Analysis of 120 pectoralis major flaps for head and neck reconstruction

Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction

INTRODUCTION

The pectoral myocutaneous flap (PMF) is a workhorse regional reconstructive option for head and neck defects. It is commonly used for primary reconstructions due to its advantages or as a life-boat flap in the salvage of failed reconstructions of free flaps. However, it also has intrinsic drawbacks, such as perfusion problems and partial or complete flap loss. Although there are many studies about the advantages and use of PMF in the literature, the number of studies about salvage of this workhorse flap is inadequate. We aimed to present the use of the pedicle of previously performed PMF as a recipient for free flaps in head and neck reconstruction.

METHODS

Between January 2022 and August 2023, 10 free flaps were used in nine patients (three females and six males) who had previously undergone head and neck reconstruction with PMF. The age of the patients ranged from 54 to 74 years. Seven out of the nine PMFs were previously performed by different surgical teams. Squamous cell carcinoma (SCC) was the reason for primary surgeries in all patients and the PMFs were used for right lower lip and right submandibular defect, left lower lip and mentum defect, lower lip defect, right lower lip and right submandibular defect, right retromolar trigone defect, right buccal defect, left anterolateral esophageal defect, right retromolar trigone defect and left anterolateral pharyngoesophageal defect reconstructions. The problems were partial skin island necrosis and wound dehiscence in six patients and total skin necrosis in three patients. The partial skin island necroses already showed that the pedicles were unproblematic. For patients with total skin island necrosis the muscle stalks so the pedicles were also unproblematic which were confirmed by physical examination and Doppler device. After complications, the finally defects were located in the lower lip, left lower lip and mentum, right lower lip and right submandibular area, left anterolateral esophageal area and left neck, right buccal area, right retromolar trigon, left anterolateral pharyngoesophageal fistula and left neck. The sizes of the defects were between 3 × 4 cm and 11 × 17 cm. For all patients, the pedicle of the previously harvested PMF was used as a recipient for free flaps. Since the PMF was flipped over the clavicula for the reconstruction previously, the pedicle was so close to skin or skin graft which was used for coverage of the muscle stalk. The Doppler device was used first over the clavicle where the PMF was flipped for vessel identification. After marking the vessels, a vertical zigzag incision was made on the skin or skin graft. The perivascular fatty tissue and the pedicle were encountered with minimal dissection by the guidance of Doppler. After meticulous microscopic dissection, the pedicle of PMF was prepared for anastomoses as usual. Six radial forearm free flap (RFFF) and four anterolateral thigh flap (ALT) flaps were used in the head and neck reconstructions for the nine patients.

RESULTS

The sizes of the flaps were between 4 × 5 cm and 12 × 17 cm. The diameters of the recipient arteries were between 0.9 and 1.2 mm. Recipient veins were approximately the same diameter as the arteries. In one patient, two vein grafts were used for lengthening both the artery and vein to reach recipient vessels. End-to-end anastomoses without vein grafts were performed in the remaining patients. One arterial thrombosis that manifested on the first postoperative day was salvaged successfully. Hematoma was seen in two patients and wound dehiscence was seen in three patients. There was no partial or total flap necrosis and all flaps survived. The follow-up period ranged from 2 to 12 months. Despite successful reconstructions, two patients died during the follow-up period due to unrelated conditions. Functional results were acceptable in the remaining patients.

CONCLUSION

The pedicle of previously used pectoral myocutaneous flaps may be a useful alternative option as the recipient for free flaps in head and neck reconstruction.

Pedicled flap transfer after chest wall malignant tumor resection and potential risk of postoperative respiratory problems for patients with low FEV1.0

Introduction

Musculoskeletal transfer for chest wall tissue defects is a crucial method, and pedicled flaps around the chest wall are preferred in terms of location and simplicity of transfer. These require special care because of complications such as partial necrosis, fistula, wound dehiscence, infection, hematoma and restricted function of the arm or shoulder. However, studies of respiratory function are rare. In the present study, we investigated the complications including respiratory problems after wide resection for malignant chest wall tumors with musculoskeletal pedicle transfer.

