The pectoralis major myocutaneous flap in head and neck reconstruction. Analysis of complications

Extended Pedicled Perforator Plus Submental Flap for Large Cheek Defect Reconstruction

The submental flap is an alternative repair technique in the maxillo-facial region when microsurgical reconstruction is not required or is difficult to apply. The purpose of this study was to illustrate the benefits of restoring the cheeks with an extended pedicled submental flap.

Method

Eight patients aged 58 to 81 years with cheek cancer presented to the surgery department at the Benha University Hospital in Egypt, from May 2019 to October 2021 for the removal of their tumors and reconstruction of the resulting defects, using the extended submental perforator plus pedicled artery flap.

Results

The average blood loss was 250 cm³ (range: 50-400 cm³). The average operation took 3 hours to complete, including excision and rebuilding (a range of 2.5 to 3.5 hours). The length of the postoperative hospital stay was 2 to 4 days. Fortunately, there was no complete flap loss; nonetheless, distal flap necrosis in one case left a raw area, which was allowed to heal naturally, and hemorrhages in two cases were conservatively handled.

Conclusions

For the reconstruction of cheek abnormalities, the submental flap is a viable alternative, particularly in older patients or patients whose overall health has declined and who need less severe therapies and quicker surgery. The submental flap, which conceals the donor site, provides a dependable supply of skin for facial resurfacing with excellent color, shape, and texture matching. The flap is quick, and easy to raise.

A Meta-analysis of Complication Rates Among Various Surgical Modifications of Pectoralis Major Myocutaneous Flap

The purpose of this study is to aggregate and summarize the complication rates among various modified techniques of pectoralis major myocutaneous flap harvesting. Various databases were searched from its inception to September 2020. Studies describing surgical management of head and neck oncologic reconstruction using pectoralis major myocutaneous flap and its surgical modifications were included in study. All included studies: (1) described a pectoralis major flap harvesting technique categorized by author as conventional technique, bipaddle or bilobed flap, segmental flap, flap transfer using subclavicular route, skin paddle over Pectoralis Major, Flap with Multiple vascular supply, U shaped skin paddle, modified short incision technique; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total 183 studies were included. Segmental flap (0.20%), flap with multiple vascular supply (5.18%) and parasternal skin flap (6.38%) had the highest rates of total complications and were the only techniques to show a statistically significant increase in odds ratio compared with conventional technique (odds ratio 1.89, 9.05 and 7.26, respectively, P < 0.05). Bipaddle flap (57.48%) and u shaped skin flap (78.05%) show statistically significant decrease in odds ratio as compared to conventional technique. Among all the modifications in surgical technique of pectoralis major myocutaneous flap harvesting bipaddle flap and u shaped skin flap show least total complication rates. But on the contrary rates of partial flap necrosis and fistula are significantly higher in bipaddle flap as compared to conventional technique. As such, the choice of surgical technique should primarily be made based on the defect size, patient selection and surgeons' discretion rather than the presumed complication rate.

Tracheal Rupture After Tracheostomy Tube Exchange in a Patient With Recurrent Oral Cavity Spindle Cell Carcinoma

Oral Cavity Spindle Cell Carcinoma (OCSCC) is a rare variant of squamous cell carcinoma involving the nasopharynx and oral mucosa. This tumor has a high propensity to invade local structures of the head and neck region, making surgical removal challenging and potentially morbid for the patient. Here, we report a case of OCSCC and the complications that were confronted during its surgical resection. Additionally, a review of the literature regarding OCSCC complications and their treatments was performed.

Colgajo submentoniano en la reconstrucción de cabeza y cuello

Introducción. Los colgajos del territorio de la arteria submentoniana pueden ser utilizados como un colgajo cutáneo, musculofacial y osteocutáneo, realizando cierres primarios del defecto del sitio donante, sin generar defectos funcionales ni estéticos mayores. Métodos. Describir la experiencia de nuestro equipo quirúrgico, las complicaciones relacionadas con el uso del colgajo y los resultados oncológicos, así como los desenlaces tardíos durante el seguimiento de los pacientes incluidos en el estudio. Resultados. Se incluyeron veintiún pacientes, con una edad media de 66 años (rango 52 - 86), con patología oncológica de lengua, labio inferior, paladar blando, nariz, órbita y orofaringe. Todos los pacientes fueron sometidos a disección selectiva ipsilateral del cuello, tras la extracción del colgajo y en todos los casos se preservó el nervio mandibular marginal. Se registraron complicaciones como la necrosis parcial. La estancia hospitalaria media fue de 8 días. Conclusiones. El colgajo de la arteria submentoniana ha mostrado resultados favorables debido a su uso versátil, amplio arco de rotación, color y baja morbilidad del sitio donante. Se recomienda realizar estudios más robustos, que incluyan la experiencia de diversos especialistas en países que compartan las mismas limitaciones técnicas y características sociodemográficas.

Technical Considerations and Outcome Analysis of Using Extended Bipaddle Pectoralis Major Myocutaneous Flaps for Reconstructions of Large and Complex Oral Cavity Defects: Expanding the Horizons

Reconstruction of large and complex defects arising from resection of advanced oral cancers requires free flaps or multi-staged reconstructions using a combination of pedicled flaps. Bipaddle (pectoralis major myocutaneous (PMMC) flap is a good alternative for reconstruction of such defects, especially in low-middle-income countries (LMIC). However, care should be taken while expanding its limits to avoid unnecessary morbidity. We discuss technical considerations while extending the PMMC flap design beyond the usual boundaries and analyse surgical and quality of life (QOL) outcomes in our patients with large (≥ 10 cm) oral cavity defects while using extended bipaddle PMMC flaps. We retrospectively analysed the results of 72 oral cancer patients with large buccoalveolar defects with at least one dimension ≥ 10 cm who underwent single-stage reconstruction using extended bipaddle PMMC flaps between January 2018 and December 2019. Total flap loss was seen in one patient and partial loss in 10 (13.8%) patients, while 18 (25.1%) patients had major complications (Clavien-Dindo grade III). Discharge from hospital was delayed beyond a mean of 6 days in 15 (20.8%) patients and the start of adjuvant treatment was delayed in 5 patients (6.9%). On univariate analysis, age > 50 years, female gender, the largest dimension and flap area were significant factors increasing morbidity. The QOL outcomes were acceptable. The satisfactory results from our series reaffirm that extended bipaddle PMMC flaps are a viable alternate option for such reconstructive challenges in resource-limited centres. However, age, gender, the defect dimensions and flap area should be taken into consideration while using this flap.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-021-01345-1.

