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

A Shaped Pectoralis Major Muscle Flap under Indocyanine Green Fluorescence Angiography for Sternal Wound Infection

The treatment of a sternal wound infection is challenging because it requires radical debridement and reconstruction with a well-vascularized flap. The defects after debridement are three-dimensionally complex, especially if synthetic grafts are involved. Although the pectoralis major muscle (PMM) flap is useful for reconstruction, it is difficult to fill up the complex dead space surrounding the vascular prosthesis when using a conventional PMM flap. Herein, we describe a new technique of splitting and shaping the PMM flap to fit the complex defect. Intraoperative indocyanine green fluorescence angiography was used to assess dynamic blood flow of the PMM supplied by internal mammary artery perforators. This technique allows the PMM flap to be split and shaped to securely fit the dead space, which may improve the healing rate.

Practicality and Hemodynamic Advantage of Microvascularly Augmented Pectoralis Major Musculocutaneous Flap: Technical Approach and Evidence Based on Indocyanine Green Angiography

ABSTRACT

We have recently shown that including the blood flow from the lateral thoracic artery (LTA) in addition to the thoracoacromial artery in the pectoralis major muscle musculocutaneous (PMMC) flap (bipedicle PMMC flap) can increase the perfusion of the flap. We also developed the concept of the supercharged PMMC flap, in which the LTA included in the flap was once cut and anastomosed to a cervical artery under a microscope. It is an effective solution to maintain the additional blood flow from the LTA, when the length of the LTA is compromised for reconstruction. The mandibular reconstruction of an oral cancer patient was performed with a supercharged PMMC flap. Intraoperative indocyanine green angiography was performed in a single pedicle, bipedicle, and supercharged conditions, and the videos were analyzed with a quantitative assessment system of perfusion using some parameters. As a result, blood supply from the LTA was essential for flap survival in this patient, and supercharging from the cervical artery improved flap perfusion compared with the perfusion in the bipedicle condition. The supercharged PMMC flap can resolve the compromise of pedicle length and be also hemodynamically advantageous, thus making the reconstruction more reliable than the conventional technique.

Evaluating Pedicled Pectoralis Major Myocutaneous Flap Reconstructions for Oral Malignancy and the Influence of Laterally Based Rotational Advancement Flap on Donor Site Integrity and Nipple Position in Male Patients

Oral cancer poses a significant health burden, particularly in the male population of India. This study focuses on evaluating the outcomes of 48 pedicled Pectoralis major myocutaneous (PMMC) flap reconstructions in male patients with oral malignancy. Given the challenges associated with microvascular flap reconstructions, especially in advanced cancer cases, older patients, and resource-constrained settings, the PMMC flap still serves as a valuable alternative. The study introduces a novel approach by incorporating a laterally based rotational advancement flap (LBRA) to address donor site integrity and decrease the nipple-areolar complex (NAC) displacement. Traditionally, PMMC flap designs tend to cause inward shifting of the NAC during chest donor site closure, impacting the aesthetic outcome. Surgical techniques involved wide local resection, neck dissection, and PMMC flap reconstruction. The Flap design included a horizontal orientation with adjustments based on defect location. Additionally, a laterally based rotational flap from the chest aided in donor site closure. Results demonstrate the versatility and reliability of PMMC flap reconstructions, with no total flap necrosis or major complications observed in the 48 cases. The LBRA technique effectively mitigated NAC displacement. The study contributes to the existing literature by providing insights into the advantages of PMMC flap reconstructions and introducing a technique to optimize donor site closure and decrease the medial shifting of the nipple. The adaptability, reliable vascular supply, and simplified learning curve make the PMMC flap a preferred choice in resource-constrained settings with high patient demand. In conclusion, this research underscores the continued relevance and effectiveness of the PMMC flap in head and neck reconstruction, offering satisfactory cosmetic and functional results. The introduction of the LBRA technique adds a nuanced dimension to improve outcomes, particularly in male patients with oral malignancy.

Bilobed Pectoralis Major Myocutaneous Flap Reconstruction: a Single Institution Experience of 150 Patients and Methods to Prevent Complications

Introduction

Bilobed PMMC flap is done for patients who have diseases that require resection of oral cavity mucosa along with the overlying skin, either because of direct tumor invasion to the skin or for achieving adequate tumor-free base of resection. The versatility of the flap allows it to be used to cover both inner and outer linings for a full-thickness defect.

Materials and Methods

This was a single-center, retrospective, observational study carried out in the Department of Head and Neck Oncology at a regional cancer center from January 2019 to December 2019. A minimum follow-up duration for all patients was 6 months. The primary endpoint was to study the results and complications associated with bilobed PMMC flap reconstruction and factors affecting it, as well as their management.

