OTAF Score: A Novel Scoring System for Selection of an Ideal Local and Locoregional Flap for Oncoplastic Head and Neck Reconstruction

INTRODUCTION
With the advent of microsurgical free tissue
transfer in head and neck reconstruction, local and
locoregional flaps tend to lose some popularity [1].
However, free flaps are still technique-sensitive,
time consuming procedures, necessitate adequate
blood vessels with careful monitoring and also not
suitable in some patients [2]. In the other hand,
some surgeons become more reluctant the select
383
the option of free tissue transfer when lackingof
expertise and advanced equipment andwith more
the interest of cost-effective medicine as well [1].
For these reasons, in reconstruction of head
and neck defects, local and locoregional flaps are
very helpful [1]. By considering multiple criteria
in each flap, the reconstruction of defects could
be individualized by judgement of these cases and
the more suitable flap for each. The defect management
is related to many factors such as defect
site, size, patient comorbidity as well as the etiology
of the defect weather traumatic or post malignancy
which necessitates some specialized management
and reconstruction as well [3].
Modern trends in post malignancy reconstruction
target more aesthetic and functional outcome
with more patient satisfaction [1].
From the oncological point of view, flap reconstruction
of the defects should be compatible with
some oncological considerations like cervical
lymph node dissection and radiotherapy. Technical,
aesthetic and functional factors are also so important
in the reconstruction decision [3].
The submental island flap based on the submental
artery has become more popular in head and
neck reconstruction and well suited for defects of
the oral cavity [1]. However, the latissimus dorsi
musculocutaneous pedicled flap has its advantages
in the head and neck reconstruction as it has large
surface area, great arc of rotation and high ability
to cover distal (cephalad) defects when compared
with any pedicled musculocutaneous flap used in
reconstruction of head and neck. Also, this flap
provides non-irradiate tissues as the flap is totally
outside the field of radiotherapy when used in
management of previously irradiated head and
neck malignancy [4]. Deltopectoral flap has its
advantages of having an easy technique with dependable
pedicles. Also, it has good color match
with the face [5]. Paramedian Forehead flap is an
axial flap based on supratrochlear artery which is
very useful for repair of nasal defects with good
functional and cosmetic outcome [3,10]. The nasolabial
flap usually used for facial defects especially
nasal reconstruction because of its unique
colour and texture match to that of the nose [6].
Anteriorly based cervicofacial flap is a large rotational
flap, needingwide undermining flap that be
able to reconstruct a sizable defect without leaving
a sizable donor one. If the dissection level in the
subcutaneous plane, this flap has a randomly pattern
blood supply but with multiple perforators such as
deep and transverse facial arteries. However, if the
plane of dissection was deep to superficial musculoapponeurotc
system and platysma it attains an
axial blood supply becoming an axial flap [7].
Focused evaluation of the multiple advantages
and disadvantages of this armamentarium of available
flaps in a novel scoring system became our
motive in order to maximize the benefits of this
multifactorial approaches.
This study aims to evaluate the importance of
oncological, technical, aesthetic and functional
considerations in selection between different types
of local and locoregional flaps used in head and
neck oncoplastic reconstruction. These flaps were
having different examples of blood supply pattern
as being random, pedicled island and pedicled non
island flaps to propose a novel scoring system in
selection of an ideal local and locoregional flap
for oncoplastic head and neck reconstruction.
PATIENTS AND METHODS
52 local and locoregional flaps were created in
52 patients who were squeduled for head and neck
tumour resection and defects reconstruction. 28
patients needed cervical lymph nodes dissection.
These patients have been classified into six groups
according to the flaps used in reconstruction of the
defects; 11 submental pedicled flaps and 4 latissimus
dorsipedicled flaps, 11 deltopectoral flaps,
8 paramedian forehead flaps,10 nasolabial flaps
and8 anteriorly based cervicofacial flaps were
created.
The data were collected as a prospective study
throughout a 2-year period. The protocol of the
study has been approved by Ethical Committee of
ZagazigUniversity Hospital.
Age, gender, type, site of tumor, site and size
of defects which has been reconstructed, type of
384 Vol. 42, No. 2 /OTAF Score: A Novel Scoring System for Selection of an Ideal
the flap used and complications, operative findings
and outcomes of the reconstructions, were reviewed.