Use of Single Chimeric Free Flaps or Double Free Flaps for Complex Head and Neck Reconstruction

BACKGROUND

 Free flaps have become the preferred reconstructive approach to restore form and function for patients presenting with complex head and neck defects. For composite, complex defects for which a regular free flap might not meet all reconstructive demands, adequate coverage can be achieved with either a single chimeric free flap or a double free flap.

METHODS

 We performed a single-center retrospective chart review of patients who underwent either single chimeric free flap or double free flap reconstruction. Indications for reconstruction included defects resultant from head and neck tumor or osteoradionecrosis resections. We extracted the following variables: tumor location, defect, flap(s) performed, and postoperative complications. Unpaired t-tests were performed to evaluate for statistically significant differences in complications encountered between the single chimeric versus the double free flap patient groups.

RESULTS

 In our series of 44 patients, a total of 55 single chimeric and double free flaps were performed. We found no significant difference in overall complications (p = 0.41) or flap/skin paddle loss (p = 0.45) between the groups. There were three total flap losses; two patients underwent successful salvage procedures and one patient died. The anterolateral thigh (ALT) was the most common free flap (70%) used in our series, and 98% of our patients completed successful reconstruction.

CONCLUSION

 As the initial reconstructive effort is critical for achieving favorable long-term outcomes in complex head and neck cases, effective and safe techniques should be employed to ensure optimal delivery of care. We believe that single chimeric and double free flap techniques should be appropriately utilized as part of the armamentarium of head and neck reconstructive microsurgeons.

Bilobed PMMC in Females: Our Challenging yet Meritorious Experience

The gold standard reconstructive options for full-thickness defect of the oral cavity after resection of malignant lesions are the free flaps. But in developing nations due to resource constraints, it cannot be offered to all. Hence, pectoralis major myocutaneous (PMMC) flap as bilobed flaps is most commonly used. Bilobed flaps are technically demanding, and in females, it is more challenging due to higher complication rates especially in large breasts. There has been no major reported data evaluating outcomes of bilobed PMMC in females. This is a retrospective evaluation of outcomes of patients who underwent the bilobed PMMC flap reconstruction for full-thickness defect of the oral cavity after resection of malignant lesions from June 2018 to December 2019. Out of 80 patients, all patients ultimately had adequate tissue coverage for the defect with acceptable facial aesthetics. Functional outcomes with regards to oral continence, speech and swallowing were encouraging. Our study had 33.75% flap-related complications. Fifteen percent of patients developed varying degrees of flap loss, of which only 3.75% had total flap loss and 11.25% had partial flap loss which was managed accordingly. Our study concludes that with careful planning, raising of flap based on sound anatomic concepts and applying oncoplastic techniques, shortcomings of bilobed female PMMC can be addressed and still used as suitable alternatives for free flap for full-thickness oral cavity defects in limited resource settings.

Analysis of the efficacy of the pectoralis major myocutaneous flap in reconstructive head and neck surgery

INTRODUCTION

Although free flaps have been used predominantly in past decades for the soft tissue reconstruction of head and neck malignancies, Pectoralis major myocutaneous flap (PMMF) is still a reliable workhorse for patients with co-existing co-morbidities or low economic status where free flaps are not feasible.

PATIENTS AND METHODS

It was a retrospective study done on 36 patients of head and neck malignancies over the period of 5 years in which PMMF was used as a method of reconstruction in our hospital. Patients were followed up for a period of one year and outcome of PMMF was evaluated.

RESULTS

Out of 36 patients 31 were of oral cancer and 5 were of carcinoma hypopharynx. Incidence of total flap necrosis was nil and partial flap necrosis was 16.6%. Orocutaneous fistula was found in 16.6%, wound dehiscence was in 19.4% and infection was found in 13.5% of patients. Non-flap related complications were found in 13.8% of patients. 35 out of 36 patients (97.2%) eventually achieved satisfactory surgical outcome of PMMF reconstruction.

CONCLUSION

PMMF is a reliable method of reconstruction for head and neck malignancies especially in basic healthcare settings. With minimal expertise and groundwork, it is still a cost-effective workhorse flap for head and neck reconstruction.

Submental Artery Island Flap in Oral Cavity Reconstruction. An Observational, Retrospective Two-centre Study

Introduction  The submental flap provides an alternative technique in orofacial reconstruction, especially in situations in which free flaps are not available, or the patients are unfit. Objective  To demonstrate the oncological safety and benefits of this flap in oral cavity reconstruction. Methods  A total of 14 patients with oral cavity cancers, who underwent submental flap reconstruction from January 2016 to January 2018, were included in the study. Results  There were 11 male and 3 female patients with a mean age of 66.7 ± 14 (Min: 52/Max: 91) years old. The most common primary tumor site was the mobile tongue in 12 (85.7%) patients. All of the patients underwent ipsilateral selective neck dissection after the flap was harvested. Flap partial necrosis was observed in one patient, and total necrosis in another one. The mean follow-up was of one year. Nonlocal or regional recurrences were observed. Conclusion  Submental island flap represents a good option in oral cavity reconstruction in a restricted setting or in patients considered not fit for free flap reconstruction. Preoperative selection of clinically neck node-negative patients is essential due to the potential risk of occult metastasis.