Methods

A total of 13 patients (15 operations) who underwent wide resection of primary, recurrent, or metastatic malignant chest wall tumors and musculoskeletal pedicle transfer for coverage of tissue defects were enrolled in the present study. A retrospective review of all patients was performed using data collected from hospital records and follow-up information. The complications of musculoskeletal transfer after chest wall wide resection, including respiratory problems, are evaluated.

Results

Rib or sternal resection was performed in 12 operations, and only soft tissue resection was performed in 3 operations. Latissimus dorsi (LD) pedicle transfer was performed in 13 operations, and pectoralis major (PM) pedicle transfer was performed in 2 operations; basically, wounds were closed primarily. Surgical complications were observed following 5 of the 15 operations (33.3%). Respiratory complications were seen in 7 of the 15 operations (46.7%). Patients with respiratory complications showed significantly lower preoperative FEV1.0% values than those without respiratory complications (p = 0.0196). Skin resection area tended to be higher in the complication group than in the no complication group (p = 0.104).

Discussion

Pedicled myocutaneous flap transfers such as LD, PM, and rectus abdominus can be used following multiple resections. After harvesting LD or PM, the wound can be closed primarily for an 8-10-cm skin defect in patients with normal respiratory function. However, for patients with low FEV1.0%, after primary closure of LD or PM transfer for wide soft tissue defects, attention should be paid to postoperative respiratory complications.

Effect of Amniotic Membrane Nerve Wrapping in Final Results of Traumatic Peripheral Nerve Repair

BACKGROUND

Preventing perineural adhesions and scars formation in the traumatic peripheral injuries is very important on the recovery process. We aimed to evaluate the effect of using the amniotic membrane wrapping on the results of surgical treatment of damaged peripheral nerves.

METHODS

This cohort study included 30 patients with symptoms of acute peripheral nerve injuries due to penetrating trauma in the forearm or wrist in January 2019 to November 2020 referred to the Hand and Microsurgery Department, 15 Khordad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. In 15 patients, after nerve repair, amniotic membrane coverage was used around the nerve, all patients were followed for 12 months. Ultrasound study for neuroma formation and nerve regeneration was determined based on EMG and NCV findings. The modified Medical Research Councile classification (MRCC) was used to evaluate of motor and sensory recovery.

RESULTS

In the amniotic membrane wrapping group, all patients had nerve regeneration and functional nerve recovery occurred after 12 months. In the control group, 5 patients (33.4%) did not have nerve recovery and had functional and sensory impairment. In terms of functional capabilities; there was a significant difference in pinch strength, grip power and MRCC scoring between the two groups. Moreover, the mean volume of neuroma in these patients who used amniotic membrane covering was 2.7 mm³ and in the control group, it was 3.9 mm³ (P=0.001). Five patients who did not have a damaged nerve, the neuroma volume was 4.8 ± 0.9 mm³.

CONCLUSION

The use of amniotic membrane covering is effective methods in the improve results of peripheral nerve repair and nerve function recovery.

Reconstruction of a large chest wall defect using bilateral pectoralis major myocutaneous flaps and V-Y rotation advancement flaps: a case report

Bilateral pectoralis major myocutaneous (PMMC) flaps are commonly used to reconstruct large chest wall defects. We report a case of large chest wall defect reconstruction using bilateral PMMC flaps augmented with axillary V-Y advancement rotation flaps for additional flap advancement. A 74-year-old male patient was operated on for recurrent glottic squamous cell carcinoma. Excision of the tumor resulted in a 10×10 cm defect in the anterior chest wall. Bilateral PMMC flaps were raised to cover the chest wall defect. For further flap advancement, V-Y rotation advancement flaps from both axillae were added to allow complete closure. All flaps survived completely, and postoperative shoulder abduction was not limited (100° on the right side and 92° on the left). Age-related skin redundancy in the axillae enabled the use of V-Y rotation advancement flaps without limitation of shoulder motion. Bilateral PMMC advancement flaps and the additional use of V-Y rotation advancement flaps from both axillae may be a useful reconstructive option for very large chest wall defects in older patients.