Oncological and technical considerations were
reviewed in each case postoperatively. A questionnaire
shared by three plastic surgeons in aesthetic
and functional ones except patient opinion which
were reported 3 to 6 months after reconstruction.
(Table 1).
Operative techniques:
Submental flap:
At the border of the lower mandibular arch the
upper flap boundary is marked with determination
of the lower boundary by a pinch test. The flap
length can be totally or partially span from both
mandibular angles designed according to the defect
size. The incision of the skin paddle wascontinued
with the incision of the cervical lymph nodes
dissection weather unilateral or bilateral neck
dissectionwas performed. Firstly, the inferior incision
of the flap with the neck dissection incision
are were until reach the subplatysmal plane. Submandibular
gland was excised with great care to
the preserve submental vessels on its superior
surface. Afterwards, the course of the submental
vessels was followed. Elevation of the submental
flap in the subplatysmal plane from the non-pedicle
side going medially to the midline then the dissection
become deeper to the digastric muscle in the
pedicle side. A calf of mylohyoid muscle also was
included as a deep level of dissection to protect
the submental vessels and its perforators as a useful
modification of the traditional technique. The more
length of the pedicle needed the more proximal
dissection was done. Tunneling of the floorof the
mouthtunnel was performedwith average size i.e.
passing two fingers with ease, through the submandibular
triangle to pass the flap to the mouth
cavity when needed for tongue or other intraoral
reconstruction. Primary closure of the donor site
with undermining of the posterior border of it and
putting a vacuum drain.
Pedicled latissimus dorsimyocutanous flap:
According to the defect needed to be covered,
a skin territory is designed over the latissimus dorsi
muscle with suitable site, orientation and size
taking care to have a width less than 8cm to permit
direct closure of the donor site. The skin island
associated with the whole latissimus dorsi muscle
are included after separation from the dorsolumbar
origin and the humeral insertion being only attached
to thoracodorsal pedicle. A tunnel is made between
the pectoralis major muscle and the clavicle allowEgypt,
J. Plast. Reconstr. Surg., July 2018 385
ing the flap to reach the recipient site without
tension. Closure of the donor site in layers with
preferable more than one vacuum drain for a prolonged
period aiming to minimize the incidence
of seroma or hematoma collection which are not
uncommon complications in these flaps for large
surface area dissection.
Deltopectoral flap:
An axial pattern fasciocutaneous flap based on
the 2nd and 3rd internal mammary artery major
perforators in the 2nd and 3rd intercostal spaces,
2cm lateral to the sternum. Minor perforatorsin
the 1st and 4th spaces can also be used associated
with the major perforators. The flap is marked
from the sternal border laterally to the deltoid area.
For increasing distant point reach of the flap in
head and neck reconstruction, different modifications
were done. Extension of the lateral limit of
the flap into the tip of the shoulder or even the
upper lateral arm was done for this purpose with
increasing the risk of partial flap loss. Pre-expansion
or delay procedure which is performed byelevation
of the flap and return it back to the donor site or
incising it in a separate preliminary stage for days
or weeks to help in reorientation of the flap blood
supply and minimizing flap loss after reconstruction.
The flap is generally transferred as a twostage
procedure, one for defect coverage and the
other for flap separation after three or four weeks,
but in an attempt to convert that to a single stage
the skin between the defect and the flap pedicle is
simply incised to let the proximal part of the flap,
nearby the pedicle, be included in the neck skincircumference.
Closure of the donor site may be
allowed primarily especially in old patients with
redundant skin otherwise partial skin thickness
graft was needed.
Paramedian forehead flap:
An axial flap based on supratrochlear artery
which is exiting the orbit at the supraorbital rim
level lateral to the midline by 1.7 to 2cm. The flap
consists of skin and subcutaneous tissue with the
deeper frontalis muscle and the associated fascia.
