Bilobed PMMC in Females: Our Challenging yet Meritorious Experience

Dumbbell-Shaped Bipaddled Pectoralis Major Myocutaneous Flap for Composite Commissural Defects: A Defect-Driven Modification

Pectoralis major myocutaneous flap (PMMF) has been a workhorse in orofacial reconstruction. Although microvascular tissue transfer has gained popularity in major tertiary centers, several infrastructural factors limit its use in many facilities, particularly in developing countries with high caseloads. Numerous modifications have been made to the PMMF since its inception. Here, we present a novel technique for reconstructing composite commissural defects with PMMF by modifying the skin paddle design to a dumbbell shape. Both ends of the paddle are used to line intraoral and extraoral defects, while the constricted middle portion recreates the commissure. We report the outcomes of a cohort of 7 patients treated at our institution, describing the modified PMMF design, harvesting, and in-setting techniques used in oral carcinoma cases involving the commissure. We have detailed the study outcomes for each patient, including the various complications related to the flap, donor, and recipient sites.

The pectoralis major myocutaneous pedicled flap-Its past and current practice in a dedicated microsurgery service. Review of the literature, and debunking controversies

BACKGROUND

The pectoralis major myocutaneous pedicled (PMMP) flap is still considered by many a workhorse flap in head and neck (H&N) reconstruction, despite free flap surgery advancing. The authors aimed to examine this claim and associated myths and controversies by analyzing literature trends and revealing the role of the PMMP flap in a well-established microsurgery center.

METHODS

The senior author's reconstructive H&N practice between 1995 and 2022 was reviewed to describe and critically judge primary and secondary PMMP flap decisions to provide invaluable lessons learned and debunk common controversies related to complex H&N reconstruction. A literature review from 1978 to 2022 evaluated PMMP flap articles from plastic surgery and allied H&N specialties, with a deeper analysis on publications from 2010 onward.

RESULTS

In 27 years of practice, the senior author performed 2871 major H&N reconstructions, including 27 PMMP flaps. Both primary (13/27) and secondary (14/27) PMMP flaps decreased over time. Indications shifted from external skin compromise (fistulae/metastases) to complex medical morbidity and high-risk neck status. Neck status was increasingly evaluated based on any previous violation, surgical or irradiative, rather than simply number of remaining vessels. A literature review revealed an ongoingly abundant and primary PMMP flap use, largely by non-plastic surgeons.

CONCLUSION

The PMMP flap can and should be reserved for complex, high-risk or free flap-exhausted cases. Thus, current indications deserve redefinition. Multidisciplinary collaboration in specialized centers with plastic surgeons is imperative to ensure appropriate reconstructive rational and protect patient outcomes, as changing reconstructive hands and starting anew risks reconstructive regression.

Ipsilateral Cervicodeltopectoral Flap: A Forgotten Technique, Revival in the Era of Microvascular Reconstruction

Oral cavity cancer is one of the most common cancers in India responsible for significant morbidity and mortality in Indian subcontinent. Majority of cases present in advanced stages which requires extensive reconstruction following tumor resection. Microvascular free flap reconstruction is now considered standard of care for reconstruction for major head and neck skin-mucosal defects but, many factors still act as hindrance like patient's comorbidities, long operating hours for microvascular reconstruction, logistic and financial issues from patient's side. In such situation it is better to have a backup plan for reconstruction of major head and neck defects using pedicled flaps. Pectoralis major myocutaneous (PMMC) flap has been the workhorse flap for head and neck reconstruction since its introduction four decades ago. But relying too much on PMMC flap for major skin-mucosal defects especially in female patients is associated with complications and risk for flap failure leading to catastrophic and significant patient morbidities. Our study involves the use of two flaps for head and neck reconstuction involving skin-mucosal defects i.e PMMC flap for mucosal defect and cervicodeltopectoral (CDP) flap for skin defect. As of now there has been no retrospective or prospective study done which has given a conclusive statement regarding use of these two flaps simultaneously for head and neck reconstruction to the best of our knowledge. In our experience from the present study, CDP flap offers an excellent alternative for extensive head and neck reconstruction and can be readily included in the surgeon's armamentarium with proper planning and meticulous handling.

Submammary Approach for Harvesting Pectoralis Major Myocutaneous Flap in Females with Oral Cavity Cancers: Report of Technique and Our Experience

Background

Oral squamous cell carcinoma is one of the most common types of cancers affecting both male and female population worldwide. Currently gold standard for reconstruction of oral cavity defects is free flap reconstruction. However, in developing countries due to large case load, infrastructural and resource constraints, Pectoralis major myocutaneous flap is still widely being used. Harvesting PMMC flap in females is challenging due to thick fat and breast tissue affecting its reliability and also increased donor site morbidity. This article aims at highlighting our experience with harvesting PMMC flap in female patients by submammary approach and its outcomes.

Methods

A total of 23 female patients who underwent wide local excision of oral cavity cancers and reconstruction with PMMC flap were included. Data was analysed as mean, median, mode, percentages and statistical averages.

Results

Majority of patients belonged to 40-60 years of age group (60.86%). Buccal mucosa was the most common site of primary lesion in 16 patients (69.56%). Out of the 23 patients who underwent PMMC flap reconstruction, recipient site complications were seen in 4 patients including total flap loss in 2 patients (8.69%), minor complications, e.g. infection in 2 patients (8.69%). Donor site morbidity in the form of axillary seroma was seen in only 1 patient (4.34%).

Conclusion

In our experience, PMMC flap is still a viable option for reconstruction especially in resource constraint settings. Submammary approach to PMMC flap harvest is a safe technique as it is associated with minimum recipient site complications whilst preserving donor site anatomy and thereby reducing donor site morbidities to minimum.