Reconstruction of circumferential oro- and hypopharyngeal defects with U-shaped pectoralis major myocutaneous flap.

OBJECTIVE: The purpose of the study was to evaluate the effectiveness of a U-shaped pectoralis major myocutaneous flap (PMMF) to reconstruct a large circumferential defect involving the oro- and hypopharynx. STUDY DESIGN AND SETTING: Retrospective case series. RESULTS: Twelve patients with advanced oro- and hypopharyngeal cancer (stage IV) underwent surgery resulting in a circumferential defect of pharyngoesophageal segment (PES). Those defects were reconstructed using a U-shaped PMMF. Four pharyngocutaneous fistulas were observed postoperatively and healed spontaneously within 3 to 7 weeks. Eight patients were able to resume a regular diet. A voice prosthesis was functional in 5 patients. CONCLUSION: This preliminary study shows that this technique is a simple and effective method with acceptable morbidity rate and satisfactory functional results. We demonstrate that this procedure allows the reconstruction of large defects involving the oro- and hypopharynx in irradiated patients. This technique could be an interesting alternative for surgical teams suffering from the absence of a microsurgical team. EBM rating: C-4.     

The pectoralis major myocutaneous flap in head and neck reconstruction

Summary This paper discusses the pectoralis major myocutaneous flap, its anatomy, preparation, and dissection, for use in head and neck reconstruction. Illustrative cases are reviewed and the advantages of this flap presented.     

Reconstruction of sternal defects with pectoralis major muscle flap

The earliest treatment of the median sternotomy defects was serial debridements and secondary healing. The muscle flaps that can be used in reconstruction of the presternal defects are pectoralis major muscle flap, rectus abdominis muscle flap, vertical rectus abdominis muscle flap, latissimus dorsi muscle flap with or without skin island, bipedicled pectoralis-rectus muscle flap, and external oblique muscle flap. Pectoralis major muscle flap can be used either as bilateral or unilateral rotation advancement flap, island flap, turnover flap, split turnover flap, and segmental muscle flap. Forty-eight patients with median sternotomy defects, who were treated with pectoralis major muscle flap, were included in this study. The complications were mortality, flap loss, flap dehiscence, persistent infection, and hematoma. The patients were evaluated in terms of functional loss after the operation by shoulder movement measurements. Various techniques of flap transfer can be used for the closure of a presternal defect; almost all presternal defects can be covered with the pectoralis major muscle in a single stage operation. In our opinion, the pectoralis major muscle flap should be the first choice of treatment for sternal defects.     

Microvascular salvage of a failing pectoralis major myocutaneous flap

Summary While being elevated prior to reconstruction of a left-sided neck defect, a pectoralis major myocutaneous island flap was rendered ischemic by the inadvertant transection of the pectoral branch of the thoracoacromial artery. In order to save the flap, a microvascular repair between the distal end of this vessel and the ascending branch of the transverse cervical artery was performed. The flap was successfully revascularized and the patient went on to uneventful healing with 100% flap viability. This technique could be used following similar technical error in the elevation of any axial pattern flap providing that suitable vessels for repair were present.     

Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube

BACKGROUND: This study reports our experience with fasciocutaneous reconstruction of circumferential pharyngoesophageal defects using an anterolateral thigh flap wrapped around a salivary bypass tube. METHODS: The charts of 14 patients were reviewed. All patients who had reconstruction of a pharyngoesophageal defect using an anterolateral thigh flap with a salivary bypass tube between 2001 and 2005 were included. RESULTS: There were 10 men and 4 women (mean age, 61 years). There were no fistulae reported, and the stricture rate was 14%. Eleven patients achieved oral diet sufficient to have the gastrostomy or jejunal tube removed. The patients who had tracheoesophageal puncture for voice developed functional speech. There were no flap losses. However, problems with salivary tube migration in the early cases have led to technique refinement. CONCLUSIONS: The low complication rates and the excellent functional outcomes make the anterolateral thigh flap in combination with a salivary bypass tube a viable option for reconstruction of these difficult defects.     

Reconstruction of the larynx and cervical trachea with the pectoralis major myocutaneous island flap

Trauma to the anterior cervical region, whether blunt or penetrating, is life threatening and often causes a major loss of tissue to both the larynx and the trachea. We report our experience in reconstructing the larynx and trachea with the pectoralis major myocutaneous island flap in an unusual case of extensive traumatic cervical injury.     

Reconstruction of major orbital-maxillary defects with free latissimus dorsi myocutaneous flap

Reconstruction following excision of tumors of the orbital-maxillary region represents a challenge to the head and neck surgeons. Microvascular techniques have significantly improved the possibilities of an adequate three-dimensional repair. Among the different available options, the latissimus dorsi myocutaneous flap (LDMF) has been considered, as it seems to fulfill the requirements for a functional obliterations of the orbital-maxillary cavity and to restore the facial contour. Two cases of large orbital-maxillary defects repaired with a LDMF are reported; in one of them the intraoral palatal competence and lining were achieved through a temporalis muscle flap. Technical remarks are presented and discussed as well as the indications and possibilities for more sophisticated reconstructions, aimed at a better cosmetic outcome.     

Pharyngo-esophageal reconstruction by pectoralis major myocutaneous flaps

Summary The authors want to show that the island pectoralis major myocutaneous flap has proved to be now the most effective for immediate pharyngoesophageal and neck reconstruction as stated in three preliminary publications which were the first positive reports about this technique.     