Reconstruction of a Pharyngeal Cutaneous Fistula Using a Bi-Paddled Pectoralis Major Flap for a Patient with a Possibility of Future Postoperative Radiotherapy

BACKGROUND Pharyngocutaneous fistulas are often difficult to treat because pharyngeal contents tend to leak into the cervical layer causing wound infections or abscesses. If reconstruction with free flaps is difficult, pedicled pectoralis major flaps are an option. CASE REPORT A 51-year-old male patient who had undergone radiation and chemotherapy for laryngeal cancer was scheduled for total laryngectomy with combined skin resection for local tumor recurrence. Reconstruction with a left deltopectoral (DP) flap was performed. However, a pharyngocutaneous fistula constructed due to cervical soft-tissue infection required reconstruction using a right bi-paddled pectoralis major muscle. The anterior pharyngeal wall was reconstructed with the medial skin island, and the lateral skin island was folded back to reconstruct the soft tissues. Since this was the patient's third recurrence, the possibility of subsequent local recurrences, and hence of the need for radiation therapy, were high. In such cases, the pedicle of the pectoralis major muscle flap is normally closed using a DP flap. However, in the present case, the DP flap had already been used on both sides. We therefore utilized a right bi-paddled pectoralis major flap for cervical reconstruction. CONCLUSIONS We successfully reconstructed the cervical skin and soft tissue thickly, and primarily-closed the donor site, by creating a second skin island from surplus areas of the existing skin island. This method is particularly useful for the reconstruction of cervical skin and soft tissues due to the possible need for future radiation therapy, when the use of free flaps and DP flap is unfeasible.

The Use of Pectoralis Major Musculocutaneus and Deltopectoral Flaps in Oromandibular Defects Reconstruction

The main complication in patients with combined treatment of head, neck, mandibular and maxillary tumors is osteoradionecrosis, which appears after radiation therapy. Radiation therapy is widely used to treat cancer, but growing concern is related to the risk of osteoradionecrosis after treatment. This can occur after radiation therapy. Below, we would like to describe the treatment of osteoradionecrosis, which appeared 5 years after radiation therapy in a 54-year-old male patient. In 2012, a patient in Turkey was diagnosed with adenocystic carcinoma of the tongue base, and surgery was performed to remove the tumor after the patient underwent a course of radiotherapy. In 2016, the patient underwent again a surgery for tumor recurrence. In December 2017, the patient was admitted to our clinic with osteoradionecrosis. We performed segmental resection of the mandible, type I right-sided modified neck dissection, reconstruction of the mandible with a titanium plate and a pectoralis major muscle skin flap. The technique described in this case is the insertion of a well-vascularized tissue into the pre-irradiated and necrotic hypovascular region of the mandible with a skin-muscle flap of the pectoralis major muscle wrapped around the plate for reconstruction. As a result, a pectoralis major flap coverred the mouth floor on internal side and the outside skin defect was covered with a deltopectoral one. The viability of the skin-muscle flap of the pectoralis major muscle was assessed using clinical monitoring, checking the flap every four hours for the first 3 days. This study describes a successful outcome.

Submental Island Flap versus Free Flap Reconstruction for Complex Head and Neck Defects

Objective

Complex soft tissue reconstruction of the head and neck requires a viable, versatile, and dependable flap. Free flaps, such as the radial forearm and anterolateral thigh flap, have been the mainstay of complex head and neck reconstruction. However, a local pedicled flap, such as the submental island flap (SIF), could be a more effective and less demanding alternative. This systematic review and meta-analysis aim to compare free tissue transfer (FTT) with the SIF for head and neck reconstruction.

Data Sources

We performed a systematic search in PubMed and EMBASE databases. Meta-analysis was performed on outcomes reported in ≥3 studies.

Review Methods

Candidate articles were assessed for eligibility by 2 authors. Three authors performed data extraction and methodological quality of the included studies using the Newcastle-Ottawa Quality Assessment Form for Cohort Studies.

Results

The search strategy resulted in 450 studies, of which 7 were included in the analysis, yielding 155 SIF and 198 FTT cases. Operating time and length of stay were significantly lower for the SIF than for FTT ( P = .05 and P = .0008). There was no significant difference between the groups for complete flap loss, debulking revisions, and oncologic recurrence.

Conclusion

These results suggest that the SIF reduces length of stay and operating time as compared with FTT in head and neck reconstruction. These findings suggest that the SIF can be considered an alternative reconstructive option to FTT when evaluating intraoral, lateral facial, skull base, and parotidectomy defects, given comparable defect size and tumor biology.

Submental island flap reconstruction for carcinoma of the oral cavity: Experience in 30 cases

Objective

The submental flap can be utilized for soft tissue reconstruction in oral cavity malignancies because due to its close approximation to the surgical site, fewer donor site morbidity and the cost effectiveness of the procedure.

Methods

A total of 30 patients with squamous cell carcinoma of the oral cavity were included in the study from July 2012 to August 2015 in a tertiary care referral hospital. Patients with clinical staging I/II/III (T1/T2/T3, N0) oral malignancy were included in the study. Patients with nodal metastasis irrespective of the stage of disease and patients with chronic medical illness/revision cases were excluded from the study. Submental island flap was utilized for the reconstruction of the soft tissue defect in each patient. Patients were followed at monthly interval till 6 months in the postoperative period.

Results

The buccal mucosa (12 patients), tongue (10 patients) and floor of mouth (8 patients) were the subsites in the oral cavity. Partial and complete skin necrosis was found in 4 and 2 patients respectively. Postoperative chemoradiation was required in 5 patients. None of the patients had loco regional recurrence till 6 months of follow-up.