Results

The median age was 45 years [24-71 years]. There were 96(64%) males and 54(36%) females. The most common sites reconstructed were lower gingivobuccal sulcus (39.1%), buccal mucosa (30.2%), and lower alveolus (16.7%). The overall complication rate was 41.3%, with 10(6.6%) patients requiring re-exploration. The average hospital stay was 11 days [5-28 days]. On doing a multivariate analysis, for various factors affecting flap necrosis, none of the factors reached statistical significance (p value > 0.05).

Conclusion

PMMC flap remains the workhorse of head and neck reconstruction. In cases of full-thickness defects in oral cancer patients, in our country, in the setup which lacks the expertise in microvascular anastomosis and with immense caseload in the head and neck cancer department, bilobed PMMC flap remains a safe and favorite alternative method for reconstruction.

[The split turnover pectoralis muscle flap: an easy and safe method for sternal wound coverage]

The conventional pectoralis muscle flap is well known for the reconstruction of sternal defects after deep sternal wound infection. The pectoralis muscle flap can be harvested as an advancement flap based on the thoracoacromial artery, or it can be harvested as a turnover flap based on intercostal perforators of the internal thoracic artery. A disadvantage of the advancement flap can be seen in its limited reach, especially for covering the lower third of the sternum. The turnover flap is well suited for coverage of the lower and middle sternal third, but then lacks the length for coverage of the cranial third. The authors describe a new method for splitting up the pectoralis turnover muscle flap along its muscle fibres in order to gain additional length. Between 2017 and 2022, we treated 12 patients with this method. Total wound coverage and closure have been achieved in all 12 patients. Thus, the split turnover pectoralis flap is a safe and effective method for sternal wound treatment.

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.

Head and Neck Reconstruction With 2-Stage External Pectoralis Major Myocutaneous Flap Transfer

BACKGROUND

In head and neck surgery cases where skin is severely scarred or adhered to surrounding tissue, reconstruction can be difficult to perform using microsurgical tissue or conventional pedicled pectoralis major myocutaneous flap (PMMF) transfer given the risks, which include damage to major vessels when manipulating scarred skin. For such cases, we perform a 2-stage external PMMF transfer, whereby the PMMF is directly sutured to the defect over the neck skin (without manipulation the hardened skin), and the flap division is then performed secondarily.

METHODS

A total of 30 patients who had histories of radiotherapy (60-70 Gy) and prior neck dissection received the 2-stage external PMMF transfer procedure. Indications for the flaps included pharyngeal fistula closure in 12 patients, reconstruction for mandibular necrosis after radiotherapy in 8 patients, salvage surgery for partial or total necrosis of the free flap in 4 patients, and simultaneous reconstruction after tumor excision in 6 patients. Two patients underwent a second external PMMF transfer from the contralateral side because of postoperative complications, yielding a total of 32 flap transfers.

RESULTS

Twenty-nine flaps showed complete flap survival, whereas 3 had partial necrosis. Other complications, despite complete flap survival, included large fistulas requiring additional surgery for fistula closure (1 patient) and small fistulas that were closed without requiring reoperation (7 patients).

CONCLUSIONS

External PMMF transfer offers a safe, simple, and effective option in cases where free flap surgery is considered difficult or the risks associated with neck manipulation are high.

Using indocyanine green angiography to achieve complete engraftment of pectoralis major myocutaneous flaps

Although the pectoralis major myocutaneous (PMMC) flap is among the useful reconstructive materials following oral cancer ablation, this flap has an unstable blood circulation that could result in partial necrosis of the skin paddle. This report describes the usefulness of indocyanine green angiography (ICGA) to achieve complete engraftment of the PMMC flap. Five patients with oral cancer underwent reconstruction with a PMMC flap after cancer ablation. During the skin paddle design and flap elevation, the blood supply to the flap was assessed by ICGA. Areas of the skin paddle that showed no ICG fluorescence were excised. Consequently, prior to transfer to the recipient site, the blood supply to all flaps was confirmed with indocyanine green visible at the edge of the skin paddle, and complete engraftment was achieved without partial necrosis. Based on the results observed, ICGA would make a useful contribution to complete engraftment of the PMMC flap.

Mango-shaped Bi-paddled pectoralis major myocutaneous flap reconstruction for large full-thickness defects post resection of squamous cell carcinoma of oral cavity: An analysis of 232 cases

Objectives:

The objective of the study was to examine the feasibility of bi-paddled pectoralis major myocutaneous (PMMC) flap reconstruction in patient undergoing full thickness composite resection.