The flap is marked by using of a template for
accurate design which is surgically and cosmetically
critical. The pedicle is narrowed as we go near the
pedicle with minimal width of 1.5cm. Harvesting
of flap was started after injecting a vasoconstricting
solution. To allow for ease rotation, the contralateral
side to the defect can be used except if there is a
scar or other contraindication. When starting to
harvest the tip, the skin and subcutaneous tissue
are incised were elevated using skin hooks. After
mobilization of the flap tip, finger dissection is
done going deep to the galea layer in the intermediate
part of the flap. Once we reach the level of
superior aspect of the eye brow the dissection is
deepened subperiosteally using 15 blade then a
blunt dissector to protect the pedicle which penetrate
the frontalis muscle at this level. We stop
dissection if the flap reaches the defect without
tension or if not, we may continue dissection under
the corrugator muscle to provide an additional
length. Closure of the donor site may need a skin
flap or may occur primarily with better aesthetic
outcome especially when reconstructing a small
sized defect or in old aged patients with redundant
forehead skin.
Nasolabial flap:
The nasolabial flaps aregenerally used for facial
defects especially nasal reconstruction because of
its unique colour and texture match to the nasal
skin. Although of being a non-axial flap when
using the skin or fasciocutaneous parts only, the
nasolabial flap has a rich blood supply and harvested
as a pedicled thin flap not considering 3:1 length
to width ratio, as typically considered in random
patterned flaps. The flap marking is performed
with a lap pad using a reverse Gillie test to insure
adequate length for flap rotation. Also, a template
of the defect is created by foil and then marked
along the donor site in the nasolabial fold and the
inferomedial incision margin is usually placed
along the nasolabial crease resulting in a hidden
donor site scaring. The flap is dissected and elevated
sharply along its borders to the mid-cheek level.
Then it is dissected bluntly to the flap base. When
needing thin contour, the flap is thinned leaving a
minimal subcutaneous fat or only to the level of
deep dermal layer. Careful flap insetting is done
under little tension. The second stage of separation
is usually after three weeks. Single stage flap
design can used as a useful modification in certain
cases.
Anteriorly based cervicofacial flap:
The flap has been usually used for cheek defects.
After defect preparation, extension of incision from
its lateral aspect inferior to the ear lobule and may
reach nearby the tip of the mastoid process. The
dissection plane was deep to the superficial musculoaponeurotic
system (SMAS) in the face and in
subplatysmal plane in the neck to enforce the flap
vascularity. Care of unintentional injury of the
marginal mandibular branch of the facial nerve
near the lower mandibular border must be taken.
The lateral incision extends downward and backward
for a length nearly equals the defect diameter
then the inferior incision is directed medially at
ninety-degree angle or less according to the cervical
skin redundancy that facilitates closure donor
site angle i.e. old patients usually have more neck
skin laxity which is of great help in this step.
Closure of the donor site occurs primarily, with
VY advancement or rarely necessitates a skin
graft. Regarding the area of defect coverage,a dogear
deformityoftenhas occurredin the inferomedial
area of the defect closure and may be managed at
the same time of reconstruction or later in a separate
step for avoidance of flap vascularity compromise.
386 Vol. 42, No. 2 /OTAF Score: A Novel Scoring System for Selection of an Ideal
RESULTS
Fifty-two patients with head and neck tumours
were managed in Zagazig University Hospitals in
multidisciplinary team approach by onco-surgeons
and reconstructive surgeons. As regards to the
variations of pre-requisites, operative findings and
outcomes of reconstructions, twenty considerations;
grouped as oncological, technical, aesthetic and
functional considerations were reported in each
case separately (Table 1).
All positive considerations were grouped and
compared in each flap type with the other types.
(Tables 2,3,4,5 respectively).
Table (1): An example of a flap OTAF considerations fulfillment for a given reconstruction. The OTAF score (oncological,
technical, aesthetic and functional score) is the number of positive items in each group i.e. in this case O2/T5/A6/F3.
