STERNOCLEIDOMASTOID FLAP
description
Transcript of 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
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)
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)
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 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
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 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
STERNOCLEIDOMASTOID FLAP
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
STERNOCLEIDOMASTOID FLAP
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
STERNOCLEIDOMASTOID FLAP
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
STERNOCLEIDOMASTOID FLAP
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