Two modifications of pectoralis major myocutaneous flap (PMMF)

Pectoralis major myocutaneous flap is the most commonly used versatile flap in head and neck reconstructive surgery. The use of entirely tubed pectoralis major myocutaneous flap for reconstruction of the hypopharynx following total laryngectomy and total pharyngectomy has a disadvantage of bulkiness of the flap and poor postoperative deglutition. One-stage reconstruction of the entire hypopharynx utilizing a combination of pectoralis major myocutaneous flap and dermal graft minimizes bulkiness, thus achieving satisfactory to excellent functional results. The operation has been performed on four patients with excellent deglutition. The pectoralis major myocutaneous flap is utilized to reconstruct the anterior and lateral walls of the hypopharynx, the dermal graft for the posterior wall as far superior as the vault of the nasopharynx. The operative procedure is described. Pectoralis major myocutaneous flap usually provides enough length to reach the distant site of the surgical defect. On occasion, however, additional length is desirable to avoid tension along the suture line. This becomes apparent when a random portion of elevated pectoralis major myocutaneous flap presents questionable viability which may require further trimming. Resection of the medial half of the clavicle can provide additional length of this flap by 2 cm to 2.5 cm.     

Platysma myocutaneous flap revisited

The platysma myocutaneous flap has seen limited application in the reconstruction of head and neck defects over the past decade. There are anatomical and physiological reasons for this. There has been an emphasis on the anatomical vascular supply and method of preparation of the platysma myocutaneous flap and its use in the oral cavity. This article emphasizes the use of this flap for reconstruction of defects of the base of tongue, hypopharynx, lateral pharyngeal wall, and supraglottis. The criteria for selection of the platysma myocutaneous flap as a method of reconstruction, and the limitations, are outlined. New variations of harvesting the flap based on randomized muscular support are described. Specific complications as seen in our group of patients add certain precautions in the use of the platysma myocutaneous flap.     

The use of the platysma myocutaneous flap for reconstruction in the head-neck area -- a retrospective study

OBJECTIVE: Following extended tumor resections in the head-neck area options immediate defect reconstruction is needed to reduce healing time and improve rehabilitation. Reconstruction of significant areas of mucosal defects is best accomplished by introduction of a pliable regional transplant. The platysma myocutaneous flap has been used for defect reconstruction in head and neck area since more than 20 years. Its popularity is limited. Since 2001 in our department the platysma mucocutaneous flap is used for such reconstructions. We present a retrospective study evaluating our experience with the platysma myocutaneous flap. METHOD: From 2001-2003 25 patients have been subjected to surgical reconstruction applying the platysma mucocutaneous flap. The primary tumor was located in 16 patients (64 %) in the oropharynx, in 5 patients (20 %) in the hypopharynx and in 4 patients (16 %) in the oral cavity. Evaluation was based on medical records including the operative reports. All patients get a follow up in our outpatient clinic. RESULTS: The platysma flap is easy to harvest and has a low general risk level. Complications are minor and may be avoided by exact preoperative planning. Necrosis of the skin-muscle-flap was observed only after resection of the A. carotis externa (two cases). In these 2 cases an operative revision was necessary (stenting of the pharynx or secondary reconstruction by pectoralis major-flap). The resection of the A. facialis (three cases) did not lead to a serious complication. CONCLUSIONS: Considering the exact indication the platysma flap is suitable for reconstruction of surface defects in the pharynx and oral cavity. A special attention is given to the ipsilateral vascular supply and the length of the muscular pedicel. It proved to be a cost effective method due to the less time and personal expenditure.     

Combined use of pectoralis major myocutaneous and free radial forearm flaps for reconstruction of through-and-through defects from excision of head and neck cancers

OBJECTIVES: The aim of this study was to examine the outcome and complication in patients who underwent reconstruction with combined use of pectoralis major myocutaneous flap (PMMCF) and free radial forearm flap (FRFF) for the through-and-through defect after surgical resection for head and neck cancer. METHOD: Twelve patients underwent primary reconstruction with the combined use of PMMCF and FRFF for through-and-through defect of facial or cervical skin and oral or pharyngeal mucosa resulting from treatment of head and neck cancer. Free radial forearm flap was used for three patients with oral mucosal defect, two patients with oropharyngeal mucosal defect, and two patients with defect from total laryngopharyngectomy. The osteocutaneous FRFF was used for five patients with defect of oral mucosa and mandible. Pectoralis major myocutaneous flap was used for seven patients with facial skin defect and five patients with cervical skin defect. RESULTS: All PMMCFs and FRFFs were successful. Early complications were minor and occurred in 4 (33%) of 12 patients. No delayed complication was observed. During the follow-up period, 5 patients died of disease between 10 and 52 months. Currently, 6 patients are alive with no evidence of disease and 1 patient developed a distant metastasis to the lung. The follow-up period ranged from 12 to 54 months. CONCLUSION: For patients with through-and-through defect after resection of mucosa of upper aerodigestive tract and skin, the combination of PMMF and FRFF reconstruction achieved optimal long-term results.     