Considerations Fulfillment
Case no. 24 (Anterior basedcervicofacial flap for cheek reconstruction)
Oncological:
1- Compatibility with cervical dissection if needed
2- Compatibilitywith radiotherapy if needed
Technical:
3- Positive defect coverage regarding size and arc of rotation
4- Positive defect coverage regarding distal point reach
5- Safe to harvest; no potential to injure precious structures
6- Pliability and 3D fabrication potential if needed
7- Single stage procedure
8- Short hospitalization period (one-day surgery procedure)
9- Rapid to harvest (less than one hour)
10- Compatibility with critical patient general condition
Aesthetic:
11- Preserving the original form of the reconstructed area
12- Limited Length of the incision
13- Adequacy to fill the contour of the reconstructed defect
14- Absence of donor site defect or graft
15- Color, nature, texture and hair bearing match
16- Obtaining a good aesthetic outcome
17- Optimal patient satisfaction
Functional:
18- Good facial motor function
19- Good specialized sites function (i.e. oral cavity, nasal cavity,
tongue or eye lids according to the reconstructed part)
20- No or minimal donor site functional morbidity
++
++
++
+
+
+++++
++
+
Positive or
non-conflicting Negative
_
__
_
N.B.: The first and second oncological and first and second technical considerations are obligatory. The item is counted positive if it has
fulfilledor not conflicting with the consideration. By using these considerations, every flap has been evaluated and scored by summation of
its positive considerations in each category for example: The OTAF score of anterior based cervicofacial flap for cheek reconstructionin case
no. 24 was O2/T5/A6/F3.
Table (2): Oncological considerations fulfillment (no. of positive cases) of 6 types of flaps in 52 cases after tumour resection
and defects reconstruction.
Oncological
Considerations
1- Compatibility with
cervical dissection
if needed
2- Compatibilitywith
radiotherapy
if needed
10
9
Submental flap
11 cases
Pedicled
latissimus
dorsi 4 cases
4
4
Deltopectoral
flap 11 cases
11
11
Head flap
8 cases
8
8
Nasolabial flap
10 cases
10
10
Anteriorly based
cervicaofa 8 cases
8
8
Egypt, J. Plast. Reconstr. Surg., July 2018 387
Table (3): Technical considerations fulfillment (no. of positive cases) of 6 types of flaps in 52 cases after tumour resection and
defects reconstruction.
Technical
Considerations
3- Positive defect coverage regarding
size and arc of rotation
4- Positive defect coverage regarding
distal point reach
5- Safe to harvest; no potential to
injure precious structures
6- Pliability and 3D fabrication
potential if needed
7- Single stage procedure
8- Short hospitalization period (oneday
surgery procedure)
9- Rapid to harvest (less than one
hour)
10- Compatibility with critical patient
general condition
9
8
–
9
10
–
–
6
Submental
flap
11 cases
Pedicled
latissimus
dorsi 4 cases
4
4
–
3
2
–
–
–
Deltopectoral
flap 11 cases
9
8
11
11
3
–
7
11
Head flap
8 cases
7
7
8
8
–
6
6
8
Nasolabial
flap 10
cases
7
7
8
8
–
6
6
8
Anteriorly
based
cervicaofa
8 cases
6
7
5
8
7
–
–
6
Table (4): Aesthetic considerations fulfillment (no. of positive cases) of 6 types of flaps in 52 cases after tumour resection and
defects reconstruction.
Aesthetic
Considerations
11- Preserving the original form of the
reconstructed area
12- Limited Length of the incision
13- Adequacy to fill the contour of the
reconstructed defect
14- Absence of donor site defect or
graft
15- Color, nature, texture and hair
bearing match
16- Obtaining a good aesthetic
17- Optimal patient satisfaction
6
8
+
10
–
8
7
Submental
flap
11 cases
Pedicled
latissimus
dorsi 4 cases
3
–
+
1
–
–
–
Deltopectoral
flap 11 cases
2
–
+
–
9
9
–
Head flap
8 cases
6
7
+
6
6
7
7
Nasolabial
flap 10
cases
10
7
+
10
10
9
10
Anteriorly
based
cervicaofa
8 cases
7
2
+
7
7
8
8
Table (5): Functional considerations fulfillment (no. of positive cases) of 6 types of flaps in 52 cases after tumour resection
and defects reconstruction.
