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Superficial Versus Deep Plane Dissection Of Cervicofacial Flaps For Cheek Reconstruction: A Systematic Review And Meta-analysis For Rates Of Complications
Minh NQ Huynh, MD1, Sorush Rokui, BSc2, Matthew McRae, MD, MHSc1.
1McMaster University, Hamilton, ON, Canada, 2University of British Columbia, Vancouver, BC, Canada.

Purpose:
Cervicofacial flaps represent an excellent option for coverage of cheek defects secondary to oncologic resection, trauma or infection. However, there remains clinical equipoise regarding whether superficial plane (SP) or deep plane (DP) dissection results in the lowest rates of complications and optimal outcomes. Proponents of DP dissection cite reduced rates of flap necrosis, ectropion, or hematoma formation. In contrast, SP dissection has been cited to have similar rates of complications, shorter operating time, and less risk of facial nerve injury.
This systematic review aims to evaluate outcomes of SP and DP for cheek reconstruction to determine if superficial plane dissection is non-inferior to deep plane dissection with respect to complications and patient outcomes.
Methods:
A systematic review across Pubmed, MEDLINE, Embase, CENTRAL, CINAHL and Cochrane Database of Systematic Reviews databases (from date of inception to October 2019) was conducted. Original research assessing cohort outcomes of cheek reconstruction using cervicofacial flaps with SP, DP or both was included. Outcome measures included flap necrosis, ectropion, hematoma formation, facial nerve injury, and requirement for further operative or non-operative intervention. A meta-analysis of proportions was conducted to examine the pooled rates of complications.
Results:
Of 881 citations identified for review, 10 met the inclusion criteria. In total, 284 patients received SP (mean age= 64.8 yrs, mean defect size= 26.3 cm2) while 40 patients received DP (mean age= 69.3 yrs, mean defect size= 24.1 cm2).
Overall, reported rates of complications were low for cervicofacial flaps. The proportion of necrosis, ectropion, and hematoma were 2.71% (95% CI: 0.00-10.65%, I2=0.80, p=0.01), 2.95% (95% CI: 0.00-8.18%, I2=0.56, p=0.01), and 0.01% (95% CI: 0.00-2.91%, I2=0.20, p=1), respectively. No cases of facial nerve injury were reported.
Sub-group analysis demonstrated comparable rates of complications between superficial and deep plane dissection. The rates of: necrosis was 3.96% (95% CI: 0-13.46%, I2=0.85, p<0.01) and 0.26% (95% CI: 0.00-18.67%, I2=0, p=0.57); ectropion 3.82% (95% CI: 0.27-9.79%, I2=0.66, p<0.01) and 1.22%, (95% CI: 0.00-15.05%, I2=0.20, p=0.0.28); and hematoma were 0.01% (95% CI: 0.00-0.03%, I2= 0.34, p=0.16) and 2.63% (95% CI: 0.00-13.61%, I2= 0.00, p=1.00) for SP and DP, respectively. Other complications (e.g. hypertrophic scarring, wound healing difficulty) were noted with low incidence.
Conclusions:
Superficial plane dissection of cervicofacial flaps exhibit similar rates of complications to deep plane dissection. However, published literature is limited regarding deep plane dissection. Further studies elucidating the role of dissection depth for cervicofacial flaps, with direct comparison, are required to better assess the advantages of superficial and deep plane dissection.


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