The pectoralis major myofascial flap for intraoral and pharyngeal reconstruction.

The pectoralis myocutaneous flap has been widely used for reconstruction of oral cavity and pharyngeal defects. However, it has several disadvantages, such as chest distortion, hair growth at the reconstructed site, and excessive bulk, all of which can be avoided by the use of the pectoralis myofascial flap. Oral cavities and pharyngeal defects, ranging in size from 4 to 9 cm in largest' dimension, in 26 patients were reconstructed with the pectoralis myofascial flap. All but three defects were successfully reconstructed. The surface of the flap was covered by squamous epithelium in 1 month. The flap remained healthy during and after radiotherapy. The pectoralis myofascial flap is ideal for soft-tissue coverage of small- to medium-size oral cavity and pharyngeal defects. Its major advantages over the pectoralis myocutaneous flap are decreased bulk and improved cosmesis.     

Free radial forearm flap versus pectoralis major myocutaneous flap reconstruction of oral and oropharyngeal defects: a cost analysis

Objectives: The free radial forearm flap has replaced the pedicled pectoralis major myocutaneous flap and it has become the ‘workhorse flap’ used by many head and neck reconstructive surgeons for soft tissue reconstructions. Cost implications of radial forearm flap reconstruction within the context of the overall health care in a particular system need to be investigated particularly before it is labelled as ‘costly only’. Design and Setting: Forty patients who underwent immediate free radial forearm flap reconstruction for oral or oropharyngeal soft tissue defects were matched with patients who underwent pectoralis major myocutaneous flap reconstruction for similar defects. The 2 years of which the overall management costs according to the hospital perspective were calculated were divided into four periods: operative period, the postoperative phase, follow‐up during first year and follow‐up during second year after discharge. Results: The total costs within the first 2 years were comparable at ∼50 000 euros. The lower costs of hospital admission (24 days versus 28 days; P = 0.005) in the postoperative phase outweighed the higher costs of the surgical procedure (692 min versus 462 min; P < 0.005) in radial forearm flap patients when compared with pectoralis major flap patients. Conclusions: Oral and oropharyngeal reconstruction with radial forearm flap is not more costly than pectoralis major flap reconstruction. Given the better functional outcome and the present cost analysis, reconstruction of oral and oropharyngeal defects is preferably performed using free tissue transfer.     

双岛胸大肌皮瓣在头颈肿瘤切除、重建术中的应用

目的 探讨双岛胸大肌皮瓣在头颈肿瘤术后组织缺损修复重建应用的效果及优点。方法 应用双岛胸大肌皮瓣,对头颈肿瘤术后组织缺损的8例患者进行修复重建。结果 重建后的咽腔无狭窄,颈部皮肤均成活。皮瓣I期愈合7例;皮瓣重建颈部皮肤面边缘轻度坏死1例,经处理后愈合。患者于术后8～12d(平均10d)开始进食;术后14～20d(平均16d)出院。结论 双岛胸大肌皮瓣血供丰富,组织量多,是同时修复头颈肿瘤术后皮肤、黏膜双重缺损的优选方法。     

Oral cavity reconstruction using pectoralis major muscle and amnion

The pectoralis major myocutaneous flap has become the mainstay of major oral cavity reconstruction. The flap provides excellent soft-tissue bulk and cavity or surface lining for major defects. There is a high rate of primary take. However, the flap has some deficiencies. A group of patients were identified that are likely to have less than ideal results with the pectoralis major myocutaneous flap technique. In these cases, the flap has been modified and amnion has been added. Initial results indicate enhancement of reconstruction with the modified technique.     

Repair of head and neck defects with thin and double-lined pectoralis flaps

The evolution of nondelayed , single-stage repairs of extensive ablative defects of the upper aerodigestive tract with thin, skin-lined pectoralis myogenous and myocutaneous flaps is described, with particular emphasis on technique and applicability. To date, 15 such modified flap reconstructions of the oral cavity, oropharynx, and pharyngoesophagus have been performed. Other than one instance of flap failure, no significant short- or long-term complications were noted. The functional results of these repairs are equivalent to other, less convenient or technically more difficult methods of reconstruction.     

Pulmonary atelectasis after reconstruction with pectoralis major flaps

Forty-four patients were reviewed to determine the incidence of atelectasis following pectoralis major myocutaneous flap reconstruction of head and neck defects. Patients underwent tumor resection with subsequent pectoralis major myocutaneous flap reconstruction (flap group, n = 24) or another major head and neck procedure (control group, n = 20). Chest roentgenograms taken on the first postoperative day were scored for atelectasis by preestablished criteria. Sixty-five percent of control and 70% of flap patients demonstrated postoperative atelectasis roentgenographically. The flap patients with skin paddles larger than 40 cm2 had a 60% incidence of major atelectasis compared with 5% in control patients. The skin island area was strongly correlated with the atelectasis score in the flap group. These results suggest that atelectasis is common following pectoralis major myocutaneous flap reconstruction of head and neck defects. As well, decreased chest wall compliance after primary closure of large donor defects may contribute to the atelectasis observed.     