The pectoralis major myocutaneous flap combined with free jejunal transfer for aerodigestive tract reconstructions

Occasionally carcinomas of the proximal third of the esophagus invade the trachea. In these cases potential cure or adequate palliation can only be achieved by extensive resection of the hypopharynx, the proximal esophagus and the trachea. Sometimes the sternal manubrium has to be removed to obtain adequate margins of resection. Under these circumstances reconstruction of the digestive tract and creation of a properly functioning tracheal stoma can be challenging. A procedure is described in which a mediastinal tracheal stoma is created by centering the terminal portion of the trachea in a pectoralis myocutaneous flap after resection of the sternal manubrium. Digestive tract reconstruction is achieved by free jejunal transfer. For high thoracic carcinomas the manubrectomy allows resection via a proximal route and facilitates reconstruction. Similarly the integrity of the distal esophagus and stomach can be maintained. The technique is illustrated in two patient reports.     

The versatility of the pectoralis major myocutaneous flap

A consecutive group of 50 patients requiring pectoralis major myocutaneous flap reconstruction after head and neck surgery is presented. The tissue defects for reconstruction are divided into five groups to identify any defects in which the flap is more likely to be at risk of complication. Other risk factors such as preoperative radiotherapy, chemotherapy plus radiotherapy, and septic recipient site are analyzed. Its particular use in a "Third World" type population is noted.     

Reconstruction of chin and lower lip using bilateral segmental pectoralis major myocutaneous flap with functional support

Summary A 21-year-old man sustained an extensive high voltage electrical injury to his lower face, lower lip, chin, mandibular symphysis and floor of mouth. He lost all soft tissue as well as the outer cortex of the mandibular symphysis and lower teeth at the entry site. This soft tissue and skin loss was replaced by a left segmental pectoralis major myocutaneous flap [3] for lining of floor of the mouth and a right segmental pectoralis major myocutaneous flap augmentation of the chin and lower lip. The function of muscles and modiolus and orbicularis oris was reasonably regained by using bilateral temporalis muscle functional support [7]. The soft tissue on the left lower face was replaced by expanding the skin and soft tissue on the left submandibular area.     

Pectoralis major myocutaneous flap for reconstruction of partial circumference hypopharyngeal defects

Reconstruction of partial defects of the Hypopharynx and Cervical esophagus following resection for locally advanced carcinoma, by pectoralis major myocutanous flap (PMMF) was studied in 30 consecutive cases over a period of 5 years from 1988–1992 at the Tata Memorial Hospital. Patients with circumferential excisions were excluded for the purpose of this study. Two patients died in the post-operative period due to massive upper GI haemorrhage and cerebrovascular accident. These 2 patients were excluded from further analysis. Satisfactory oral intake was achieved in 26 (85%) patients. Pharyngocutanous fistula (PCF) developed in 10 (29%) patients. Anastomotic strictures developed in 4 patients, out of 2 were benign and 2 were due to recurrence of disease. Median hospital stay in patients who developed PCF was 39 days as against 14 days in those who did not develop PCF. With a minimum follow up of two years 47% patients are dead of disease, 32% are lost to follow and only 14% are alive and free of disease. Statistical analysis using univariate and multivariate tests failed to reveal any significant predisposing risk factors for PCF. Patch PMMF for the reconstruction of partial defects of the hypopharynx is a safe and reliable procedure.     

An unusual complication of the pectoralis major myocutaneous flap

The development of myocutaneous flaps has been a major advance in reconstructive surgery of the head and neck. The pectoralis major myocutaneous flap has proven to be the most reliable and versatile for use in this area. There have been several reports of its advantages with few complications noted. This article reports two patients who developed osteomyelitis of the rib in the donor area of the pectoralis major myocutaneous flap. The etiology of this potentially serious complication is discussed and the management is outlined.     

Reconstruction of trunk defects with bilobed myocutaneous flap.

This study describes the use of the bilobed myocutaneous (MC) flap for reconstruction of trunk defect. The authors employ this flap because it offers a greater flexibility in the use of available tissue than many other local conventional flaps, is easy to design, safe to elevate, and causes minimal donor-site morbidity. The bilobed MC flaps are based on their main muscular pedicle. The standard bilobed flaps are generally based on a random pattern blood supply, which were restricted to rigid length-to-width ratios to ensure viability. They are usually indicated in the repair of small defects of the nose, and scalp. When we want to apply to reconstruct on the larger trunk defect, especially for the potential to cause life-threatening complications, the bilobed M-C flap might be considered for reconstruction to decrease the potential risk of the complications.     

改良胸大肌岛状肌皮瓣在颌面部缺损修复重建中的应用

目的 探讨改良的胸大肌岛状肌皮瓣在颌面部软组织缺损修复中,延长血管蒂及改善皮瓣血运的可行性.方法 自2002年至2009年,对11例颌面部软组织缺损创面,应用改良的胸大肌岛状肌皮瓣进行修复.术中通过彻底松解血管蒂(胸肩峰动脉胸肌支),完全断开蒂部肌肉组织,将血管蒂从锁骨后骨膜下穿过,以增加血管蒂长度.切取皮瓣远端时携带部分腹直肌前鞘,并保留肋间血管的穿支与胸肩峰动脉胸肌支远端的吻合血管,以改善皮瓣远端的血运.结果 11例患者获随访2～36个月,胸大肌岛状肌皮瓣未发生坏死或部分坏死.2例患者术后发生腮腺漏,1例发生口腔内霉菌感染,1例发生轻度睑外翻.结论 改良的胸大肌岛状肌皮瓣在修复颌面部软组织缺损中可以延长血管蒂,增加转移范围,并具有改善皮瓣远端血运的优点.     

Reconstruction of major abdominal wall defects using the tensor fasciae latae myocutaneous flap

Five cases of abdominal wall reconstruction using the tensor fasciae latae myocutaneous flap are described. This flap provides a deep layer of tissue of sufficient strength to prevent herniation and external cover in a single stage repair. We regard it as the method of choice in the reconstruction of major defects of the abdominal wall.