STERNOCLEIDOMASTOID FLAP

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


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


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


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)

branch of suprascapular artery (m3; 2 cm x 0.5 mm;

posteriorly near clavicular origin)

m1

D

m2

m3

STERNOCLEIDOMASTOID FLAPFLAP TYPE

muscularor

musculocutaneousor

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)


ARC OF ROTATION

Distally based flap:

middle and lower neck


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


FLAP MODIFICATIONS

osseomusculocutaneous flap with the entire or partial

medial third of the clavicle(mandibular reconstruction)

also

functional muscular flap(facial reanimation)


APPLICATIONS

Coverage:

anterior neck, posterior necklower face, midlateral face

oral cavityoccipital scalp

Reconstruction:

mandiblefacial reanimation

STERNOCLEIDOMASTOID FLAPGUIDELINES 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


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


GUIDELINES FOR FLAP ELEVATION

Incisions:

Skin island isolated

Muscle exposed through transverse neck incision or vertical incision


FLAP ELEVATION TECHNIQUESSTANDARD 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


FLAP ELEVATION TECHNIQUESDISTALLY 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


FLAP ELEVATION TECHNIQUESVASCULARIZED 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


EXTENSION OF PEDICLE LENGHT

rotation arc increases withrelease of insertion of SCM

orextension of skin island inferior to clavicle for 1 or 2 cm

TRANSPOSITION

Tunnelled under mandible for intraoral reconstruction


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

DONOR SITE CLOSURE

Directly

RECONSTRUCTIVE SURGERY PRINCIPLES, ANATOMY AND TECHNIQUES

S J MATHESF NAHAI

CHURCHILL LIVINGSTON EDS1997

STERNOCLEIDOMASTOID FLAP

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