Perioperative clinical factors affecting volume changes of reconstructed flaps in head and neck cancer patients: free versus regional flaps

Postoperative volume changes in reconstructed flaps are known to influence the functional restoration of resected areas of the upper aerodigestive tract. The purposes of this study were to estimate the volume decreases in flaps and investigate clinical factors affecting the volume decrease. The medical records of 19 patients who underwent ablation and flap reconstruction surgeries for head and neck cancers were reviewed. The volume of the reconstructed flap was measured at 3, 12, and 24 months postoperatively using CT or MR imaging and the 3D-DOCTOR software. The relationships between volume changes and perioperative clinical parameters were examined. The primary tumor locations were the nasal cavity and paranasal sinus, oropharynx, oral cavity, and hypopharynx in 8, 6, 4, and 1 case, respectively. Twelve patients underwent anterolateral thigh flap (ALTF) reconstruction, and seven patients underwent pectoralis major myocutaneous flap (PMMCF) reconstruction. Twelve (63.2%) patients received postoperative radiation. The estimated volume decreases at 12 and 24 months postoperatively for ALTF were 20.9 and 24.8%, respectively, while those for PMMCF were 7.3 and 10.8%, respectively. Among clinical factors, only the type of flap affected the volume change. When determining the volume of reconstructed flaps, the type of flap must be considered. It was recommended to make free and regional flaps at least 20 and 10% larger, respectively than the actual defect.     

Fracture of the clavicle following the island type of pectoralis major myocutaneous flap for reconstruction of head and neck defect

Fractures of the clavicle following radical neck dissection (RND) and/or radiation therapy have been previously noted in the literature. Interestingly, we experienced three cases of clavicular fracture, which were considered to have resulted from pectoralis major myocutaneous flap (PMMCF). All of these three cases had received the combined treatment of RND, PMMCF and postoperative radiotherapy on the side of fracture. In all three cases, ipsilateral lower neck received 4,500 cGy and island type of PMMCF was used for reconstruction of surgical defect in head and neck area. All fractures noted between 1 and 3 years postoperatively occurred on the medial portion of the clavicle. Devascularization after stripping of periosteum and altered mechanics of the clavicle following resection of clavicular head of pectoralis major muscle may contribute to develop this rare complication in addition to the effect of radiotherapy and RND. We present three cases of the clavicle fracture following the island type PMMCF with a review of literature.     

The Platysma Myocutaneous Flap: Underused Alternative for Head and Neck Reconstruction

Objectives The use, advantages, and disadvantages of the platysma flap were assessed. Study Design Retrospective review of the medical records of patients undergoing platysma flap reconstruction of the upper aerodigestive tract from 1987 to 2001. Methods Information regarding the tumor, surgical procedure, flap design, and outcome emphasizing complications and function was extracted. Associations between putative risk factors for flap failure and outcome were assessed using the χ² test. Results Thirty‐four patients underwent reconstruction with platysma flaps. Surgical defects included the oropharynx, oral cavity, and hypopharynx. Nine patients had had prior radiation therapy and all had some dissection of the ipsilateral neck. There were 5 postoperative fistulas (15%), flap desquamation was noted in 6 cases (18%), and 2 patients experienced loss of the distal skin closing the donor site. Complications were not associated with prior radiation. Hospital stay ranged from 5 to 21 days (mean, 10 d). There were no returns to the operating room or need for additional reconstruction. All but 1 patient resumed a normal diet within 3 months of surgery. There were no recurrences of cancer in the dissected neck regions. Conclusions The platysma flap is simple and versatile with properties similar to the radial forearm free flap. The rate of complications is similar to other published series, and problems encountered were manageable using conservative methods with excellent functional and cosmetic outcomes. These facts support the contention that the platysma myocutaneous flap can serve as a viable alternative to free tissue transfer and has advantages over pectoralis major pedicled flaps for reconstruction of many head and neck defects.     

