An improved technique for development of the pectoralis major myocutaneous flap

Identification of Novel Surface Landmarks for Inframammary Pectoralis Major Myocutaneous Flap- A Prospective Single Centre Study

The inframammary skin paddle design of pectoralis major myocutaneous flap (PMMCF) is versatile with significant merits. However, lack of early identification of the vascular pedicle poses a risk on the flap integrity. This study aims to establish stable surface landmarks for identification of the pectoral branch of thoraco-acromial artery (PB-TAA), the chief vascular pedicle in PMMCF. A prospective observational study was planned and inframammary design of PMMCF was harvested to reconstruct defects secondary to oncologic resection of cancers of gingivobuccal complex. The mid-nipple line (NL) and xiphoid line (XL) were the proposed surface anatomical landmarks. The horizontal distance between the pedicle traversing in the deep surface of the pectoralis major muscle and the NL was measured. It is a single center prospective study. A total of 63 patients were included in the study. The distance of the PB-TAA from the NL was found to be 1.18 ± 0.48 cm medially and 0.8 ± 0.19 cm laterally. The mean differences between the medial and lateral pedicle locations were statistically significant (p < 0.01). This study suggests that the NL could prove to be a standard surface anatomical landmark for identification of vascular pedicle in inframammary skin paddle design of PMMCF.

Distal positioning of the skin paddle of pectoralis major myocutaneous flap in head and neck reconstruction

BACKGROUND

To assess outcomes of pectoralis major myocutaneous flap (PMF) wherein the skin paddle (SP) was positioned with its distal portion extending beyond the lower border of pectoralis major by ≥2 cm (PMF-d).

METHODS

Consecutive head and neck reconstructions with PMF-d (n = 110). SP dimensions l2 (distal extent below the lower border of pectoralis major), l1 (proximal extent above lower border of pectoralis major), and b (breadth) were recorded. Endpoints were SP necrosis, recipient dehiscence, early fistula, and persistent fistula.

RESULTS

Median values of l2 , l1 , and b were 3.0, 6.0, and 6.0 cm, respectively. When l2  = 2.0-3.0 cm, SP necrosis occurred in only one (1%) subject (with obesity). When l2 was ≥3.5 cm, necrosis occurred in four (16%) subjects, three of whom also had l1 /l2  < 2.0 (proximal SP < 67% of entire SP). Statistically, increased l2 was the only risk factor for necrosis (p = 0.001). Overall, incidence of recipient dehiscence, early fistula, and persistent fistula were 32 (29%), 20 (20%), and 3 (3%), respectively. Persistent fistula occurred only in the setting of SP necrosis and/or re-irradiation.

CONCLUSION

Careful patient selection, adequate proximal SP, and l2  = 2.0-3.0 cm is associated with a negligible risk of necrosis. The enhanced reach and laxity and additional skin surface area and soft tissue volume conferred with PMF-d facilitate recipient wound healing.

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.

A Modified Design of the Pectoralis Major Myocutaneous Flap for Reconstruction of Head and Neck Defect

ABSTRACT

Even though the pectoralis major myocutaneous flap (PMMF) still has an important role in the free flaps ear, it is reported to have drawbacks such as the limited cephalad extension and high incidence of total or partial flap necrosis. Various modifications have been attempted to augment the limited cephalad extension and a stable blood supply.The aim of this study is to describe a modified design of the skin paddle and preparation of the PMMF, to achieve stable blood circulation and sufficient pedicle length. The priority skin paddle is the medial part for its stable blood supply, and the lateral margin should be adjusted as needed. During the harvesting, the lateral thoracic artery (LTA) is preserved to protect the perforating branches, and the anterior sheath of the rectus abdominis muscle is used as a suture margin to prevent damage of the thin muscle of the PMMF. The skin paddles in this study are larger than those previously reported. All of the 21 patients in our study, the skin paddles show complete survival with no partial necrosis of skin paddle, fistula, or wound dehiscence.It is worthwhile to consider and preserve the LTA as a major contributor to a lateral and distal PMMF. This study would be useful in future and preparation of the PMMF in head and neck reconstruction.