Ipsilateral carotid bypass outcomes in hostile neck anatomy

OBJECTIVE

To determine differences in outcomes among patients undergoing ipsilateral carotid bypass with hostile or normal neck anatomy.

METHODS

Single-center retrospective review of all ipsilateral extracranial carotid bypasses performed between 1998 and 2018.

RESULTS

Forty-eight patients underwent ipsilateral carotid bypass from the common carotid artery to either the internal carotid artery or carotid bifurcation during the study period. Seven patients were excluded owing to either a lack of follow-up or missing data. The indications for intervention included infected patches, aneurysmal degeneration, symptomatic and asymptomatic stenosis or restenosis, carotid body tumors, neck malignancy, and trauma. In 25 procedures (61%), there was a hostile neck anatomy defined as a prior history of external beam neck irradiation or neck surgery. Among this group, 12 pectoralis muscle flaps were performed for reconstructive coverage. Conduits included polytetrafluorethylene (n = 21), great saphenous vein (n = 9), superficial femoral artery (n = 7) and arterial homograft (n = 4). All superficial femoral artery conduits were used in the hostile neck group (P = .03). The overall mean time of follow-up was 22 months, with all bypasses remaining patent with no significant clinical stenosis. The 30-day ipsilateral stroke and myocardial infarction rates were 4.88% each, all within the hostile neck group, with no 30-day mortalities for the entire cohort. One-third of the muscle flaps were performed in the setting of infected patches (P = .02) with no significant differences in perioperative outcomes with use. The overall median hospital length of stay was significantly increased in patients receiving muscle flap coverage (3.0 vs 7.0 days; P = .04).

CONCLUSIONS

In patients with a complex carotid pathology, ipsilateral carotid bypass is an effective solution for carotid reconstruction. Different conduits should be used depending on the indication. Muscle flap coverage should be considered in hostile settings when primary wound closure is not feasible.

Effectiveness of pectoralis major myocutaneous flap in the surgical management of oral cancer: A retrospective study

INTRODUCTION

Over 80,000 oral cancer cases get diagnosed each year in India, majority undergoing extensive resections owing to their late presentation. Pectoralis major myocutaneous (PMMC) flap is a pedicled axial pattern flap which is based on thoracoacromical artery. It is readily available as a viable alternative to free flap reconstruction, especially for the economically poor and malnourished patients. Its proximity to head and neck structures gives added advantage to reconstruct complex and large volume oral and maxillofacial defects. It provides a relatively good possibility of functional and aesthetic restoration providing both mucosal lining and skin cover.

MATERIALS AND METHODS

This was a prospective observational study of 29 PMMC flap reconstructions, conducted between 2013-2016. The reconstruction outcomes assessed in this study were divided into two categories namely "success" and "failure" based on certain functional parameters observed during follow-up of 1 year. The complications were broadly classified as major/minor and flap related/non-flap related. We assessed the feasibility of using a PMMC flap for reconstructing various subsites of oral cavity cancer. Further, the association of patient variables with complication rates and outcome of reconstruction were analysed.

RESULTS

Out of 29 patients overall complications were noted in 15 (51.7%) cases with a female preponderance. Flap-related complications were noted in 9 whereas non-flap-related complications were seen in 6 patients. Major and minor complications were noted in 2 (both flap related) and 13 cases respectively. Complete full thickness flap necrosis was not encountered in any patient. Patients with flap skin paddle size ≤ 36 cm² (n = 12) had significantly increased overall complication rates. Despite complications a high success rate (93.1%, n = 27) was achieved with this mode of reconstruction.