Tumours of the posterior pharyngeal wall: the use of the platysma flap

Posterior pharyngeal wall tumours are infrequent neoplasms with a very poor prognosis. The 5 year survival rate ranges from 3% to 32%. Most authors agree that the treatment of choice is surgery with post-operative radiotherapy. The results of treatment of 36 patients (tumour excision plus bilateral neck dissection and post-operative radiotherapy) in which the posterior pharyngeal wall defect was closed with a platysma myocutaneous flap were compared with other forms of repair (13 patients). The 5 year survival rate was 17.2% in the whole group. Laryngeal voice was achieved in 79% of patients having a platysma flap reconstruction. The platysma myocutaneous flap is very satisfactory for the repair of the posterior pharyngeal wall as it is easy to perform, it is oncologically safe and its functional results match well with other forms of reconstruction, with the advantage of laryngeal preservation.     

Platysma myocutaneous flap for repair of hypopharyngeal strictures

Hypopharyngeal strictures, either isolated or in conjunction with laryngeal and esophageal strictures, can occur following lye ingestion. Extensive stricture formation requires reconstruction to create a functional funnel system that empties below the cricoid. Esophageal replacement is not a substitute for adequate hypopharyngeal reconstruction. The pectoralis major muscle is often inadequate, because it yields too much bulk and often leads to continued aspiration. The platysma myocutaneous flap for hypopharyngeal reconstruction has not been previously reported. The inferiorly based platysma myocutaneous flap was used in two of our patients with lye burns, and bilateral superiorly based flaps were used in one. All are able to eat normally and have no significant stenosis. The platysma myocutaneous flap is a relatively simple and reliable alternative that is within the capability of every head and neck surgeon.     

Platysma transverse myocutaneous flap: a 21 case series of an overlooked reconstructive method for facial skin defects

IntroductionSince the first report of a platysma transverse myocutaneous flap in 1977, few articles about this flap design have been added to the literature.ObjectiveOur aim is to describe our department’s experience with platysma transverse myocutaneous flap.MethodsA retrospective review of all patients undergoing platysma transverse myocutaneous flap reconstruction between 2011 and 2019.ResultsThere were 16 men and 5 women in this series. The mean patients’ age was 72.7 years old. In eight cases, we had wound complications, including four wound infections, one hematoma and three distal flap ischemia problems. Distal flap ischemia occurred only in cases that advanced beyond the midline and with length-to-width ratio equal to or over three to one. Neck dissection was performed in two of these three cases with ischemic complications.ConclusionSeveral factors may influence platysma transverse myocutaneous flap survival. Usually a long and narrow flap, especially crossing the neck midline and associated with neck dissection are more prone to poor outcomes.     

下咽及颈段食管缺损修复的供区选择和临床评价

目的：探索下咽及颈段食管缺损的分类及不同类型缺损的修复方法选择原则和临床疗效。方法：2007—01—2012-06期间共行下咽及颈段食管缺损修复术39例。根据下咽及颈段食管缺损程度分为环周／近环周缺损组（A组,23例）和部分缺损组（B组,16例）;根据颈部血管状况分为颈部血管状况不良组（22例）和颈部血管状况良好组（17例）。供区选择主要根据缺损程度和颈部血管状况决定。A组采用股前外侧皮瓣8例、胃上提6例、桡侧前臂皮瓣3例、空肠瓣和胸大肌肌皮瓣各3例;B组采用舌骨下肌肌皮瓣8例、桡侧前臂皮瓣3例、胸大肌肌皮瓣5例。观察皮瓣的存活率、手术并发症、功能效果和肿瘤治疗的临床转归。结果：全组并发症发生率为12．8％（5／39）。A组空肠瓣、股前外侧皮瓣、胸大肌肌皮瓣坏死各1例,皮瓣坏死均发生在颈部血管状况不良组;B组发生咽瘘1例,无皮瓣坏死。全组2例未能经口进食,其余病例无进食障碍;保留喉功能16例均发音良好。全组2年、3年总生存率分别为72．1％和65．2％。结论：下咽及颈段食管缺损修复供区的选择应根据缺损程度、颈部血管状况和组织瓣的特性综合分析,个体化应用。个体化下咽及颈段食管修复可获得满意的临床疗效。     