Pectoralis Major Myocutaneous Flap for the Reconstruction of the Palatal Defect

It is always a challenge for the soft tissue reconstruction of the palatal defects in advanced malignancies of the oral cavity because of the higher chance flap failure. PMMC flap can be successfully used in patients with advanced malignancies to repair the palatal defect without any significant postoperative complication. In the present case, we have presented a case of malignant melanoma of gingivobuccal complex, involving the hard palate where the palatal defect was successfully reconstructed by the PMMC flap.

Pectoralis Major Myocutaneous Flap Reconstruction for the Mandibular Defects in Advanced Oral Cavity Malignancies: A Retrospective Study of 30 Cases

To evaluate the utility of the pectoralis major myocutaneous (PMMC) flap for the reconstruction of the mandible in advanced oral cavity malignancies in the Indian population. It was a retrospective study contained 30 patients with advanced oral cancer from July 2012 to August 2016. The PMMC reconstruction was done in all the patients to repair the bony defects in segmental/hemi mandibulectomy. The patients were followed up for a mean period of 6 months in the postoperative period and the utility of the PMMC flaps were evaluated. The mean age of the patients was 45 years (range 30-63 years). The average Karnofsky performance status score was 70 and majority of the patients had history of chronic medical illness. Of the 30 PMMC flaps, partial necrosis of the skin was noticed 2 (06.66%) patients. Orocutaneous fistula was detected in 2 (06.66%) patient and 3 (10%) patients presented with wound dehiscent in the immediate postoperative period. 3 (10%) patients had recurrence of the disease. PMMC flap can be a reliable option for advanced oral malignancies, especially in patients with poor status with the coexisting chronic illness. Due to the presence of a definite vascular pedicle, ease of harvesting the flap, quick surgical procedure, and the minimal postoperative morbidities, it can be considered as a valid alternative to the free flap to repair the bony defect, especially in patients with low socioeconomic corridor like India.

Crossed pectoralis major myocutaneous flap for recurrent oral cavity cancers

Background:

Oral cavity cancers are fairly common and have propensity to recur locally. Since Pectoralis Major Myocutaneous (PMMC) flap is the most widely used first flap for reconstruction, it is exhausted at the earliest and recurrence poses a formidable challenge for reconstructive surgeon. Present study evaluated the feasibility of contralateral Pectoralis Major Myocutaneous Flap for reconstruction after resection of recurrent tumour.

Methods:

This was a study of the patients presenting with recurrent oral cavity cancer after exhausted ipsilateral Pectoralis Major Myocutaneous Flap (PMMC) in whom we used contralateral Pectoralis Major Myocutaneous Flap (Crossed PMMC Flap) for reconstruction between October 2013 to June 2016.

Results:

Five patients with recurrence underwent reconstruction with contralateral Pectoralis Major Myocutaneous Flap. In all the flap was successfully used to reconstruct defects involving the entire buccal mucosa and in one patient the flap could be used to reconstruct full thickness resection defect(crossed bipedal PMMC Flap) with ease.

Conclusion:

Crossed Pectoralis Major Myocutaneous Flap can be used safely and reliably for reconstruction of the buccal mucosal defect and in selected patients even for full thickness cheek defect as folded bipaddle Pectoralis Major Myocutaneous Flap.

Extending the Arc of Rotation of the Pectoralis Major Myocutaneous Flap for Orofacial Reconstruction via a Modified Subclavicular Route Through the Clavipectoral Fascia

PURPOSE

Drawbacks of the conventional supraclavicular overlay of the pectoralis major myocutaneous flap (PMMF) include the resultant unesthetic cervical bulge and the limited cephalad extension that limits its use to mandibular or cervical defects. This study discusses the technique and comparative advantages of a more esthetic subclavicular route through the clavipectoral fascia that allows an increased arc of rotation to reconstruct orofacial defects.