Conclusion

The submental island flap is considered to be the reliable option for the soft tissue reconstruction in oral cancer because of dependent vascular pedicle, less donor site morbidity and the lower cost compared to the free flaps, often preferred in patients with a lower socioeconomic condition.

Unusual and Unique Variant Branches of Lateral Cord of Brachial Plexus and its Clinical Implications- A Cadaveric Study

INTRODUCTION

Adequate knowledge on variant morphology of brachial plexus and its branches are important in clinical applications pertaining to trauma and surgical procedures of the upper extremity.

AIM

Current study was aimed to report variations of the branches of the lateral cord of brachial plexus in the axilla and their possible clinical complications.

MATERIALS AND METHODS

Total number of 82 upper limbs from 41 formalin embalmed cadavers was dissected. Careful observation was made to note the formation and branching pattern of lateral cord. Meticulous inspection for absence of branches, presence of additional or variant branches and presence of abnormal communications between its branches or with branches of other cords was carried out.

RESULTS

In the present study, we noted varied branching pattern of lateral cord in 6 out of 82 limbs (7%). In one of the limb, the median nerve was formed by three roots; two from lateral cord and one from medial cord. Two limbs had absence of lateral pectoral nerve supplemented by medial pectoral nerves. One of which had an atypical ansa pectoralis. In 2 upper limbs, musculocutaneous nerve was absent and in both cases it was supplemented by median nerve. In one of the limb, coracobrachialis had dual nerve supply by musculocutaneous nerve and by an additional branch from the lateral cord.

CONCLUSION

Variations of brachial plexus and its branches could pose both intraoperative and postoperative complications which eventually affect the normal sensory and motor functions of the upper limb.

Reconstruction in oral malignancy: Factors affecting morbidity of various procedures

AIMS AND OBJECTIVE

(1) To study the age and sex distribution of patient with oral malignancies. (2) To analyze various types of surgery performed. (3) Evaluation of reconstruction and factors affecting complications and its relation to the type of reconstruction.

MATERIALS AND METHODS

Cases of oral malignancies, undergoing surgery for the same in Sri Aurobindo Medical College and PG Institute, Indore from the period from October 1, 2012, to March 31, 2015.

RESULTS

Out of analysis of 111 cases of oral malignancy, 31 (27.9%) cases were in the fifth decade of life with male to female ratio 1.9:1. The commonest site of cancer was buccal mucosa. Forty-seven cases (43.2%) were in stage IVa. Diabetes was the most common co-morbidity reported, accounting for 53.9% of cases with reported morbidity. Tobacco chewing was the common entity in personal habits. All the cases underwent neck dissection along with resection of the primary. Hemimandibulectomy was the most preferred form of primary resection accounting for 53.15% (59 cases), followed by wide resection of primary 27% (30 cases). Pectoralis major myocutaneous (PMMC) flap only was the most common reconstruction across the study population. PMMC alone accounted for 38.7% (43 cases). The infection rate was 16.21%. PMMC alone accounted for 5 out of 18 (27.8%) of total infection rate, and 4.5% of the total study population. PMMC + deltopectoral accounted for 5 out of 18 (27.8%) of total infection rate, and 4.5% of the total study population.

CONCLUSION

PMMC is a major workhorse for reconstruction with better functional outcome and acceptance among operated patients.

Case Reports of Two Unusual Donor Site Complications of the Pectoralis Major Myocutaneous Flap and Literature Review

The pectoralis major myocutaneous flap (PMMF), once considered a workhorse flap for head and neck reconstruction, is still used for a wide range of head and neck reconstruction in the era of microvascular free tissue transfer flap (MFTF) for many reasons including low donor site morbidity. Numerous studies have reported the flap-related complications of PMMF in depth but have seldom discussed the donor site complications in detail. This article reports 2 unusual donor site complications and reviews the published data on general donor site complications resulting from PMMF use.

The adequacy of lymph node harvest in concomitant neck block dissection and submental island flap reconstruction for oral squamous cell carcinoma; a case series from a single Egyptian institution

BACKGROUND

Squamous cell carcinoma (SCC) is a fairly common tumor of the oral cavity. This tumor may affect any part of the mucosa of the oral cavity especially the tongue, the floor of the mouth and lips. The encountered intra-oral defects after tumor resection are often large and require climbing up the reconstruction ladder to more complex reconstructive options for accepted functional and cosmetic results to be achieved. However, most of the patients are old with medical co-morbidities requiring fast, simple, less morbid reconstructive option such as local flaps. The myocutaneous submental island flap has emerged as a simple and fast reconstructive technique that provides thin, pliable tissue with adequate volume and reliable blood supply. However, one major concern regarding the utility of the submental flap for repair of post-ablative tumor defects is the presumed interference with adequate lymph node neck dissection.

METHODS

In this study, we present a cohort of thirty-six consecutive patients who were operated for oral SCC. All patients were offered submental island flap reconstruction of their resultant defects together with ipsilateral selective neck block dissection of levels I, II, III and IV; and the nodal yield of each level was tested pathologically.

RESULTS

Nodal harvest was ≥ 12 in 88 % of the patients. Complications were encountered in two patients (5.5 %).

CONCLUSION

Our data suggest that adequate cervical lymph nodes dissection, specifically level I and II cervical lymph nodes, can be fulfilled with concomitant submental island flap elevation.

A technical note about flap fixation technique to prevent salivary fistulas in reconstructive oral cavity surgery

Salivary fistulas are frequent complications in oral oncological reconstructive surgery by means of pedicled or free flaps. The most common risk factors are malnutrition, advanced disease, and healing alterations due to radiation therapy or infections. However, they can be observed also in healthy patients where the flap suture breakdown is the only cause. During the reconstructive phase, flaps are anchored to the remnant tongue, hyoid bone, and residual gingival mucosa; the last structure often does not offer suitable margins for a strong suture. The aim of this study was to propose a transmandibular fixation of the flap that allows, in a safe, efficient, and unexpensive way, the creation of a saliva-proof neofloor of the mouth, independently from the quality and thickness of residual gingival mucosa.