CONCLUSION

The PMMC flap reconstruction is a versatile, reliable and an affordable single staged procedure with a high success rate in terms of achieving treatment goals. Although it has moderately high complication rates, but PMMC flap proved to be a workhorse in locally advanced cases of head and neck cancer at the end of 1 year follow-up.

Comparison of Clinical and Functional Outcomes Using Pectoralis Major and Cutaneous Free Flaps for Hypopharyngeal Squamous Cell Carcinoma

Background

The purpose of this study was to compare postoperative morbidities and functional outcomes of pectoralis major myocutaneous (PMMC) flap and cutaneous free flap reconstruction approaches in hypopharyngeal squamous cell carcinoma patients.

Methods

We retrospectively reviewed records from 99 patients who underwent hypopharyngeal reconstruction with a cutaneous free flap (n=85) or PMMC flap (n=14) between 1995 and 2013. Morbidity was classified into hospitalization, medical, or flap-related complications. Functional outcomes were classified into oral re-alimentation and decannulation time.

Results

The overall flap-related complication rate was higher in the PMMC flap group (n=8, 57.1%; P=0.019), but the medical morbidity rate was higher in the cutaneous free flap group (n=68, 80%; P=0.006). The rate of pneumonia was higher in the cutaneous free flap group (n=48, 56.5%; P=0.020). Pulmonary premorbidity was the variable most significantly associated with pneumonia (odds ratio=3.012, P=0.012). There was no statistically significant difference in oral re-alimentation and decannulation time between the two groups.

Conclusions

Although the functional superiority of free flaps has been reported in many studies, our results do not support this hypothesis. One limitation of our study is the relatively smaller flap size and fewer PMMC flap cases compared with the cutaneous free flap group. The low postoperative medical morbidity incidence rate in the PMMC flap group was clinically significant; however, the free flap group had more flap-related complications. Thus, PMMC flaps should be considered a viable option, especially for patients with pulmonary premorbidities.

Pectoralis major myocutaneous flap for head and neck reconstruction: risk factors for fistula formation

The pectoralis major myocutaneous flap (PMMF) is a safe and versatile flap used widely for head and neck cancer reconstructions, but one of the major and most feared complications is oro- or pharyngocutaneous fistula. Herein, we attempt to establish risk factors for fistula formation in reconstructions of mucosal defects in the head and neck using PMMF through retrospective analysis of PMMF performed during 3 years at a single institution, with a total of 84 procedures. There were 69 men and 15 women, with a mean age of 59.5 years. There were 15 cases of partial flap loss, two total flap losses and 31 fistulas. The independent risk factors for fistula formation were preoperative serum hemoglobin < 13 g/dl, preoperative serum albumin < 3.4 g/dl and hypopharynx reconstruction. The PMMF is still a very useful flap and this is the first multivariate analysis analysing risk factors for fistula formation. These findings are helpful in selecting patients with elevated risk of fistula formation, and therefore preventive measures can be undertaken to avoid potentially serious complications.

Contemporary role of pectoralis major regional flaps in head and neck surgery

Countless disadvantages of the "old" pectoralis major have been listed while the amazing versatility of the free flap armamentarium gives the opportunity to suit the defect deriving from virtually every ablative head and neck surgery with a tailored reconstruction. Nevertheless, pectoralis major is still the "workhorse" for head and neck reconstruction in developing countries thanks to its ease of harvest, and minimal requirements in term of instrumentation. Furthermore, even in facilities with a high volume of reconstructions by free flaps, a certain number of pectoralis major flaps is still raised every year. The history, present role and current indications of the most widely head and neck reconstructive procedure ever has been reviewed.