MATERIALS AND METHODS

Patients with orofacial defects that were reconstructed with a PMMF through the modified subclavicular route were included in this retrospective cohort study, which aimed to compare the gain in extension accorded through the modified subclavicular tunnel over an initial conventional supraclavicular overlay. Outcome variables included the dimension of each skin paddle and the cross-sectional area of each flap. Other variables, such as age and gender, also were investigated. Complications that arose from this technique were statistically compared with these variables and with those from previously reported studies. All data analyses were performed using Pearson χ² and correlation tests.

RESULTS

Twelve patients (7 women and 5 men) who underwent a primary reconstruction with the PMMF during a 1-year period from November 2010 to November 2011 were selected for this study. All 12 flaps survived; 3 developed minor postoperative complications that resolved within the 3-month review period. A PMMF with an average dimension of 12.75 × 6.0 × 3.725 cm and cross-sectional area of 20.65 cm² could pass through this modified tunnel, achieving an average gain in extension of 3.2 cm that enabled the reconstruction of defects up to and above the level of the oral commissure. Apart from skin paddle dimension, all other variables were not found to be statistically related to the extension accorded by the modified route. Complications that occurred appeared to be related only to the cross-sectional area of the flap.

CONCLUSION

The increased cephalad extension afforded by this modified subclavicular route through the clavipectoral fascia permitted the reconstruction of orofacial defects that would otherwise have required free vascularized grafts with microvascular surgery and avoided the unesthetic cervical bulge from conventional supraclavicular overlays of the PMMF.

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.

Enhanced morbidity of pectoralis major myocutaneous flap used for salvage after previously failed oncological treatment and unsuccessful reconstructive head and neck surgery

Introduction. The reconstruction of complex cervicofacial defects arising from surgical treatment for cancer is a real challenge for head and neck surgeons, especially in salvage reconstruction surgery and/or failed previous reconstruction. The pectoralis major myocutaneous flap (PMMF) has been widely used in these specific situations due to its reliability and low rate of failure or complications. Objectives. Identify factors that determine complications and influence the final outcome of the reconstructions with PMMF in salvage cancer surgery or in salvage reconstruction. Methods. A cross-sectional study design was used to evaluate a sample including 17 surgical patients treated over a period of ten years that met the inclusion criteria. Results. Reconstruction was successful in 13 cases (76.5%), with two cases of partial flap loss and no case of total loss. Complications occurred in 13 cases (76.5%) and were specifically related to the flap in nine instances (52.9%). An association was identified between the development of major complications and reconstruction of the hypopharynx (P = 0.013) as well as in patients submitted to surgery in association with radiation therapy as a previous cancer treatment (P = 0.002). The former condition is also associated with major reconstruction failure (P = 0.018). An even lower incidence of major complications was noted in patients under the age of 53 (P = 0.044). Conclusion. Older patients, with hypopharyngeal defects and submitted to previous surgery plus radiation therapy, presented a higher risk of complications and reconstruction failure with PMMF.

Surgical Approach and Laser Applications in BRONJ Osteoporotic and Cancer Patients

Bisphosphonates-related Osteonecrosis of the Jaw (BRONJ) has been reported with increasing frequency in literature over last years, but its therapy is still a dilemma. One hundred ninety patients affected by BRONJ were observed between January 2004 and November 2011 and 166 treated sites were subdivided in five groups on the basis of the therapeutical approach (medical or surgical, traditional or laser-assisted approach, with or without Low Level Laser Therapy (LLLT)). Clinical success has been defined for each treatment performed as clinical improvement or complete mucosal healing. Combination of antibiotic therapy, conservative surgery performed with Er:YAG laser and LLLT applications showed best results for cancer and noncancer patients. Nonsurgical approach performed on 69 sites induced an improvement in 35 sites (50.7%) and the complete healing in 19 sites (27.5%), while surgical approach on 97 sites induced an improvement in 84 sites (86.6%) and the complete healing in 78 sites (80.41%). Improvement and healing were recorded in 31 (81.5%) and 27 (71.5%) out of the 38 BRONJ sites treated in noncancer patients and in 88 (68.75%) and in 69 (53.9%) out of the 128 in cancer patients.