Extended pectoralis major myocutaneous flap in head and neck reconstruction

Although the pectoralis major myocutaneous flap is often used in head and neck reconstruction, the extension of the skin paddle beyond the inferior limits of the muscle has not been well described. We aim to clarify the design and application of this extended flap in head and neck reconstruction. In this retrospective study, consecutive cases of extended pectoralis major myocutaneous flap reconstruction of post-ablative head and neck defects at a single tertiary referral center were included for analysis. In 7 cases an extended pectoralis major flap was utilized, in which the skin paddle was extended beyond the inferior border of the pectoralis major to include the rectus sheath. Skin and soft tissue as well as composite defects of the oral cavity, parotid/temporal region and neck were reconstructed. All flaps healed satisfactorily with no loss of skin viability. The extended pectoralis major myocutaneous flap is robust and has versatile applications for reconstruction of large, high and three dimensionally complex defects in the head and neck region.

Soft tissue reconstruction after hemimandibulectomy in oral malignancies: a retrospective study

AIMS

The present study was under taken to evaluate the efficacy of various local and regional soft tissue flaps used for reconstruction after excision of various malignant lesions of the mouth and also to evaluate complications with length of hospital stay after the reconstruction.

MATERIALS AND METHODS

The study was a record based retrospective analysis of 127 patients who were histologically proven squamous cell carcinoma of the oral cavity for which excision of the lesion along with segmental mandibulectomy and primary reconstruction with local or regional flaps was the treatment modality.

RESULTS

The male:female mean age is 48.27:48.79. The Z-proportionality test for intra oral reconstruction showed 5% level of significance (P < 0.05) between pectoralis major myocutaneous flap (PMMC) and other flaps. Difference between deltopectoral (DP) and PMMC, PMMC and primary closure at 1% level of significance, i.e. P < 0.01 was found for extra oral defects. The mean stay was found to be 31.31 days. Recurrence rate of 11% was reported.

CONCLUSION

A total of 127 patients formed the study group. In the absence of bone reconstruction PMMC still continues to be the "work horse" of reconstruction following wide excision and hemimandibulectomy.

Improved skin paddle survival in pectoralis major myocutaneous flap reconstruction of head and neck defects

OBJECTIVE

To examine our outcomes with skin paddle survival using pectoralis myocutaneous flaps in reconstruction of the head and neck. The pectoralis major myocutaneous flap has been associated with a notable incidence of distal skin necrosis and flap loss. Our experience has been favorable compared with that reported in the literature.

METHODS

Retrospective medical record review of 81 cases of pectoralis major muscle flap reconstruction performed in 78 patients from 1995 to 2008 using a flap harvest technique that is slightly different from the classic descriptions. Data were obtained regarding coexisting health conditions and perioperative complications, which were divided into major and minor categories. Major complications were defined as total flap failure or greater than 25% skin paddle loss. Minor complications and donor site complications included fistulas that were managed conservatively, wound dehiscence not requiring additional surgery, local infections, seromas, and hematomas.

RESULTS

Of the 81 flaps performed, 22 complications were encountered. Total flap loss was not encountered in any patient. The overall major complication rate in myocutaneous flaps was 3 of 76 (4%), with these cases consisting of significant skin paddle loss. Minor complications occurred in 14 of 81 myofascial and myocutaneous flaps (17%). Donor site complications of the chest wall occurred in 5 of 81 flaps (6%).

CONCLUSIONS

Skin paddle necrosis may be minimized with modifications of the classic technique. We believe that extension of the skin flap over the rectus sheath is the cause of distal skin flap necrosis. The pectoralis major myocutaneous flap remains a valuable reconstructive option in the head and neck.

Management of Salivary Fistulas After Microvascular Head and Neck Reconstruction

Salivary fistulas after head and neck microvascular reconstruction are difficult problems whose treatment remains controversial. Although aggressive, early operative intervention has been suggested by some groups, we have found that many patients respond to conservative management with bedside debridement and aggressive local wound care. The purpose of this study was, therefore, to review our experience with the management of postoperative salivary fistulas.

METHODS

A retrospective review was performed and all patients who developed a salivary fistula after microvascular head and neck reconstruction over a 7-year period at Memorial Sloan-Kettering Cancer Center were identified and evaluated.

RESULTS

Six hundred thirty-seven patients underwent reconstruction during the study period. Of these, 35 patients developed a postoperative salivary fistula (5.4%). The majority of patients (81%) who developed fistulas shortly after the index procedure (<30 days) were successfully treated with conservative management. Similarly, 50% of late salivary fistulas (>30 days) responded to bedside debridement and wound care. There were no significant differences in the rate of total flap loss, carotid artery blowout, delay in onset of adjuvant radiation therapy (>6 weeks), or return to oral feeds between the conservative and operatively managed groups.

CONCLUSIONS

Aggressive surgical intervention in early postoperative salivary fistulas is usually not necessary, although the treatment plan should be individualized. Bedside debridement and aggressive wound care are adequate in most cases of early salivary fistulas. This approach is not associated with an increased rate of complications.