Materials and Methods:

Inclusion criteria: The subjects chosen were patients with clinically T4A squamous cell carcinoma of buccal mucosa, lower alveolus, and maxilla in with skin involvement. Patients required a full-thickness composite resection of intraoral lesion, bone (mandibular segment and/or maxilla), and overlying involved skin and had modified radical neck dissection. Exclusion criteria: Patients not requiring full thickness composite resection including skin. Patients were observed postoperatively for early and late postoperative complications, starting of oral feeding, post-operative trismus, and dysphagia during subsequent follow-up and cosmetic outcome.

Results:

Overall, the complication rate was 33.8% out of which only 7.8% required major re-surgery with second flap reconstruction. This is comparable with other large series of PMMC flap. Clavien-Dindo Grade I complications were seen in 9.5%, Grade II in 69.7%, Grade IIIA in 13.4%, and Grade IIIB in 7.45% of patients. Full-thickness partial flap necrosis included necrosis of either the external or the internal skin paddle. There were 15 cases – 6.5% of full thickness external paddle necrosis. These were mostly in patients with bite composite resections and having a larger random fasciocutaneous distal component of the flap without underlying muscle. Furthermore, 40% of these patients were females. In females, the flap necrosis comprised 4 of the 12 patients (33.33%).

Conclusion:

Pectoralis major mycocutaneous flap has been a boon to reconstruction of the oral cavity post its inception. In case of locally advanced squamous cell carcinomas of the oral cavity, in many instances, there is a clinically significant cervical lymph nodal spread vessels post mandating a comprehensive lymph node dissection. PMMC flap provides a robust well vascularized muscular cover to the cervical vessels poststernocleidomastoid excision.

Lateral Thoracic Artery Can Stabilize Circulation in the Pectoralis Major Myocutaneous Pedicle Flap: Single-center, Prospective, Uncontrolled Case Series

Background

Head and neck reconstructions using the pectoralis major myocutaneous pedicle flap (PMMF) with thoracoacromial artery alone are prone to hemodynamic instability, possibly leading to infection, prolapse, hematoma, seroma, and partial or total flap failure (6%-71%). Aside from unstable blood circulation, reported risk factors for these complications include feminine gender, smoking, and having diabetes mellitus. Preservation of the lateral thoracic artery in addition to the thoracoacromial artery has been suggested as a way to improve unstable blood circulation in the PMMF.

Methods

This is a single-center, prospective, uncontrolled case series. Circulation to the PMMF was studied intraoperatively with and without lateral thoracic artery clamping after harvest. Indocyanine green (ICG) angiopathy, a quantitative hemodynamic assessment method, was used to analyze three parameters: maximum intensity (Imax), time from start of ICG to maximum intensity (Tmax), and slope of intensity (Smax = Imax/Tmax). Hemodynamic parameters, such as pulse rate and blood pressure, were all within normal ranges. Allergy to contrast media was criterion for exclusion.

Results

Six patients all had oral cancer as their primary disease. Their background was characterized by established risk factors: four patients had a history of smoking, two had diabetes mellitus, and two were women. Postoperatively, no patients had complications at the recipient or donor sites. Mean results of the analysis were Imax: 60 ± 47, Tmax: 91 ± 55, Smax: 0.8 ± 0.5 in the clamped group and Imax: 85 ± 40, Tmax: 73 ± 42, Smax: 1.8 ± 1.5 in the un-clamped group. Significant difference was observed in Imax (P = 0.03) and Smax (P = 0.03).

Conclusion

Lateral thoracic artery preservation appears to be useful for stabilizing blood circulation to the PMMF, including in patients considered to be at high-risk for complications, such as women, smokers, and patients with diabetes mellitus.

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.

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.

Nuts and bolts of PMMC flap in oral cancer and its clinical outcome in 168 indian patients: A retrospective analysis

Introduction

The gold standard for reconstruction is the microvascular free flaps, whereas pedicled flaps are generally employed as a rescue procedure. Pectoralis major myocutaneous flap (PMMC) flap being a reliable flap is associated with high rate of complication. So, the purpose of this study was to check and assess the predictability of PMMC Flap and its clinical outcome in 168 Indian patients.

Materials and method

We conducted a retrospective study of PMMC flap which was harvested in 168 Indian oral cancer patients in 3 years time span. Patients were kept on follow up for 1-3 years. Rate of complication were documented for flap necrosis and wound dehiscence; and patient related data like neck bulk acceptance and range of motion were recorded. Gender comparison of complications were also documented.