Evaluation of the pectoralis major flap for reconstructive head and neck surgery

Purpose

The pectoralis major myocutaneous flap (PMMF) is a commonly used flap in reconstructive head and neck surgery, but in literature, the flap is also associated with a high incidence of complications in addition to its large bulk. The purpose of the study is the evaluation of the reliability and indication of this flap in reconstructive head and neck surgery.

Patients and methods

The records of all patients treated with a PMMF between 1998 and 2009 were systematically reviewed. Data of recipient localization, main indication, and postoperative complications were analyzed.

Results

The male to female ratio was 17:3, with a mean age of 60 years (45-85). Indications in 7 patients were recurrence of a squamous cell carcinoma, in one case an osteoradionecrosis and in 12 cases an untreated squamous cell carcinoma. In 6 male patients (30%), a complication appeared leading to another surgery.

Conclusion

The PMMF is a flap for huge defects in head and neck reconstructive surgery, in particular when a bulky flap is needed in order to cover the carotid artery or reconstructive surgery, but the complication rate should not be underestimated in particular after radiotherapy.

Injectable biomaterials for regenerating complex craniofacial tissues

Engineering complex tissues requires a precisely formulated combination of cells, spatiotemporally released bioactive factors, and a specialized scaffold support system. Injectable materials, particularly those delivered in aqueous solution, are considered ideal delivery vehicles for cells and bioactive factors and can also be delivered through minimally invasive methods and fill complex 3D shapes. In this review, we examine injectable materials that form scaffolds or networks capable of both replacing tissue function early after delivery and supporting tissue regeneration over a time period of weeks to months. The use of these materials for tissue engineering within the craniofacial complex is challenging but ideal as many highly specialized and functional tissues reside within a small volume in the craniofacial structures and the need for minimally invasive interventions is desirable due to aesthetic considerations. Current biomaterials and strategies used to treat craniofacial defects are examined, followed by a review of craniofacial tissue engineering, and finally an examination of current technologies used for injectable scaffold development and drug and cell delivery using these materials.

Reconstruction of defects caused by bisphosphonate-induced osteonecrosis of the jaws

Reconstructive surgery of defects for any disease or injury including bisphosphonate-induced osteonecrosis of the jaws requires an understanding of the pathophysiology of the condition. Related to bisphosphonates, it is the apoptosis (programmed cell death) of the osteoclast that inhibits, and in some cases stops, bone renewal/remodeling altogether. Therefore, reconstruction begins with a debridement of resection considering this mechanism. For intravenous bisphosphonate-induced osteonecrosis defects of the mandible, most resections are immediately reconstructed with a rigid titanium plate provided that secondary infection is controlled, there is sufficient soft tissue present, and a resection margin containing variable bone marrow can be achieved. For some similar defects with significant secondary infection, a delayed rigid plate placement after the recipient site has healed and is infection free represents another option. In those defects in which there is a significant soft tissue loss, flap reconstruction may also be necessary. The pectoralis major myocutaneous flap is the most predictable and most commonly used flap, followed by the trapezius myocutaneous flap, and stemocleidomastoid flap. Bone graft reconstructions are rarely needed, and are often not indicated due to minimal benefit for the patient, anesthetic risks, or active cancer at metastatic sites. However, in selected cases, mostly for breast cancer or prostate cancer patients with continuity defects from intravenous bisphosphonate-induced osteonecrosis, standard cancellous marrow grafting with platelet-rich plasma growth factor supplementation has been successful. Maxillary resections are treated with prosthodontic obturators as they are in primary cancer surgery. Reconstruction of oral bisphosphonate-induced osteonecrosis defects usually takes the form of alveolar grafting and/or dental implant placements, and only rarely requires grafting of continuity defects. Standard grafting techniques and dental implant placements can be used if guided by the published serum C-terminal telopeptide (CTX) test. The guidelines are less than 100 pg/mL = high risk, 100 pg/mL to 150 mg/mL = moderate risk, and greater than 150 pg/mL = minimal risk.