Pectoralis major musculocutaneous flap with nipple-areola complex in head and neck reconstruction: preliminary results of a new modified method

Pectoralis major musculocutaneous flap remains the workhorse tool for head and neck reconstruction. Flap failure in head and neck reconstruction is a devastating complication with a high morbidity and mortality. Inclusion of nipple-areola complex on the skin paddle stabilizes the blood circulation in the skin island of the pectoralis major musculocutaneous flap. A modified use of pectoralis major musculocutaneous flap with nipple-areola complex on the skin island was performed in 11 male patients in head and neck reconstructions with success without partial or total skin island necrosis. We recommend the inclusion of nipple-areola complex on the skin island of the pectoralis major musculocutaneous flap in head and neck reconstructions to increase the blood supply of the skin paddle. We concluded that the skin island of the pectoralis major musculocutaneous flap might include the areola and nipple complex in patients with large defects of the head and neck, which stabilize the blood circulation in the skin island.

How we do it: Regular infusion of local anaesthetic in the pedicle of pectoralis major myocutaneous flap to shorten hospitalization of surgically treated head and neck cancer patients

Keypoints *Regular infusion of the flap with local anaesthetic for 6 days postoperative via an indwelling catheter is easy. *It does not cause any complications. *It shortens hospitalization by 7 days. *The necessary catheter is readily available.

Endoscopic assisted harvest of the pedicled pectoralis major muscle flap

The Pectoralis Major flap is a reliable and versatile flap for head and neck reconstruction. However, it is associated with donor site scarring on the anterior of the chest wall. Endoscopic assisted harvest of a pedicled pectoralis major muscle flap was performed on three patients for head and neck reconstruction. The average incision length was 4.5 cm, the average time taken to harvest the muscle was 37 min. All patients were discharged from hospital on the 5th to 8th postoperative day and one patient had a seroma. Endoscopic harvest of the pedicled Pectoralis major muscle flap minimises postoperative scarring.

Vascular Compromise of the Pectoralis Major Musculocutaneous Flap in Head and Neck Reconstruction

In head and neck reconstructive surgery, the pectoralis major musculocutaneous flap is a major reconstructive tool, both in primary as well as secondary reconstructions. In a few cases the authors have been able to demonstrate that when the pectoralis major musculocutaneous flap is translocated to the mouth through a noncompromised neck tunnel, as is done for head and neck reconstructions, the taut lateral pectoral nerve is seen to compress the vascular pedicle of the flap, adversely affecting its vascularity, which can lead to partial or total necrosis of the flap. The authors explain this feature, very specific to this flap, with the help of a prospective series of patients.

Critical oropharyngocutaneous fistulas after microsurgical head and neck reconstruction: indications for management using the "tissue-plug" technique

Despite advances in head and neck reconstruction with free-tissue transfer techniques, oropharyngocutaneous fistulas continue to present challenging and potentially lethal complications. The authors present a system for prioritizing these fistulas and the surgical management of nine patients in whom critical fistulas developed after microsurgical head and neck reconstruction. The indications for aggressive management of these fistulas were primarily dependent on their location. Three peristomal and six midneck fistulas were considered critical because of the risk of aspiration pneumonia and carotid artery blowout, respectively. Fistulas located in the submental and/or submandibular region were considered noncritical and were managed conservatively. Using the concept of a "tissue plug" for fistula repair, a dermal component (i.e., a deltopectoral or pectoralis major pedicled flap) is guided through the fistula, and with external traction the tissue "plugs" the tract. No sutures are placed directly in the surrounding friable tissue. There were no partial or total flap losses. There were two fistula recurrences in patients who had received postoperative radiation therapy. One of these recurrences was due to tumor recurrence within the previous fistula and was managed with palliative measures. The other fistula recurrence was closed with a local-flap procedure on an outpatient basis. All patients resumed oral feeding, except for the patient in whom tumor recurrence was suspected. This tissue-plug technique can be used in the management of critical peristomal and/or midneck oropharyngocutaneous fistulas not only to obliterate the tract but also to augment volume and vascularity in already damaged, ischemic, and deficient tissue.

[Pedicled pectoralis major musculocutaneous flaps]

A retrospective series of 76 pedicled pectoralis major musculocutaneus flaps is presented. We used this technique in reconstruction after head and neck tumours resections and in complications of oncological surgery such as pharyngostomes or orostomes. Most of these flaps were used in reconstruction of oral cavity and in postradiotherapy salvaje surgery cases. We also analyse the presence of complications at the donor and receiver sites and its correlation with different parameters like protein levels, haemoglobin, administration of radiotherapy and its dose, previous quimiotherapy and the influence of systemic diseases.

Early wound complications in advanced head and neck cancer treated with surgery and Ir 192 brachytherapy

OBJECTIVES

Brachytherapy, either as primary or adjuvant therapy, is increasingly used to treat head and neck cancer. Reports of complications from the use of brachytherapy as adjuvant therapy to surgical excision have been limited and primarily follow Iodine 125 (I125) therapy. Early complications include wound breakdown, infection, flap failure, and sepsis, and late complications may include osteoradionecrosis, bone marrow suppression, or carotid injuries. The authors sought to identify the early wound complications that follow adjuvant interstitial brachytherapy with iridium 192 (IrS92).

STUDY DESIGN

A retrospective chart review of all patients receiving adjuvant brachytherapy at a tertiary medical center over a 4-year period.

METHODS

Nine patients receiving Ir192 brachytherapy via afterloading catheters placed during surgical resection for close or microscopically positive margin control were evaluated. It was used during primary therapy in six patients and at salvage surgery in three. Early complications were defined as those occurring within 6 weeks of surgical therapy.

RESULTS

The overall complication rate was 55% (5/9), and included significant wound breakdown in two patients, minor wound dehiscence in three, and wound infection, bacteremia, and local tissue erosion in one patient each. All complications occurred in patients receiving flap reconstruction and one patient required further surgery to manage the complication. Complication rates were not associated with patient age, site, prior radiotherapy, timing of therapy, number of catheters, or dosimetry.

CONCLUSIONS

The relatively high complication rate is acceptable, given the minor nature of most and the potential benefit of radiotherapy. Further study should be undertaken to identify those patients who will achieve maximum therapeutic benefit without prohibitive local complications.