Results

The most common complication was wound dehiscence in 11 (6.5%) patients. Partial flap necrosis was observed in 3 (1.8%) female patients. There was no case of total flap necrosis. Questionare method was used for patients to record neck bulk acceptance. Range of motion was evaluated during follow up period. Follow up period of all the patients was 1-3 years.

Conclusion

PMMC flap is still a well founded 'workhorse' flap for reconstruction in head and neck cancer patients and can be used successfully with acceptable morbidity.

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.

Importance of Choke Vessels in Injectable Fillers

Knowledge of facial anatomy is indispensable for dermatologists and plastic surgeons practicing aesthetic medicine, especially for those using fillers, as injection of fillers may be associated with serious complications such as vascular occlusion and blindness. Angiosome and choke vessels play an important role in vascular incidents occurring after filler injections. The objective of this article was to outline the anatomy and pathophysiology of choke vessels, a concept which is not well known to dermatologists.

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.

Significance of the Lateral Thoracic Artery in Pectoralis Major Musculocutaneous Flap Reconstruction: Quantitative Assessment of Blood Circulation Using Indocyanine Green Angiography

Free tissue transfer is the preferred reconstruction option in most major head and neck reconstructions. The pectoralis major muscle musculocutaneous (PMMC) flap is commonly used in salvage of necrotic free flaps and is the first choice for patients who are not candidates for free flaps. The lateral thoracic artery (LTA), which is thought to contribute to blood perfusion of the inferior and lateral mammary area, is not preserved in a conventionally harvested PMMC flap. With regard to blood supply, it has been suggested that the LTA should be preserved, in addition to the pectoral branch of the thoracoacromial artery, when a skin island is designed in the lower chest to attain a pedicle length sufficient for head and neck reconstruction. However, an effect on hemodynamic improvement using the LTA has not been shown quantitatively. In this study, we examined 8 patients with oral cancer who underwent reconstruction procedures with a bipedicle PMMC flap that included the LTA, in addition to the thoracoacromial artery. Intraoperative indocyanine green angiography was performed to examine circulation to the PMMC flap with or without LTA clamping after harvesting. After image processing, data were analyzed using a new quantitative perfusion assessment system with parameters that we recently established for assessment of peripheral arterial disease of the lower limbs. All patients had good clinical courses with whole-flap survival, no vascular insufficiency of the skin island, and no fistula formation. Intraoperative indocyanine green angiography showed an increased inflow rate into the skin island in an LTA-declamped condition in all cases, implying that the preserved LTA increased the blood supply to skin islands in the pectoralis major muscle. We conclude that preserving the LTA in a PMMC flap can increase blood perfusion and stabilize the vascularity of the flap, making the reconstruction more effective and reliable than with use of a conventionally harvested flap. Therefore, it is worthwhile to preserve the LTA as a major contributor to a lateral and distal PMMC flap.

Pectoralis Major Musculocutaneous Flap With a Midline Sternal Skin Paddle for Head and Neck Reconstruction: A New Design

PURPOSE

The pectoralis major musculocutaneous (PMMC) flap is a classic flap for head and neck reconstruction, relatively unpopular with the advancement of microsurgery and free flaps. The classic parasternal paddle design provided a thick flap with a small rotation arch leaving objectionable scarring. Our new symmetric midsternal design overcomes these problems.

METHODS

Chart review was done from the years 2000 to 2017. Flap skin paddle was placed symmetrically on both sides of the midsternal line. The pectoralis major (PM) muscle and aponeurosis were attached in the lateral half of the skin paddle. Most of PM muscle was elevated with the thoracoacromial vessel and dissected to the main trunk, where the PM muscle was cut and used for bulk. The flap was transferred to the neck and lower mandibular area. The flap was inset either supraclavicularly, covering the anterior neck, or subclavicularly, for intraoral/maxillary defects.

RESULTS

Eight patients underwent head and neck reconstruction using the new design of PMMC flap between the years 2000 and 2017. The etiologies of the defect were radiation necrosis in 3 patients, repair of cutaneous fistulas in 3, recurrent hypopharyngeal cancer in 1, and recurrent tongue cancer in 1 patient. There were no flap losses or major complications.

CONCLUSIONS

With the advancement of free-flap techniques, the classic flaps have become less popular. Our new design supplements the PMMC flap by providing a thin pliable flap with a long pedicle and rotation arc, allowing a combination of different types of flaps to cover composite head and neck defects, especially in cases that lack a reliable recipient vessel due to radiation.