[Renaissance of pedicled flaps in oral and maxillofacial surgery]

A retrospective analysis in the period 2007 to 2011 included 71 surgically treated patients for carcinoma of the head and neck region and subsequent reconstruction with 36 pedicled distant flaps and 47 free flaps. Patient specific parameters of data collection with SPSS 17.0 were age and sex distribution, TNM stage and treatment. The specific type of flap reconstruction, duration of surgery, complications, intensive care and inpatient treatment were recorded. The results showed that the healing process was uneventful in 26 (72.2 %) pedicled flaps, 14 (38.9 %) pedicled flaps were transplanted in a preoperatively irradiated area of the head and neck region and in 86.0 % with a positive healing process. Tumor stage, general physical condition of the patient and type of therapy are the key parameters for the choice of reconstruction.

Outcomes of pectoralis major myocutaneous flap in female patients for oral cavity defect reconstruction

PURPOSE

Although much has been mentioned in the literature worldwide regarding the outcome of pectoralis major myocutaneous flaps (PMMFs), hardly any studies are available that mention the outcome of PMMFs in female patients. It has been presumed that complication rates after PMMF reconstruction in female patients are higher because of the presence of more adipose tissue in the flap. The objective of this study was to analyze our data regarding the outcomes of PMMFs in female patients with oral cancer undergoing reconstruction after tumor ablation.

MATERIALS AND METHODS

In this retrospective study from January 2008 to May 2012, performed in a single institution in south India, we have analyzed our data on PMMFs in 140 female patients with oral cancer. The operative technique used was essentially the same as that described originally by Ariyan. However, to preserve the deltopectoral flap area, the incision was appropriately modified in a manner as described by Schuller.

RESULTS

The mean age of the patients was 52.36 years, with a range from 30 to 76 years. They presented mostly with ulcers or ulceroproliferative lesions. Most of the patients had a history of tobacco and betel nut chewing. All of them underwent composite resection and reconstruction with PMMF under general anesthesia. Of the patients, 30 (21.4%) had complications, comprising infection (8), superficial flap necrosis (11), combined wound infection and superficial flap necrosis (3), total flap failure (2), and orocutaneous fistula (6).

CONCLUSIONS

PMMF reconstruction is a reliable and cosmetically acceptable method of reconstruction in female patients for oral cavity defects after tumor ablation.

Cost analysis in oral cavity and oropharyngeal reconstructions with microvascular and pedicled flaps

Reconstructive surgery of the head and neck region has undergone tremendous advancement over the past three decades, and the success rate of free tissue transfers has risen to greater than 95%. It must always be considered that not all patients are ideal candidates for free flap reconstruction, and also that not every defect strictly requires a free flap transfer to achieve good functional results. At our institution, free flap reconstruction is first choice, although we use pedicled alternative flaps for most weak patients suffering from severe comorbidities, and for pretreated patients presenting a second primary or a recurrent cancer. From July 2006 to May 2010, 54 consecutive patients underwent soft tissue reconstruction of oral cavity and oropharyngeal defects. We divided the cohort in three groups: Group 1 (G1): 16 patients in good general conditions that received free radial forearm flap reconstruction; Group 2 (G2): 18 high-risk patients that received a reconstruction with infrahyoid flap; Group 3 (G3): 20 patients that received temporal flap (10 cases) or pectoral flap (10 cases) reconstruction. We must highlight that pedicled alternative flaps were used in elderly, unfavourable and weak patients, where usually the medical costs tend to rise rather than decrease. We compared the healthcare costs of the three groups, calculating real costs in each group from review of medical records and operating room registers, and calculating the corresponding DRG system reimbursement. For real costs, we found a statistically significant difference among groups: in G1 the average total cost per patient was € 22,924, in G2 it was € 18,037 and in G3 was € 19,872 (p = 0.043). The amount of the refund, based on the DRG system, was € 7,650 per patient, independently of the type of surgery. Our analysis shows that the use of alternative non-microvascular techniques, in high-risk patients, is functionally and oncologically sound, and can even produce a cost savings. In particular, the infrahyoid flap (G2) ensures excellent functional results, accompanied by the best economic savings in the worst group of patients. Our data reflect a large disconnection between the DRG system and actual treatment costs.