The indications and complications of pectoralis major myocutaneous flap reconstruction in head and neck surgery-our experience

Most of the head and neck cancer patients in India present to the Otolaryngologist, Head and Neck surgeon in the advanced stages of their disease. Extensive resection followed by acceptable morphological & functional reconstruction is the goal for the surgeon. Use of the pectoralis major myocutaneous (PMMC) flap enables extensive ablative procedures to be carried out followed by immediate and reliable reconstruction. Thirty consecutive cases of biopsy proven squamous cell carcinoma of the head and neck region were studied. All underwent extensive resection of the tumour with pectoralis major myocutaneous flap reconstruction, with preor post-operative external irradiation. This study concentrates on the indications for and complications encountered with the use of the pectoralis major myocutaneous flap. Also included is an extensive review of the literature relating to the complications encountered with the use of this method of reconstruction.

Pectoralis major myofascial flap: a valuable tool in contemporary head and neck reconstruction

BACKGROUND

The pectoralis major myofascial (PMMF) unit is rapidly mobilized, reliable, and extremely useful in a number of clinical situations calling for vascularized soft-tissue coverage in the head and neck. Although free-tissue transfer has emerged as the preferred method of reconstruction for a large variety of defects in the head and neck, the pectoralis major muscle should be considered when vascularized soft-tissue coverage is required in this area.

METHODS

A retrospective chart review of 24 PMMF flaps performed at the University of Iowa Hospitals and Clinics between January 1, 1991, and May 1, 1996, was undertaken. Outcomes were evaluated relative to accomplishing the established preoperative surgical goals.

RESULTS

Utilization of the PMMF flap was grouped according to four primary indications: (1) protection of threatened great vessels or free flap vascular pedicles in situations of wound breakdown due to fistula or infection (7 cases); (2) vascularized soft-tissue coverage of great vessels or free-flap vascular pedicles and prevention of potential wound breakdown in surgical defects in which compromised healing was anticipated (7 cases); (3) closure of small pharyngeal defects (2 cases); or (4) vascularized coverage of the mandible following debridement for osteoradionecrosis (8 cases). The PMMF flap was 100% successful when the surgical goal was to protect exposed vascular structures and promote wound healing in the presence of fistula or infection. The PMMF flap was 100% successful in the protection of vascular structures and prevention of wound breakdown in cases where compromised wound healing was anticipated. The PMMF flap provided closure, and a vascularized surface for mucosalization, when used to primarily reconstruct small pharyngeal defects. The PMMF flap provided definitive closure in 5 of 8 (62.5%) cases of osteoradionecrosis of the mandible when it was used to invest the remaining mandibular bone. Three of 8 cases (37.5%) required further surgical management and were considered failures. An acceptable cosmetic outcome was obtained in women undergoing this procedure by using an inframammary incision. The preoperative goal of the PMMF flap procedure was met in 21 of 24 (87.5%) cases. There was a major complication rate of 12.5% as well as a minor complication rate of 12.5%.

CONCLUSION

In cases requiring the protection of vital vascular structures from infection, salivary secretions or skin flap breakdown, the PMMF flap should be considered. The PMMF flap is an excellent reconstructive option in selected clinical situations, where vascularized soft-tissue coverage is required in the head and neck.

Is the pectoralis myocutaneous flap in intraoral and oropharyngeal reconstruction outdated?

METHODS

Our experience with 224 immediate pectoralis major myocutaneous flap reconstructions in patients with carcinomas of the oral and oropharyngeal cavities is presented.

RESULTS

Although flap-related complications developed in 53% of the patients, all flaps survived, and we had no major skin paddle loss. The incidence of reoperation due to flap-related complications was 2%. All other complications were minor and did not affect the length of hospitalization. Analysis showed no significant risk factors for the development of complications. Because of fistula formation, infection, or metal exposure, plate removal was necessary in 10% of the AO fixation plates used in cases of mandibular swing. This occurred in 68% of the anterior and 22% of the lateral mandibular reconstructions performed with a reconstruction plate (P < 0.05).

CONCLUSIONS

We conclude that a reconstruction plate is unsatisfactory for anterior mandibular continuity reconstruction and debatable for lateral mandibular reconstruction. At present, anterior defects are reconstructed with free vascularized osteocutaneous flaps that should probably also be used for lateral mandibular reconstruction. Furthermore, in a large number of series, it is reported that free flaps also have high complication rates and 5-10% flap loss. As all pectoralis major flaps survived in our series, it still remains a good choice in intraoral and oropharyngeal reconstruction when there is no necessity to reconstruct bone.

Reconstruction of facial soft tissues after resection of skin tumors

The aim of the present study was to analyse the results of various reconstruction techniques of the facial skin with regard to general parameters such as the patients' age and health condition and to surgical parameters such as defect size, contamination of surgical fields and the type of reconstruction. 273 cases were evaluated, comprising local flaps (217), island flaps (21), free skin grafts (22) and cutaneous or myocutaneous distant flaps (13). The overall rate of major complications was 13.5%. No correlation was found with the age or impaired health of the patients nor did contamination by oral/nasal bacterial flora or the type of restoration show any significant correlation. The size of the defect turned out to be the only variable significantly related to the occurrence of complications (p = 0.0108). The complication rate observed following the repair of defects smaller than 30 mm in diameter was 7.5% while it rated 19.1% following the repair of defects larger than 30 mm. The overall rate of partial or total flap necrosis was low (2.9%). Secondary corrections and further surgical re-entry were required in 4.7% of all patients.