Functional
Considerations
18- Good facial motor function
19- Good specialized sites function
(i.e. oral cavity, nasal cavity,
tongue or eye lids according to
the reconstructed part)
20- No or minimal donor site
functional morbidity
10
8
9
Submental
flap
11 cases
Pedicled
latissimus
dorsi 4 cases
–
3
–
Deltopectoral
flap 11 cases
–
–
10
Head flap
8 cases
7
8
7
Nasolabial
flap 10
cases
10
9
9
Anteriorly
based
cervicaofa
8 cases
7
7
7
388 Vol. 42, No. 2 /OTAF Score: A Novel Scoring System for Selection of an Ideal
Fig. (1): Case No. 18: The OTAF score of the submental flap for tongue reconstruction after hemiglossectomy O2/T5/A5/F3. APreoperative
view: Scc of the right side of the tongue, B- Marking of the submental flap, C- Right side block nech dissection,
D- Primary closure of the flap donor site, E- Immediate postoperative view after hemiglossectomy and flap reconstruction,
F- Postoperative view after 4 months follow-up with spontaneous flap skin changes to be like the oral mucosa.
Fig. (2): Case No. 12: The OTAF score of pedicled latissimus dorsi flap for full thickness cheek reconstruction after resection of inner
cheek epithelioma and failed reconstruction with free radial forearm flap O2/T5/A3/F1. A- Full thickness left cheek defect
reconstructed with bilobedpedicled latissimus dorsi flap, B- Lip reconstructed by advancement, C- Late follow-up view after
one year.
A B
C D
E F
A
B C
Egypt, J. Plast. Reconstr. Surg., July 2018 389
Fig. (3): Case No. 7: The OTAF score of deltopectoral flap for lower lip reconstruction O2/T6/A3/F1. A- Donor area of the deltopectoral
flap by second and third perforators of internal mammary vessels, B- Resection of the tumour with suprahyoid neck dissection
and elevation of the deltopectoral flap, C- Flap insetting to the lower lip defect, D- Preoperative view E- Postoperative view
after 5 months of follow-up.
Fig. (4): Case No. 9 : The OTAF score of deltopectoral flap for preauricular skin reconstruction O2/T7/A3/F3. A- Preoperative view
with critical general condition which is not suitable for prolonged complicating surgery, B- Postoperative view 14 days after
operation; note that the cervical skin was incised and the pedicle of the flap was included in to convert the transfer to a single
staged procedure, C- Intraoperative view after parotidectomy with extensive skin defect, D- Closure of the donor site
withpatial skin closure and the remaining part necessitated a skin graft, E- Immediate postoperative view, F- Three weeks
postoperative view.
Fig. (5): Case No. 14: The OTAF score of paramedian forehead flap for nose reconstruction O2/T7/A6/F3, A- Preoperative view
(scc), B- Coverage of the defect after resection of the lesion with skin graft to the donor site, C- Final view after the second
stege (separation); note the size of the skin graft on the donor site was minimized with the spontaneous graft contracture.
A B C
D E
A B
C D E F
A B C
Fig. (6): Case No. 24: The OTAF score of anteriorly based cervicofacial flap for cheek reconstruction O2/T5/A6/F3. A- Preoperative
view, B- Extensive cheek defect post resection with subplatysmal dissection; taking care not to thin the flap or injure the
marginal mandibular nerve nearby the lower mandibular border, C- Coverage of the defect as a rotational flap. A dog ear
is formed in the lower medial part of the defect cautiously managed not to impair the flap vascularity.
390 Vol. 42, No. 2 /OTAF Score: A Novel Scoring System for Selection of an Ideal
DISCUSSION
The current study evaluates different twenty
considerations used in selection of the local and
locoregional flaps used in fifty-two cases of post
malignancy head and neck reconstruction. These
considerations were classified into four main
groups; oncological, technical, aesthetic and functional
considerations. The fifty-two patients' defects
in the current study were reconstructed with six
different types of flaps.
Oncological considerations:
Regarding the oncological considerations, compatibility
of the used flap with cervical lymph
nodesdissectionprocedure or radiotherapy, if needed,
was of utmost importance. However, if the site
of the flap harvesting or insetting is not involved
in cervical dissection procedure or radiotherpy the
flap was considered compatible oncologically. In
the other hand, in the present study, some flaps
have required further precautions. Regarding the
submental flaps, cautious excision of the submandibular
gland and avoiding submental vessels
injury on its superior surface and level 1B lymph
node dissection (submandibular L.N.) so achieving
a thorough lymphadenectomy. In the present study,
cervical dissection was done in these cases with
cautious pedicle dissection and contralateral submental
flap was not needed except in two cases.