胸大肌肌皮瓣卷筒在下咽颈段食管环周缺损修复中的应用

目的 探讨胸大肌肌皮瓣卷筒在晚期喉咽及颈段食管肿瘤切除术后环周缺损修复中应用的可行性及远期疗效.方法 回顾性分析2004年12月至2008年10月对30例头颈鳞癌原发灶肿瘤切除后出现下咽和颈段食管环周缺损的患者选择行胸大肌肌皮瓣卷筒修复的临床资料.其中下咽癌22例,颈段食管癌7例,喉癌术后放疗后复发累及下咽1例.术前接受放疗者5例,外院手术后复发者3例.采用全喉全下咽切除者12例,全喉全下咽切除颈段食管切除者18例,均行胸大肌肌皮瓣卷筒修复.结果 术后咽瘘4例,其中2例有术前放疗史,2例有糖尿病史,均换药治愈.2例患者出现吻合口狭窄,均位于口咽部上吻合口处,经反复扩张后缓解,术后吞咽功能均恢复.全部患者均进行随诊,术后随访时间8～56个月,中位随访时间18个月.以Kaplan-Meier法计算生存率,1年及3年生存率分别为71.4%及42.5%.结论 胸大肌肌皮瓣卷筒修复晚期咽喉及颈段食管肿瘤切除后的下咽和颈段食管环周缺损效果可靠.可用于放疗及手术后复发肿瘤切除后环周缺损的修复.     

胸大肌肌皮瓣在侵犯下咽晚期头颈鳞癌手术切除术后缺损修复中的应用

目的 探讨不同情况下应用胸大肌肌皮瓣(PMF)修复下咽颈食管区域重要和复合缺损的方法和可行性。 方法 采用PMF单独或联合其他修复方法,结合对修复方法的改良,采用不同方式修复晚期和复发性下咽癌和喉癌侵犯下咽颈食管区域手术切除术后下咽颈食管巨大和复合性缺损59例,缺损类型包括下咽颈食管部分缺损、下咽颈食管环周缺损以及下咽颈食管缺损合并颈前软组织巨大复合缺损。 结果 完成单纯PMF覆盖法26例,椎前筋膜游离植皮加PMF覆盖4例,PMF覆盖加颈前表面游离植皮2例,PMF覆盖下咽加胸三角皮瓣(DPF)修复颈前缺损2例,单纯PMF皮管16例,PMF皮管加肩胸皮瓣表面覆盖4例,胃上提加PMF覆盖3例,双岛瓦合PMF 2例。术后20例出现了不同程度并发症,除1例院内死亡外,其余均经妥善处理治愈,恢复吞咽功能。 结论 PMF适合各种情况的下咽颈食管缺损修复,特别是在颈部同时伴有巨大软组织复合缺损时,这种方法更具优越性。     

Surgical techniques and results of lateral thoracic cutaneous, myocutaneous, and conjoint flaps for head and neck reconstruction

BACKGROUND: This paper aims at presentation of our surgical techniques and results of the lateral thoracic (LT) flaps for head and neck reconstructions. METHOD: There were seven LT cutaneous, seven LT myocutaneous, and two LT conjoint myocutaneous flaps for reconstruction of head and neck mucosal or cutaneous defects. RESULTS: The largest flap size was 22 cm x 13 cm. All donor sites were closed primarily. The highest point of reconstruction was in the nasopharynx internally and zygoma externally. All flaps survived without major complication. CONCLUSIONS: The LT flap has the versatility of cutaneous, myocutaneous, and conjoint flaps with pectoralis major or latissimus dorsi myocutaneous flaps to reconstruct large surgical defects. It has a large, reliable surface area, a long pedicle to reach nasopharynx and zygoma, and has less bulky muscle to facilitate tubular reconstruction of circumferential pharyngeal defect, one-stage operation, esthetic hidden donor site scar in axillary region, and minimal donor site morbidity. It is an additional reliable pedicle flap in our armamentarium for reconstruction of both cutaneous and mucosal defects in the head and neck region.     

Tracheal reconstruction with a modified infrahyoid myocutaneous flap

Reconstruction of a tracheal defect is a challenge because it often requires invasive surgery associated with relatively high morbidity. We recently invented a less-invasive method using a modified infrahyoid myocutaneous (IHMC) flap for the reconstruction of a tracheal defect in an 83-year-old male. A tracheal defect, the right half of the cricoid cartilage plus the right three quarters of the I-IV tracheal cartilage (about 3 × 4 cm), was reconstructed with a modified IHMC flap composed of the sternohyoid and platysma muscles and a skin pedicle. Considering the age of patient, we avoided rigid reconstruction and used a soft silicone tracheal opening retainer (Koken Co., Ltd., Tokyo, Japan) as an anterior wall dilator after surgery and waited for the scarring of the flap until it become rigid enough. The postoperative course was uneventful and the trachea was reconstructed safely. Tracheal reconstruction with an IHMC flap is a useful and less-invasive alternative compared to end-to-end anastomosis or reconstruction with a forearm flap, which is currently used as a mainstay.     