The Boomerang-shaped Pectoralis Major Musculocutaneous Flap for Reconstruction of Circular Defect of Cervical Skin

We report on a patient with a recurrence of oral cancer involving a cervical lymph node. The patient’s postexcision cervical skin defect was nearly circular in shape, and the size was about 12 cm in diameter. The defect was successfully reconstructed with a boomerang-shaped pectoralis major musculocutaneous flap whose skin paddle included multiple intercostal perforators of the internal mammary vessels. This flap design is effective for reconstructing an extensive neck skin defect and enables primary closure of the donor site with minimal deformity.

Comparison of outcomes with extensive segmental pectoralis major myocutaneous flap via the anterior axillary line and the conventional technique in oral and oropharyngeal cancer

BACKGROUND

This study compared the outcomes of an extensive segmental pectoralis major myocutaneous flap (esPMMF) and a conventional pectoralis major myocutaneous flap (PMMF).

METHODS

The study enrolled 91 patients with primary oral and oropharyngeal squamous cell carcinoma (SCC) who underwent radical resection followed by reconstruction of the defect using either an esPMMF via the anterior axillary line or a PMMF. The pedicle lengths of the esPMMF and PMMF were 22-28 and 18-22 cm, respectively. The esPMMF and PMMF had skin paddle dimensions of 5 × 8 to 7 × 14 cm and 6 × 7 to 8 × 17 cm, respectively.

RESULTS

The esPMMF pedicle was longer than that of the PMMF. The range of shoulder abduction was significantly greater in the esPMMF group and the donor-site aesthetic results were better.

CONCLUSION

The esPMMF has a longer pedicle flap, enables a greater range of shoulder abduction, and has a better aesthetic result than the conventional technique.

Locoregional Flaps for Oral Cavity Reconstruction: A Review of Modern Options

Objective

To review state-of-the-art modifications and advances in soft tissue local and regional flap reconstruction of the oral cavity and to determine the role these techniques play in current practice.

Data Sources

Review of the literature regarding oral cavity reconstruction.

Review Methods

The authors describe advances in locoregional reconstructive options and assimilate data from the literature that compare recent advances to the historic standards.

Conclusions

Modern advances in regional reconstruction of the oral cavity offer outstanding results and demonstrate potential advance over free tissue transfer. These modifications demonstrate the prominent role that regional reconstruction can play in oral cavity reconstruction.

Implications for Practice

With a more complete understanding of these options, the surgeon is better able to tailor the reconstruction to the needs of the patient to provide high-quality cost-effective care.

Motor Nerve Preservation and Muscle Atrophy After Pectoralis Major Musculocutaneous Flap Surgery for Oromandibular Reconstruction

OBJECTIVE

The authors investigated the clinical and histopathologic significance of medial pectoral nerve preservation/reinnervation of pectoralis major musculocutaneous flap for oromandibular reconstruction.

MATERIALS AND METHODS

The authors compared 13 patients treated with pectoralis major musculocutaneous flap reconstruction and 6 control patients treated by rectus abdominis musculocutaneous flap reconstruction without motor nerve restoration. Subjective awareness was scored to evaluate changes in the facial contour due to muscle atrophy, and objective evaluation was performed in few patients. In addition, the authors performed histopathologic analysis of both muscle atrophy and nerve regeneration in 20 patients from whom samples were available.

RESULTS

Subjective awareness of changes in the facial contour induced by muscle atrophy was low among patients with nerve preservation/reinnervation, but there were objective changes at 3 months after surgery among patients who underwent nerve resection. In the patients who had medial pectoral nerve preservation or nerve restoration by nerve suture, favorable facial symmetry was retained at 5 years after surgery. Even though the motor nerve was preserved or restored, fatty degeneration and fibrosis were noted in approximately 30% of the total surface area of the muscle, and type I fibers had decreased to 36% that of control at 7 years after surgery. However, regressive changes were inhibited for 1 year after surgery; in contrast, changes corresponding to those noted at 7 years after surgery were observed by 3 months in the patients with nerve resection.

CONCLUSION

Thus, the authors showed that preservation or restoration of nerves can delay muscle and have highlighted the potential benefits of this approach.

Preservation of Aesthetics of Breast in Pectoralis Major Myocutaneous Flap Donor Site in Females

BACKGROUND AND OBJECTIVES

In females, raising a pectoralis major myocutaneous flap is challenging and primary closure of flap donor site causes breast deformity with medial displacement of nipple areola complex. To avoid this distortion, a new method of donor site closure is devised.