Safe reconstruction of a large cervico-mediastinal tracheal defect with a pectoralis major myocutaneous flap and free costal cartilage grafts

A large cervico-mediastinal tracheal defect in a 72-year-old man as a result of surgery for thyroid carcinoma with tracheal invasion and mediastinal lymph node metastasis was reconstructed using a pectoralis major myocutaneous flap and free costal cartilage grafts. The tracheal defect (55 mm x 30 mm) was located at the thoracic inlet adjacent to the major mediastinal vessels. Our reconstructive procedure was a two-staged surgery. In the first stage, a pectoralis major myocutaneous flap was transferred to the neck to provide a well-vascularized recipient bed for free costal cartilage grafts and to cover large vessels. Two pieces of free costal cartilage were grafted on the pectoralis major myocutaneous flap, one for the lateral wall reconstruction and the other prefabricated for the anterior wall of the trachea. In the second stage, the re-vascularized cartilage graft for the anterior wall of the trachea with overlying skin was rotated onto the trough of the remaining trachea and the closure of the tracheal defect was completed. We conclude that free cartilage grafts for the reconstruction of a large cervico-mediastinal tracheal defect can be safely used when they are combined with well-vascularized pectoralis major myocutaneous flaps.     

The trapezius myocutaneous flap.

The three trapezius myocutaneous flaps remain valuable adjuncts in head and neck reconstructive surgery. Overall, the lower vertical trapezius flap has the most versatility and reliability, and the least morbidity. There are several advantages of this flap compared to the pectoralis myocutaneous (PMC) flap. It has a thin vascular pedicle, and thus does not add excessive bulk to the neck, as the PMC can. Also, the skin island has less subcutaneous tissue and therefore more pliability than the PMC, which is a definite advantage for oral cavity and oropharyngeal defects. The trapezius flap generally has less hair than the PMC flap, and the donor scar is better hidden.     

Pectoralis major muscle flap in head and neck reconstruction

Pectoralis major muscle flaps have rarely been used on their own for head and neck reconstruction. Some of the problems experienced with myocutaneous flaps can be avoided by the judicious use of muscle flaps. These include suture line separation, excessive bulk, hair growth from the flap, and alteration of breast position. In contrast to the pectoralis major myocutaneous flap, the pectoralis major muscle flap is light and pliable. When it is employed for reconstruction in the oral cavity, oropharynx, or hypopharynx, it can be covered by a "quilted" skin graft or used on its own. We believe that pectoralis major muscle flaps provide a valuable alternative to the more bulky myocutaneous flaps in head and neck reconstruction.     

Prevention of hair growth in myocutaneous flap reconstruction

Myocutaneous flaps play a prominent role in the immediate reconstruction of surgical defects following ablative oncologic procedures in the head and neck. Transfer of hair-bearing skin into the reconstructed upper digestive tract can be a major disadvantage associated with the pectoralis major flap. De-epithelialization of skin to the dermal level, removing the majority of skin appendages, can convert a myocutaneous flap to a "myodermal" flap. Platysma myocutaneous and myodermal flaps were grafted into the oral cavity of 13 dogs. Gross and histologic evaluation confirmed decreased hair growth in the experimental myodermal flap. Wound complications and graft survival were similar for both techniques. Diminished hair growth further supports the utility of myodermal flaps in hairy male patients undergoing upper digestive tract reconstruction.     

The rhombotrapezius myocutaneous and osteomyocutaneous flaps

As more radical surgery is being performed for head and neck cancer, an increasing variety of flaps for reconstruction have been developed. The more common myocutaneous flaps for large defects are the pectoralis major, trapezius, and latissimus dorsi flaps. The lower trapezius flap, which is used for reconstruction of large lateral facial defects, is a relatively thin flap. The rhombotrapezius flap described in this article provides bulk for augmentation of facial defects. The flap, which includes the trapezius and rhomboid muscles, also offers a longer pedicle with a greater arc of rotation. This flap may include the medial border of the scapula when bone is necessary. The addition of the rhomboid muscles incorporates the dorsal scapular artery, which gives an additional blood supply to the flap. We believe that the rhombotrapezius, myocutaneous, and osteomyocutaneous flaps have a significant advantage over previously described flaps in the treatment of defects that need greater bulk and length for adequate reconstruction.     