This agree with the review of Urjeet et al., regarding
the oncological safety of the submental flap when
used post oral malignancy and did not report any
compromise of oncologic outcome. Also, random
anteriorly based cervical flap did not show any
vascular compromise with thorough cervical Lymph
node dissection and considered compatible with
cervical dissection [1]. Furthermore, in agreement
with Binelfa LF in 2010, pedicled latissimus dorsi
flap has the privilege of being outside the radiation
field if prior radiotherapy was used. So, it provides
tissues not exposed for radiation and the flap itself
A B C
D
Egypt, J. Plast. Reconstr. Surg., July 2018 391
not affected cervical dissection before reconstruction.
Hence, it is considered an oncologically
compatible flap [1].
Technical considerations:
Technical considerations were reported in the
cases of the current study. The abilities of a flap
to cover defects completely regarding its size, arc
of rotation or distal point reach are considered
critical to achieve the target of reconstruction. The
present study revealed that the pedicled latissimus
dorsi flap showed the unique potential to cover
extensive large defects, distal reach point and great
arc of rotation which is consistent with Binelfa
[11] in the other hand, Agbara et al., reported that
the forehead flap can provides distal reach of
adequate tissue both from internal oral lining and
external cover that can be used to cover defects to
the level of the lower mandibular border [12].
However, in the present study none of forehead
flap was found to reach beyond the midface. Nasolabial
flap was reported by Multani et al., [3] as
an ideal source for nasal reconstruction and the
flap can reconstruct outer or inner lining of nasal
defects in consistence with the current study. As
regards to the safety to harvest island submental
flap, during excision of the submandibular gland
it must be performed with attention to the submental
vessels on the superior glandular surface otherwise
the pedicle could be injured [1]. In the present
series, the proximal part of facial artery was injured
and ligated in one case but the flap blood supply
was not compromised as the flap received reversed
flow from the distal part of the facial artery. Also,
in seven supmental flaps, we used a mylohyoid
muscle as a calf to protect the pedicle with easier
technique and better survival. This modification
was supported by Urjeet et al., [1] as a useful
modification. In consistent to the current study,
the ability to separate the pedicled latissimus dorsi
into two vascularized paddles due to early division
of the thoracodorsal vessels provided full thickness
cheek reconstruction privilege which enhance the
fabrication property of this flap in agreement with
Binelfa [11]. Another factor was experienced in
deltopectoral flap which is the technical simplicity
with thin and pliable skin paddle. The same comment
was concluded by Bey et al., in their work
in 2009 [14]. The simple operative technique of
anteriorly based cervicofacialflap motivated Agbara
et al., to use that flap in a series of cases as it was
a good option for cheek reconstruction [12]. Island
flaps are technique sensitive and may be time
consuming in dissection of the pedicle but the time
decline with learning curve. Deltopectoral, nasolabial
and forehead flaps did not show technical
difficulty nor being time consuming operation
regarding their dissection. In anteriorly based
cervicofacial flaps, the time was consumed in
careful dissection and meticulous hemostasis.
Tollefson et al. reported that undermining of the
flap should be sufficient to avoid closure under
tension. Also, the risk of hematoma could be reduced
by meticulous hemostasis [13].
Regarding the need for a second stage, Quillen
and Ariyan identified the role of single-stage pedicled
flap in head and neck reconstruction the late
1970s [11].
In the current study, pedicled non-island flaps
like deltopectoral, forehead and some nasolabial
flaps that usually have needed other stage for
pedicle separation and flap refinement. However,
this was not a sharp role with these flaps. Four
cases of deltopectoral flaps in the present study
were converted into single stage procedures to
save another procedure in critically ill patients by
cutting the skin between the defect and the flap to
let the proximal part of the flap, nearby the pedicle,
be included in the neck skin circumference. In the
other hand, island flaps, that are traditionally single
staged, may need second stage for cutting the
tethered pedicle after adequate local flap revascularization.
Also, two random flaps needed second
stage for dog ear removal and aesthetic flap refinement.