METHODS

A parasternal skin paddle which has better vascularity is planned while doing a pectoralis major myocutaneous flap in females and a lateral flap planned along the lateral breast curve is used to cover the donor site. The lateral flap donor site is primarily closed. This prevents medial displacement of nipple areola complex.

RESULTS

A total of 47 patients underwent donor site flap closure technique. Minor complications in form of marginal necrosis near the tip of the flap were observed in 10.6 % patients. The donor breast of all these PMMC flaps had good contour and aesthetic positioning of nipple areola complex.

CONCLUSION

Donor site morbidity with respect to breast distortion has not been studied so far in case of females so our study stands unique in this aspect. Using this technique of planning PMMC in females ensures a skin paddle of better vascularity and restores the breast aesthetics.

A modified pectoralis major myocutaneous flap technique with improved vascular supply and an extended rotation arc for oral defects: A case report

The pedicled pectoralis major myocutaneous (PMMC) flap is versatile, and is widely used for the treatment of surgical defects following oral cancer resection. Although free-tissue transfer of a vascularized free flap is often preferred, the clinical benefits of the PMMC flap should not be overlooked. The conventional technique of harvesting a PMMC flap involves a single vascular supply from the pectoral branch of the thoracoacromial artery. However, this approach compromises the distal skin island of the flap, and requires an indirect blood supply via communicating vessels, which increases the potential risk of partial distal flap necrosis. When harvesting a PMMC flap for oral and maxillofacial reconstruction, preservation of the lateral thoracic artery and use of the subclavian route are alternatives that ensure sufficient blood supply and an increased rotation arc. Such an approach enables the harvesting of a PMMC flap that can reach the entire oral cavity, including the infraorbital region, palate, middle pterygopalatine fossa and nasopharynx, with no risk of vascular insufficiency to the distal skin island. In conclusion, the technique described in the present study was able to improve the blood supply of the distal PMMC flap and increase its rotation arc.

Pectoralis major myocutaneous flap in head and neck reconstruction: An experience in 100 consecutive cases

Background:

The pectoralis major myocutaneous (PMMC) flap has been used as a versatile and reliable flap since its first description by Ariyan in 1979. In India head and neck cancer patients usually present in the advanced stage making PMMC flap a viable option for reconstruction. Although free flap using microvascular technique is the standard of care, its use is limited by the availability of expertise and resources in developing world. The aim of this study is to identify the outcomes associated with PMMC flap reconstruction.

Patients and Methods:

After ethical approval we retrospectively analyzed 100 PMMC flap at a tertiary care hospital from 2006 to 2013. A total of 137 PMMC flap reconstructions were performed out of which follow-up data of 100 cases were available in our record.

Results:

A total of 100 patients were reviewed of these 86% were of oral cavity and oropharyngeal lesions, 8% were of hypopharyngeal, 3% were of laryngeal malignancies and 3 cases were of salivary gland tumor. Most tumors (83%) were advanced (T3 or T4 lesion). 95 PMMC flap reconstruction were done as a primary procedure, and 5 were salvage procedure. PMMC flap was used to cover mucosal defect in 84 patients, skin defects in 10 patient and both in 6 patients. Overall flap related complications were 40% with a major complication in 10% and minor complications in 30%. No total flap loss occurred in any patient, major flap occurred in 6% and minor flap loss in 12%. In minor flap loss patients, necrotic changes were mostly limited to skin. Orocutaneous and pharyngocutaneous fistula developed in 12 patients. 10% patients required re-surgery after developing various flap related complications Pleural empyema developed in 3 patients. Other minor complications such as neck skin dehiscence and intra-oral flap dehiscence developed in 26 patients.

Conclusion:

PMMC flap is a versatile flap with an excellent reach to face oral cavity and neck region. With limited expertise and resources, it is still a workhorse flap in head and neck reconstruction.

Successful management of oesophageal conduit necrosis by a single-stage reconstruction with the pedicled pectoralis major myocutaneous flap

Conduit necrosis is a rare but potentially devastating complication of oesophageal surgery and the subsequent reversal of oesophageal discontinuity can be challenging. An option for both cervical-oesophageal reconstruction and neck wound closure has been limited and less successful. We report a patient with colon conduit necrosis and cervical-oesophageal discontinuity whose cervial oesophagus was successfully reconstructed with a single-stage pedicled pectoralis major myocutaneous flap and neck wound closure.