Preliminary results in using the myocutaneous pectoralis major flap

The modified pectoralis major myocutaneous paddle flap has been used in 75 cases since 1982 for the closure of major defects of the oral cavity, oro- and hypopharynx and neck. Although almost all of the patients had a stage IV tumour, we had good aesthetic and functional results. There was no total flap necrosis. Three cases of partial necrosis underwent spontaneous healing. The details of the operative techniques are compared with other reconstructive methods, and the advantage of the pectoralis major flap is discussed.     

喉全切除后气管造瘘口复发癌缺损外科修复比较

目的探索喉全切除后气管造瘘口复发癌缺损外科修复的治疗效果。方法对18例喉全切除后气管造瘘口复发癌实施外科治疗。其中Ⅰ型7例,颈部单纯切口,胸大肌肌皮瓣修复颈部皮肤气管造瘘口缺损;Ⅱ型6例,颈肢或胸联合切口,前臂皮瓣或胸大肌肌皮瓣(游离前臂皮瓣5例,胸大肌肌皮瓣1例)修复部分喉咽切除;Ⅲ型3例,颈腹联合切口,游离空肠修复全喉咽、颈段食管;Ⅳ型2例,颈胸腹联合切口,胃上拉修复全喉咽、全食管。Ⅱ、Ⅲ、Ⅳ型的颈部皮肤气管造瘘口缺损均用胸大肌肌皮瓣修复。结果颈部缺损胸大肌肌皮瓣均成活;咽瘘4例(其中游离空肠1例,前臂皮瓣2例,胃上拉咽瘘出血1例);全部病例术后均能进食;随访6～74个月,3例出现不同程度吞咽梗阻。结论喉全切除后气管造瘘口复发癌外科治疗缺损,修复选择应根据原发肿瘤治疗的经过及气管造瘘口复发癌侵及范围来确定修复方法。     

The pectoralis myocutaneous flap for salvage of necrotic wounds

The authors have utilized six pectoralis major myocutaneous flaps in attempts to salvage extensive necrotic wounds of the pharynx and neck. The flap was employed in the following situations: massive necrosis of the entire neck skin with both carotid artery systems exposed, radiation necrosis of the neck skin with exposure of carotid artery, dehiscence of gastric pull-up from pharynx with resultant carotid exposure, failed trapezius flap in a radionecrotic oral cavity, and two cases of pharyngocutaneous fistula with extensive soft tissue necrosis. These flaps achieved healing in all cases. One death occurred 3 weeks following complete cutaneous healing secondary to a ruptured carotid pseudoaneurysm. One flap underwent total skin loss but the entirety of the muscle survived and the fistula was successfully closed with the back of the muscle being subsequently skin grafted. One case of dehiscence of the flap from oral mucosa resulted in a minor exposure of mandible with limited osteoradionecrosis controlled by topical means. This flap has performed extremely well in these precarious and difficult situations that previously may not have been salvageable. It has also been effective in abbreviating the required hospitalization and wound care. We conclude that the pectoralis myocutaneous flap should be the primary choice for the management of extensive postsurgical wound necrosis.     

Reconstructive options for pharyngeal and/or cervical esophageal defects

Reconstruction of the pharynx and or cervical esophagus continues to represent a formidable challenge for the head and neck oncologic surgeon. An analysis was made of 40 patients undergoing pharyngeal and/or esophageal reconstruction. The majority of these reconstructions were sometimes used in combination with skin grafts and even regional skin flaps. Those patients undergoing complete pharyngeal-esophageal reconstruction using a myocutaneous flap with soft Silastic stenting will be discussed as to the potential value of this technique. This article addresses the author's preference for particular reconstructive techniques (ie, skin graft v flap) as it relates to anatomic areas in the pharynx and esophagus. The study concludes that the myocutaneous flaps can be effectively and successfully used for the one-stage reconstruction of subtotal pharyngeal-esophageal defects. However, the reconstruction of total pharyngeal-esophageal defects continues to be a problem area, with only moderate success achieved with the techniques described.     

Pharyngoesophageal reconstruction. Is a skin-lined pharynx necessary?

Current methods of pharyngoesophageal reconstruction have in common the creation of an epithelial lined pharynx. We performed eight cases of pharyngoesophageal reconstruction with a pectoralis major muscle flap. In the first six cases, split-thickness skin was quilted onto the muscle. In the last two cases, pectoralis major muscle alone was used, allowing epithelialization to occur from adjacent mucosa. The results with this simplified technique have been as good as when a skin-grafted muscle flap was used. We prefer a pectoralis major muscle flap, with or without split-thickness skin, to a pectoralis myocutaneous flap. There is no hair growth, it is easy to tube, and a thin-walled pharynx is produced. This is an advantage for the development of an esophageal voice, and tracheoesophageal puncture can be easily performed if no voice is achieved. All of our patients received full-dose, preoperative radiotherapy. One patient developed a fistula that closed spontaneously. There have been no strictures at the pharyngoesophageal junction. All patients quickly established a good oral intake.     