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.

Three-Dimensional Anatomical Vascular Distribution in the Pectoralis Major Myocutaneous Flap

BACKGROUND

In head and neck reconstruction, the pectoralis major myocutaneous flap, located adjacent to the area of reconstruction, is a very useful and easy-to-prepare flap. However, it is reported to have an unstable blood circulation that could result in partial necrosis of the skin island. The current study investigated the detailed three-dimensional vascular network in the flap to establish a method of preparation with a stable circulation.

METHODS

The pectoralis major muscle and the anterior chest skin on 12 sides of eight fresh cadavers were subjected to angiographic procedures in which contrast medium was injected selectively to the internal thoracic artery and the thoracoacromial artery. On another fresh cadaver, resin was injected in the same manner, and a clear specimen of the pectoralis major myocutaneous flap was prepared.

RESULTS

The pectoralis major muscle consists of two anatomical vascular territories that the choke vessels in the muscle at the level of the fourth costal cartilage divide into cranial and caudal sides. The chest skin area on the caudal side where the skin island of the flap is prepared receives its blood supply from a dense anastomotic network formed by the fourth, fifth, and sixth intercostal perforating branches.

CONCLUSIONS

The blood flow in the pectoral branch of the thoracoacromial artery runs through the choke vessels that dilate at the elevation of the pectoralis major myocutaneous flap, first into the fourth intercostal perforating branches; then to the anastomotic vascular network of the fourth, fifth, and sixth intercostal perforating branches; and finally to reach the periphery of the skin island.

"Mandibular and facial reconstruction" rehabilitation of the head and neck cancer patient

Cancer surgery and its reconstruction today can result in functional and cosmetically supportive results for most patients. Today's better understanding of malignant tumor kinetics has evolved preservative and precision extirpative surgery which has on one hand enhanced cure rates and on the other hand has preserved function and appearance in such patients. Today's reconstructive techniques have a sound basis in wound healing and bone regeneration science so as to be predictable and long lasting. We now consistently reconstruct cancer patients with minimal complications and without adding undue deformity and disability. Within just the past ten years the additional advancement of osseointegrated implants has taken functional results related to chewing force and efficiency to a higher level. These implants provide for an optimal return of eating ability to closely match those with natural dentitions. Such implants have also been taken a step further with their application to facial unit restorations. Today facial units with the excellent tissue color and consistency matches made possible by available elastic materials are worn with confidence and comfort by those who require them. The messy and ineffectual adhesives of the past have been discarded. At the time of this writing the hope for the immediate future is the availability of recombinant human BMP. As the next anticipated advance in complete cancer reconstruction it has the potential to regenerate physiologically normal bone without bone grafting. The reduction in morbidity and operating room time would be an enormous step forward, as would the applicability of reconstruction to more people at a reduced cost.

Current concepts in management of facial trauma

Open reduction and internal fixation have become routine in facial fracture treatment. Methodical evaluation and treatment planning should be based on the patient's injuries, extenuating factors, and the surgeon's experience. After initial treatment, patients with facial trauma may require orthodontic alignment of teeth, endodontic therapy, osteotomies, implants, vestibuloplasties, and scar revisions to achieve an acceptable functional and cosmetic result. The oral and maxillofacial surgeon is best qualified to coordinate and help deliver this interdisciplinary approach to treatment.