10 years' experience on infrahyoid myocutaneous flap]

From May 1979 to December 1989, 260 infrahyoid myocutaneous flaps (IHMCFs) were used for reconstruction after resection of head and neck cancer in one stage. It has been certified that the IHMCF is a reliable versatile and convenient island myocutaneous flap, suitable for repairing the defect in the oral cavity, parotid region, oro- or hypopharynx particularly the tongue after hemi-excision of oral tongue to radical total glossectomy. The success rate of the IHMCF may be increased to 97% if the following points are noticed. 1. The sternal head of the sternocleidomastoid (SCM) muscle below the hyoid bone is included in the flap for protecting the platysma and the SCM branches of the superior thyroid artery to the IHMCF. 2. During cutting the tributaries of the internal jugular vein (IJV) below the level of the hyoid bone for increasing movability of the IHMCF, the cutting points must be near the anterior edge of IJV for preserving the communicating veins between the anterior jugular vein and IJV. 3. For reconstructing the oral tongue, the medial edge of the IHMCF must be designed 1 cm beyond that of the defect after partial excision of the oral tongue. Since the application of the IHMCF, the incidence of the tongue carcinoma patient (TCP) with T4 has increased from zero to 53%. The 5-year cure rate of the TCP with stage IV has raised from 11% to 42%. For N0 and N1 cases, the pure neck failure after modified neck dissection with preservation of lower 2/3 or whole length of the IJV was similar to that of the radical neck dissection.     

颈部矩形返折肌皮瓣Ⅰ期下咽重建

目的：探讨颈部矩形返折肌皮瓣Ｉ期修复下咽缺损的疗效,方法：总结我院２０例下咽 行喉全切除及下咽部分或全部切除,应用颈部矩形返折肌皮瓣Ｉ期修复下咽的临床资料,结果;２０例颈部矩形返折肌皮瓣全部成活,５例术后有小咽瘘,７～１０ｄ自愈,１例术后２个皮管下端吻合口狭窄,行ＩＩ期手术除狭窄治愈,全部病例随访３～９年,３年、５年生存率分别为５０．０％和３３．３％,结论：颈部矩形返折肌皮瓣是Ｉ期修复下咽缺损的简单易行、成功率高的有效方法。     

Esophageal reconstruction with larynx preservation using forearm-free flap

Surgery for cervical esophageal malignancy frequently involves comcomitant total laryngectomy carried out because of either oncologic or functional concerns. Though uncommon, preservation of the larynx has, in recent years, been described in patients undergoing cervical esophagectomy with reconstruction of the resulting circumferential esophageal defect achieved using either free jejunal flaps or gastric pullup procedures. The use of tubed-free cutaneous flaps for circumferential cervical esophageal reconstruction, however, has been rarely described in situations where the larynx has been preserved. We describe successful use of a tubed radial forearm-free flap for reconstruction of a circumferential cervical esophageal defect with preservation of the larynx. Use of the radial forearm flap in this situation resulted in minimal donor site-related morbidity, avoided the need for laparotomy and excellent voice and swallowing function were maintained. As such, use of tubed cutaneous free flaps can be considered an option for cervical esophageal reconstruction when the larynx has been preserved.     

应用颈阔肌肌皮瓣修复下咽腔瘢痕狭窄

目的：探讨带蒂颈阔肌肌皮瓣转移术修复下咽腔狭窄术。方法：对本组10例下咽腔瘢痕狭窄患者应用带蒂颈阔肌肌皮瓣转移行下咽腔重建术。结果：本组术后9例顺利拔除气管套管，恢复正常的呼吸、发声和吞咽功能，随访1-3年手术效果巩固。结论：带蒂颈阔肌肌皮瓣转移修复下咽腔瘢痕狭窄术，操作简单易行，并发症少，具有较高的成功率和较好的远期疗效，此肌瓣是理想的下咽腔重建材料，值得临床推广应用。     

Immediate reconstruction of pharyngoesophageal defects. Preference or reference

In this era of development in reconstruction, interest in searching for the most appropriate procedure for replacing the pharyngoesophageal defect is intense. The type of defect, depending on the level of invasion by the cancer, should be classified as partial pharyngeal, circumferential pharyngeal, or pharyngoesophageal. Within each class, the surgeon can have his preference for a reconstructive procedure according to available expertise and familiarity. In our series of 97 patients with pharyngoesophageal defects resulting from resection of laryngeal, hypopharyngeal, and cervical esophageal cancers, the patch-on pectoralis major myocutaneous flap, the tubed pectoralis major myocutaneous flap, and the stomach were used for the three types of defects, respectively. Mortality and morbidity, while kept at an acceptable level, appear to rise as the complexity of the procedure increases. This supports the argument that the reconstructive method should be selected with reference to the type of defect, which is in turn dependent on the site and behavior of the tumor. The reconstructive procedure is to fit the defect, and not vice versa.