Oropharyngeal reconstruction: current state of the art

Oropharyngeal reconstruction represents one of the greatest challenges in the surgical rehabilitation of patients with head and neck cancer. This article reviews several reconstruction methods, starting with the primary closure and healing by secondary intention all the way to the complex sensate microvascular flap reconstructions. Small defects such as tonsillar, small tongue base, and partial palatal defects may be closed primarily or left to granulate. This is assuming that there is no communication with the neck or bone exposure. Local flaps such as the palatal island, submental, and buccal mucosal flaps are used to close small to moderate-sized defects. Split-thickness skin grafts are also appropriate for small to moderate-sized defects. Larger defects such as total palatal, more than 50% of the tongue base, and composite tongue base/palatal/pharyngeal defects may be closed with regional myocutaneous pedicled flaps such as the pectoralis major, lower trapezius, or latissimus dorsi pedicled flaps. Microvascular tissue transfer is an excellent alternative for closure of moderate to large-sized defects. Free tissue transfer includes the radial forearm and the lateral arm free flaps. Both of these can have a sensory component. Free jejunal flaps are used for total or subtotal hypopharyngeal defects. Free gastro-omental flaps may be used for oropharyngeal and hypopharyngeal reconstruction as well. For defects involving bone, fibular flaps are an excellent option and can provide sensation. The scapular free flap may be used as well and offers the advantage of having two skin paddles (scapular and parascapular) for internal and external lining. Following a reconstructive ladder is extremely important in ensuring good function and, hence, improved quality of life.     

Treatment of recurrent head and neck carcinoma involving the carotid artery: carotid reconstruction with ePTFE graft

The aim of our study is to investigate the feasibility of reconstructing the carotid artery using expanded polytetraflouroethylene (ePTFE) in patients with recurrent head and neck carcinoma involving the carotid artery. Ten patients, who had recurrent head and neck carcinoma involving the carotid artery, received carotid artery resection and reconstruction with ePTFE, tissue defects were repaired by pectoralis major myocutaneous flap. Results show that eight patients did not present any vascular and neurologic complications. One patient presented slight hemiparesis, another patient developed wound infection and pharyngocutaneous fistula. The mean follow-up period was 33.1 ± 16.0 months. The 2-year survival rate was 50% (5/10), and there was one patient who survived for 60 months without locoreginal recurrence or distant metastasis. En bloc resection of tumor and involved carotid-associated ePTFE reconstruction provide effective improvement in the locoregional control of the recurrent head and neck carcinoma. The pedicle pectoralis major myocutaneous flap can provide not only wound bed with affluent blood supply for the vascular grafts, but also reparation of skin or the tissue defects of oropharynx and hypopharynx.     

Oral and pharyngeal reconstruction using the free forearm flap

Recent progress in myocutaneous and free flaps has facilitated the primary closure of various complex defects resulting from ablative surgery of head and neck cancers. The musculocutaneous flap (such as the pectoralis major flap or the latissimus dorsi flap) has in particular proved its greater versatility. The forearm free flap for intraoral defects can provide thin and pliable skin and has great potential in the reconstruction of oropharyngeal defects. Between November 1982 and August 1985, we achieved 74 free forearm flap transfers for patients with head and neck cancers. Herein we present several clinical applications of the free forearm flap and discuss its advantages and disadvantages, especially hand morbidity after flap elevation.     

Reconstruction of the hypopharynx with U-shaped pectoralis major myocutaneous flap after total pharyngo-laryngectomy

Resection of the whole circumference of the pharynx and esophagus is usually reconstructed with gastric pull-up, jejunum free graft or free forearm flap. The aim of this study was to assess the use of pectoralis major myocutaneous flap for closure of total pharyngeal defect. In 11 patients with hypopharynx and larynx cancer, total pharyngo-laryngectomy and excision of the cervical part of the esophagus and neck dissections were performed; the defects were closed with pectoralis major myocutaneous flaps. The skin island was sutured to prevertebral muscles, forming a letter U shape. Good healing was obtained in six patients, and five patients developed fistula that closed spontaneously within 3–4 weeks. The use of U-shaped pectoralis major myocutaneous flap, suturing it to prevertebral muscles, gives good functional results, and it is a simple and time-saving second choice method of reconstruction of the pharynx after total pharyngo-laryngectomy.