Aesthetic considerations:
Modern head and neck reconstruction tends to
have more cosmetically appealing results in order
to preservation of the original form of those reconstructed
areas [1]. Rotunda AM et al., [15] concluded
in their work that nose is one of the most challenging
reconstruction in the facial areas and most
demanding to obtain an optimal functional and
esthetic results. Color matching is one of the most
important characters in the selection of the reconstructing
flap. Multani et al., reported in their
review that nasolabial flaps in nasal reconstruction
were the ideal source regarding color, nature and
texture match. Furthermore, donor site morbidity
is minimal owing to placing its scar along the
nasolabial fold [3]. In the present study, also, we
reported maximal color, nature and texture match
with nasolabial flap in nasal reconstruction when
achievable. The same results were shown by Hagerty
et al., [16] for partial nasal reconstruction.
Bakamjian et al., revealed the high suitability of
deltopectoral flap for head and neck defects covering
due to the similarity of color and texture of
skin with hidden donor site [8,17]. We agreed with
the results of Bakamjian except in some males
392 Vol. 42, No. 2 /OTAF Score: A Novel Scoring System for Selection of an Ideal
with hairy chests. In these cases, deltopectoral
flaps showed some nature and hair bearing mismatch
when used in reconstruction of non-hair
bearing head and neck areas. Two cases necessitated
laser hair ablations of the transported flap area
after lip reconstruction which solved this problem.
In the other hand, men underwent tongue reconstruction
using submental flap in the current study
complained from hair growth in the newly reconstructed
tongue which was completely disappeared
by the end of the first year. In consistence with
our results, cheek reconstruction by latissimus
dorsi flap is characterized by little hair contained
in the skin of the flap donor site [18]. The submental
flap was de-epithelialized by Rahpeyma at the time
of inset to eliminate the hair follicles surgically
[19]. the anteriorly based cervicofacial flap is a
good option for cheek reconstruction due to its
proximity to the surgical area, and easily elevation
and insetting to the reconstructed area. The flap is
thin, pliable flap, usually has not required other
donor site graft and resulted in an acceptable scar
[12]. In the current study, each flap with suitable
contour was selected for each defect. Submental
flaps were found thin and were used for intraoral
reconstruction. However, Pedicled latissimus dorsi
flap were found to be bulky and were suitable in
extensive cheek reconstruction. Deltopectoral flap
showed an average contour for medium thickness
defects.
Functional considerations:
Normal or near normal functional result either
in the recipient or donor site is a golden target in
modern head and neck reconstruction. The present
study evaluated this target in three parameters i.e.
global facial function, specialized sites function
(i.e. oral cavity, nasal cavity, tongue or eye lids
according to the reconstructed part) and donor site
function as well.
Reliable restoration of facial function is a continuing
challenge in head and neck reconstruction
[20]. The unique anatomic association of the facial
skin with the close underlying muscles allow the
emotional expression and social interaction. Depending
on the thickness of the used flaps in the
current study, the thin flaps like nasolabial and
cervical flaps have achieve better facial function
preservation [9]. Bulky flaps such as pedicled
latissimus dorsi flaps have impeded facial expression
however their more reliability to compensate
the extensive defects. In consistent to this result,
depending on the flap thickness, Peng et al., reported
that anteriorly based cervicofacial flap is a
good candidate for cheek coverage as it is a thin
and pliable flap [21]. Also, Jangpreet and his colleagues
reported in their review that deltopectoral
flap were suitable coverage for head and neck skin
defects and nasolabial flap are the ideal source
was nasal reconstruction [22]. Regarding donor site
functional affection, deltopectoral flaps reported
beter functional results at the donor site than pedicled
latissimus dorsimyocutanous flaps [18]. This
result was comparable to the current study however,
the pedicled latissimus dorsi flap has not markedly
affected the shoulder function but with a patient
was using crutches to support walking,he suffered
some shoulder disability for a time after latissimus
dorsi transfer. In other case, we preferred to use
deltopectoral flap than pedicled latissimus dorsi
flap to reconstruct a large post parotidectomy defect
as the patient was an old woman suffering from
cerebrovascular strock with right hemiparesis. The
goal was to preserve her left shoulder function and
not affecting it if any myocutaneous flap has been
used.
Conclusion:
OTAF scoring system can be used as a simplified
systematic method of flap selection for post
malignancy head and neck reconstruction through
using oncological, technical, aesthetic and functional
considerations. Individualized selection for
each case still has its place however further evaluation
and modifications of this scoring system is
essential to maximize the results of our reconstructive
tools.