A salvage maneuver for the caudal part of the pectoralis major muscle in the reconstruction of superior thoracic wall defects: The pectoralis kite flap

The pectoralis major muscle flap is the most commonly used option for chest wall reconstruction. However, its utilization should be avoided in chest wall tumors infiltrating the muscle. This article presents the utilization of the caudal part of the pectoralis major muscle as a pedicled flap in cases requiring the resection of the cranial part of the muscle due to tumor infiltration. Fourteen patients with a mean age of 60.3 years were operated for malignant thoracic wall tumors between 2011 and 2014. All tumors were located on the upper thoracic area with a mean defect size of 16.6 × 12 cm. During tumor resection, the thoracoacromial vessels and pectoral branch were preserved and dissected until reaching the pectoralis muscle. After the resection of the cranial part of the muscle, the caudal part is prepared as a pedicled island flap and used for the coverage of the resultant defect. The mean postoperative follow-up period was 10.9 months. All flaps survived without any partial or total flap loss. A case of local recurrence, two cases of hematoma requiring drainage, and two cases of local wound-healing problems were the encountered complications. The pectoral kite flap is a versatile and reliable option for the coverage of small to medium upper chest wall defects with minimal morbidity, and it gives the reconstructive surgeon the opportunity to use the non-infiltrated caudal part of the pectoralis muscle instead of an unnecessary resection of the whole muscle.

T-shaped Pectoralis Major Musculocutaneous Flap for Reconstruction of an Extensive Circumferential Pharyngeal Defect

SUMMARY

In the era of free-flap transfer, the pectoralis major musculocutaneous flap still plays a unique role in head and neck reconstruction. We report on a patient with a recurrent hypopharyngeal carcinoma after total pharyngolaryngectomy and adjuvant chemoradiotherapy in whom defects included a circumferential defect of the oropharynx and the entire tongue. The defects were successfully reconstructed with a T-shaped pectoralis major musculocutaneous flap whose skin island included multiple intercostal perforators from the internal mammary vessels. This flap design is effective for reconstructing circumferential pharyngeal defects in vessel-depleted neck.

Reconstructive Surgery for Head and Neck Cancer Patients

The field of head and neck surgery has gone through numerous changes in the past two decades. Microvascular free flap reconstructions largely replaced other techniques. More importantly, there has been a paradigm shift toward seeking not only to achieve reliable wound closure to protect vital structures, but also to reestablish normal function and appearance. The present paper will present an algorithmic approach to head and neck reconstruction of various subsites, using an evidence-based approach wherever possible.

Island pectoralis major myocutaneous flap: an Indian perspective

The aim of this study is to conceive a method of raising an island PMMC flap, so as to circumvent its drawbacks of bulk, flap length and the difficulty of developing this flap in female patients. And to consider island PMMC flap as a viable reconstructive option in head and neck surgeries, especially in peripheral centres. Ours is an experimental case series. The study was done at Sri Devaraj URS Medical college, Tamaka, Kolar. Between 2009 and 2010, head and neck reconstruction was performed using this method in 20 patients who had oral cancer (18), carcinoma supraglottis (1) and mucoepidermoid carcinoma parotid (1). The patients age ranged from 16 to 75 years, and there were 15 women and 5 men. Nineteen of our patients underwent primary surgery and one patient was operated for residual disease. In (16) patient, island pmmc flap was used for intra oral closure. In (4) patients the flap was spiraled for providing skin cover. Four patients developed complications. Three were minor complications of margin necrosis and wound dehiscence, which were managed conservatively. One patient developed orocutaneous fistula, which required secondary suturing. None of our patients had a total necrosis of the flap. Island PMMC flap is still a very useful and viable option for reconstruction in head and neck surgeries, especially in lateral gingivo buccal tumours and other head and neck tumours. In institutions where microvascular expertise is not available, island PMMC flap can be an alternative with results comparable to that of free tissue transfer.

Method to help ensure survival of a very small skin paddle of pectoralis major musculocutaneous flap in head and neck reconstruction

BACKGROUND

When the required dimension of skin paddle of a pectoralis major musculocutaneous (PMMC) flap is very small, its survival often becomes questionable. We introduce a simple technique which enlarges the practical dimension of a very small skin paddle, leading to ensure the survival of a PMMC flap.

METHOD AND RESULT

A PMMC flap size of 1.5 × 4 cm was required for repair of leakage which developed 2 weeks after the primary ablative surgery for hypopharyngeal cancer. The skin paddle was designed in the size of 4.5 × 7 cm and was deepithelized except the original dimension. After the skin edge was sutured to the defect margin, the deepithelized dermal portion covered the repair site to enhance the suture.

CONCLUSION

The effective dimension of a very small skin paddle can be quite enlarged thus increasing the possibility of capturing perforators. This could decrease the risk of avulsion during flap transfer and provide backing of the repair site.