Reliability of microvascular free flaps in head and neck reconstruction

Reliable reconstructive techniques are essential in the surgical treatment of head and neck cancer patients. Free flaps have often been used as reconstructive options of last resort in the head and neck because of the need for added technical skill, a longer operating time, and a perception of poor reliability. This study reviews our experience with 39 free flaps performed by the Otolaryngology-Head and Neck Surgery Service. For the first 17 cases, an interrupted anastomotic technique was used; a running technique was performed in the remaining 22 cases. The average total ischemic time (3.7 vs. 2.7 hours; p < 0.001) was significantly less with a running technique. There were 10 complications: 7 minor would problems, 1 death from aspiration without surgical wound/flap problem, and 2 cases requiring second flaps (1 flap necrosis, 1 fistula with healthy free flap). No statistical correlation was found between complications and ischemic time, suture technique, age, or hospital (five hospitals). Free flaps are reliable and may obviate the need for sacrifice of trunk muscles for wound closure (e.g., fascicocutaneous free flaps instead of myocutaneous flaps); therefore we recommend revascularized free flaps as the primary mode of reconstruction for head and neck defects.

The effects of extended perioperative pentoxifylline on random skin flap survival

PURPOSE

This study was designed to determine the effects of long-term perioperative pentoxifylline administration on random skin flap survival in an appropriate animal model. A secondary objective was to document bioavailability of pentoxifylline in the animal model by measuring blood levels of parent compound and metabolites at regular intervals and comparing these to levels measured in humans.

MATERIALS AND METHODS

A randomized control study of the effects of oral pentoxifylline on the survival of "random" skin flaps was conducted at the animal care facility of an academic tertiary referral center on six randomly selected Yorkshire pigs. Oral pentoxifylline was administered daily to four pigs for 3 months, and two pigs received placebo. Pentoxifylline blood levels for each experimental animal were measured after 4, 8, and 12 weeks of daily dosing. Blood viscosity, fibrinogen, and hematocrit were measured for each of the six animals on day 1, day 30, day 60, and day 91. On day 91, 12 surgical random skin flaps were elevated on each of the six animals and immediately sewn back in the donor bed. Pentoxifylline dosing was continued for 2 weeks, and placebo was continued in control animals. On postoperative day 15, all animals were killed and all flaps were measured individually for area of viability. The outcome measure was the detection of statistically significant increase in survival area in skin flaps of those animals administered perioperative pentoxifylline.

RESULTS

No significant augmentation of flap survival was noted in experimental animals when compared with those in the control group; no significant difference was noted between or within groups of experimental animals. Pentoxifylline and metabolite blood levels in all experimental animals at every interval were noted to be comparable to those documented in human studies; metabolite concentrations conformed to expected patterns as observed in humans. No significant alterations of blood viscosity, fibrinogen, or hematocrit were measured in the experimental animals when compared with those in the control group. The only animal showing mean flap survival outside the 95% confidence interval was one in the control group.

CONCLUSION

No augmentation of random skin flap survival could be shown in the pig model after a 3 month regimen of daily oral pentoxifylline. Blood levels of pentoxifylline in experimental animals were compared with those documented in humans. No alteration of blood viscosity, fibrinogen, or hematocrit was noted in any of the experimental animals when compared with each other or with those in the control group.

Comparison of the rectus abdominis free flap with the pectoralis major myocutaneous flap for reconstructions in the head and neck

The pectoralis major myocutaneous flap (PMMF) is often used in the reconstruction of large head and neck defects. Unfortunately, its use is associated with a high incidence of minor complications, can distort the contour of the neck, and may cause significant donor site deformity, especially in women. This study compared 30 patients with major head and neck cancer-related defects who underwent reconstruction with a rectus abdominis free flap (RAFF) with 39 patients with similar defects who underwent reconstruction with the PMMF. The complication rate found in the RAFF group (13%) was significantly lower than that found in the PMMF group (44%; p = 0.0145). Flap necrosis was found in 10% of the PMMF group, whereas none was found in the RAFF group. The aesthetic outcome was also better in patients who had reconstructions with the RAFF. We conclude that, for most major head and neck defects, reconstruction methods that utilize the RAFF and other free tissue transfer techniques are preferable when the requisite equipment and expertise are available.

The latissimus dorsi flap in head and neck reconstructive surgery: a review of 121 procedures

The results of a prospective study of 121 latissimus dorsi flaps performed during head and neck reconstructive surgery at the Royal Marsden Hospital are presented. Three-quarters of the flaps were pedicled and one-quarter were free. All the patients underwent surgery for malignant disease. The flap failure rate was 5%, other flap related complications occurred in 19% and the overall rate of complications was 26%. Previous radiotherapy, site of reconstruction, type of flap (free or pedicled) and age of the patient were not significant risk factors. Men were more likely to have a complication than women.

Pectoralis major myocutaneous flap: analysis of complications in a VA population

Forty-five cases of head and neck reconstruction with pectoralis major myocutaneous flaps (PMMF) between 1985 and 1990 were analyzed retrospectively for complications. Thirty-two cases were done at the VA Medical Center and 13 at Albany Medical Center, a private university hospital. Total complication rate was 58%. In the VA population, complication rate was 59% as compared to 54% at the Albany Medical Center, which appears statistically not significant. It has been suggested that VA populations tend to have poorer health and socioeconomic status and are more likely to have higher complication rates. This conjecture is not borne out by this study. Complications are described and compared.

An improved technique for development of the pectoralis major myocutaneous flap

The pectoralis major myocutaneous flap is the most commonly employed muscle skin transfer used in soft-tissue reconstruction of defects of the upper neck and jaw region. This article presents conceptual and technical changes in the development of the pectoralis major myocutaneous flap that preserve a greater vascular pedicle and enhance the flap's arc of rotation. Data from 54 consecutive cases using this modified approach show a reduction in complications, a greater range of use, and consistent healing in radiated and nonradiated tissues without requiring sectioning or removing the clavicle or causing significant chest deformities. These modifications have produced a more predictable transfer compared with other reported techniques.