The lateral thoracic artery revisited

BACKGROUND

Although the variations in the origin of the branches of the axillary and subclavian arteries have been well documented, little information regarding the highly variable lateral thoracic artery (LTA) is available. Descriptions of the LTA variations may prove useful during procedures of the lateral aspects of the thorax such as reconstructive plastic surgery and modified radical mastectomy.

PURPOSE

The aim of this study was to examine the anatomy of the LTA and offer an accurate account of its variability.

METHODS

The entire course and distribution of the LTA was examined in 420 formalin-fixed adult human cadavers.

RESULTS

The LTA was found in 96.7 % of the specimens, showing great morphological variability and classified into six types according to its origin. The most common type was where the LTA arose from the thoracoacromial artery (Type I 67.62 %). In decreasing order of incidence were origins from: the axillary artery (Type II 17.02 %), the thoracodorsal artery (Type III 5 %), and the subscapular artery (Type IV 3.93 %). Additionally, multiple LTAs were present (Type V 3.09 %) and complete absence of LTA (Type VI 3.33 %) was observed.

CONCLUSION

Despite variations in origin of the vessels, our dissections demonstrated that the ultimate tissue distribution of the LTA remained typical in the vast majority of the specimens and descended on the lateral border of the pectoralis minor. Our results illustrate the need for re-evaluation of the branches of the thoracoacromial artery with possible consideration that the LTA arises from it, instead of directly from the axillary artery. We hope that the information supplied by this study will provide useful information to anatomists and surgeons alike.

Indications and outcomes for 100 patients managed with a pectoralis major flap within a UK maxillofacial unit

There are few studies reporting the role of the pedicled pectoralis major (PPM) flap in modern maxillofacial practice. The outcomes of 100 patients (102 flaps) managed between 1996 and 2012 in a UK maxillofacial unit that preferentially practices free tissue reconstruction are reported. The majority (88.2%) of PPM flaps were for oral squamous cell carcinoma (SCC), stage IV (75.6%) disease, and there was substantial co-morbidity (47.0% American Society of Anesthesiologists 3 or 4). The PPM flap was the preferred reconstruction on 80.4% of occasions; 19.6% followed free flap failure. Over half of the patients (57%) had previously undergone major surgery and/or chemoradiotherapy. Ischaemic heart disease (P=0.028), diabetes mellitus (P=0.040), and methicillin-resistant Staphylococcus aureus (MRSA) infection (P=0.013) were independently associated with flap loss (any degree). Free flap failure was independently associated with total (2.0%) and major (6.9%) partial flap loss (P=0.044). Cancer-specific 5-year survival for stage IV primary SCC and salvage surgery improved in the second half (2005-2012) of the study period (22.2% vs. 79.8%, P=0.002, and 0% vs. 55.7%, P=0.064, respectively). There were also declines in recurrent disease (P=0.008), MRSA (P<0.001), and duration of admission (P=0.014). The PPM flap retains a valuable role in the management of advanced disease combined with substantial co-morbidity, and following free flap failure.

Development of the clinical use of distant flaps for head and neck reconstruction

The reconstruction of hard and soft tissue defects, mainly after ablative oncologic surgery in the head and neck area, is an evolving field. The use of free flaps for reconstruction of the head and neck is considered to be the surgical standard. In our analysis of more than 1000 free flaps we give an overview of the development of the use of different types of free tissue transfer to the head and neck area over the last 25 years. We show that the evolving field of head and neck reconstruction raises new possibilities with new types of flaps, whereas other types of flaps disappear in the everyday clinical use. The spectrum of reconstruction possibilities broadens with the number of different flap types available to the head and neck surgeon.