Pectoralis major myocutaneous flaps for head and neck reconstruction: factors influencing occurrences of complications and the final outcome

CONTEXT AND OBJECTIVE

Pedicled flaps play an important role in cancer treatment centers, particularly in developing and emerging countries. The aim of this study was to identify factors that may cause complications and influence the final result from reconstructions using pectoralis major myocutaneous flaps (PMMFs) for head and neck defect repair following cancer resection.

DESIGN AND SETTING

Cross-sectional study at the Hospital de Ensino Padre Anchieta of Faculdade de Medicina do ABC (FMABC).

METHODS

Data on 58 patients who underwent head and neck defect reconstruction using PMMFs were reviewed. The final result from the reconstruction (success or failure) and the complications observed were evaluated in relation to the patients' ages, area reconstructed, disease stage, previous oncological treatment and need for blood transfusion.

RESULTS

There were no total flap losses. The reconstruction success rate was 93.1%. Flap-related complications occurred in 43.1% of the cases, and half of them were considered major. Most of the complications were successfully treated. Defects originating in the hypopharynx were correlated with the development of major complications (p = 0.02) and with reconstruction failure (p < 0.001). Previous oncological treatment negatively influenced the reconstruction success (p = 0.04).

CONCLUSIONS

Since the risk factors for developing major complications and reconstruction failure are known, it is important to heed the technical details and provide careful clinical support for patients in a more critical condition, so that better results from using PMMFs can be obtained.

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.

The subclavicular versus the supraclavicular route for pectoralis major myocutaneous flap: a cadaveric anatomic study

The aim of this paper was to determine if the subclavicular route of rotation improved the pectoralis major myocutaneous flap's ability to reach head and neck sites in comparison to the traditional supraclavicular rotation. We dissected 50 flaps in 25 fresh adult male cadavers. The length of the pedicle and the flap's ability to reach five anatomical head and neck sites (laryngeal prominence of thyroid cartilage, mentum, angle of the mandible, external auditory canal, and orbit) were tested by supraclavicular and subclavicular rotation. Although the average length of the flap's pedicle was higher when the subclavicular rotation was employed, there was no statistical difference between the two techniques concerning the flap's ability to reach the studied sites. Our results suggest that the subclavicular route apparently adds little to the reconstruction of head and neck defects using the pectoralis major myocutaneous flap. We believe that the indication of this technique should be evaluated on a case-by-case basis before it is recommended to keep from unnecessarily increasing the potential morbidity of the reparative procedure.

The island myocutaneous flap reconstruction in electrical burn injuries of severely traumatized cervical region

Trauma patients with high-energy injuries often present with severe tissue damage that extends beyond the immediate zone of injury and require recruitment of vascularized and massive tissues. The objective of this study was to evaluate the utility of the island myocutaneous flap for the reconstruction of the electrical burn injuries on the cervical region. We conducted a retrospective chart review on all trauma patients treated by the Department of Plastic Surgery at Changhai Hospital, Second Military Medical University who required a large amount of vascularized tissue for the reconstruction of the electrical burn injuries on the cervical region from July 1994 to June 2006. Of them, 23 patients underwent reconstruction of severe traumatic deformities and disfunction on the cervical region with 23 island myocutaneous flaps from adjacent regions. Of the 23 patients, 17 were male and 6 were female, with an average age of 38 years. Conservative surgery method for debriding necrotic tissues and three different types of island myocutaneous flaps, including pectoralis major island myocutaneous flap, latissimus dorsi island myocutaneous flap and trapezius island myocutaneous flap were used. The defect area ranged from 6 cm x 4 cm to 20 cm x 15 cm. The sizes of the dissected myocutaneous flap ranged from 8 cm x 6 cm to 35 cm x 15 cm. All the 23 cases acquired complete recovery. The secondary defect of donor areas had primary closure after being directly sutured or covered with skin grafts. Island myocutaneous flaps have distinctive advantages in treatment of electrical burn injuries on cervical region and it can obtain satisfactory functional and cosmetic outcomes.

Soft tissue coverage of the elbow in a developing country

Two cases that required soft tissue coverage to the anterior aspect of the elbow are presented. A fasciocutaneous intercostal perforator chest wall flap was used for one patient when only skin and fascia coverage was required. A latissimus dorsi myocutaneous flap was used to provide soft tissue coverage and supply motor power for elbow flexion after contracture release in the other. The surgical techniques for each of these flaps are discussed in the context of addressing soft tissue traumatic injuries about the elbow in a developing country with limited resources.

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.