCULAR ANATOMY
3 minor pedicles:
branch of posterior auricular artery
(m1; 2cm x 0.6 mm;
close to mastoid insertion)
branch of superior thyroid artery
(m2; 2 cm x 0.6 mm;
distal 1/3 of anterior muscle belly)
m1
D
m2
branch of suprascapular artery
(m3; 2 cm x 0.5 mm;
posteriorly near clavicular origin)
m3
STERNOCLEIDOMASTOID FLAP
FLAP TYPE
muscular
or
musculocutaneous
or
osseomusculocutaneous
POINT AND ARC OF
ROTATION
Based on the dominant pedicle:
level of carotid bifurcation;
anterior neck and lower face
(anterior rotation)
posterior neck and occipital area
(posterior rotation)
STERNOCLEIDOMASTOID FLAP
ARC OF ROTATION
Distally based flap:
middle and lower neck
STERNOCLEIDOMASTOID FLAP
MUSCULOCUTANEOUS FLAP
SKIN TERRITORY
anterolateral skin of the neck
located over the muscle
6 x 20 cm
coverage of intraoral and lower
facial defects
SCM
STERNOCLEIDOMASTOID FLAP
FLAP MODIFICATIONS
osseomusculocutaneous flap
with the entire or partial medial
third of the clavicle
(mandibular reconstruction)
also
functional muscular flap
(facial reanimation)
STERNOCLEIDOMASTOID FLAP
APPLICATIONS
Coverage:
anterior neck, posterior neck
lower face, midlateral face
oral cavity
occipital scalp
Reconstruction:
mandible
facial reanimation
STERNOCLEIDOMASTOID FLAP
GUIDELINES FOR FLAP
ELEVATION
Patient position:
Lying on back with head turned to
opposite side
Markings
:
Mastoid, clavicle, suprasternal
notch
Skin islands:
Standard flap: over the distal
muscle closed to its origin
Distally based flap: over the
upper proximal muscle closed to
its insertion
STERNOCLEIDOMASTOID FLAP
GUIDELINES FOR FLAP ELEVATION
Pedicle location:
Dominant pedicle: on deep surface of upper 1/3 of muscle
Distal pedicle: deep to lower 1/3 of muscle
STERNOCLEIDOMASTOID FLAP
GUIDELINES FOR FLAP ELEVATION
Incisions:
Skin island isolated
Muscle exposed through transverse neck incision or vertical incision
STERNOCLEIDOMASTOID FLAP
FLAP ELEVATION TECHNIQUES
STANDARD FLAP
Origin is divided
More distal pedicle is divided
Muscle is elevated from clavicle toward superior neck
Remaining segmental pedicle are divided
Dissection continues up toward dominant pedicle
Dominant pedicle is identified and preserved
XIth cranial nerve is preserved
Dissection is completed at level of hyoid bone
STERNOCLEIDOMASTOID FLAP
FLAP ELEVATION TECHNIQUES
DISTALLY BASED FLAP
Muscle outlined by drawing a line from mastoid to manubrium
Incision along that line and muscle identified
Muscle divided at midway along its length
Muscle mobilized from above toward distal pedicle
STERNOCLEIDOMASTOID FLAP
FLAP ELEVATION TECHNIQUES
VASCULARIZED BONE
Clavicle is cut with a saw, preserving the attachments of the origin
of the muscle from the bone
Distal pedicle is identified and ligated
The combined flap is dissected from below upward
STERNOCLEIDOMASTOID FLAP
EXTENSION OF PEDICLE LENGHT
rotation arc increases with
release of insertion of SCM
or
extension of skin island inferior to clavicle for 1 or 2 cm
TRANSPOSITION
Tunnelled under mandible for intraoral reconstruction
STERNOCLEIDOMASTOID FLAP
DONOR SITE CLOSURE
Directly
PRECAUTIONS
Spinal nerve: passing through SCM at upper and middle 1/3 junction
Internal jugular vein: closed to SCM at its origin
Great auricular nerve: closed to anterosuperior border of SCM
RECONSTRUCTIVE SURGERY
PRINCIPLES, ANATOMY AND TECHNIQUES
S J MATHES
F NAHAI
CHURCHILL LIVINGSTON EDS
1997