The pectoralis major myocutaneous flap in head and neck reconstruction

The pectoralis major myocutaneous flap (PMMC flap) represents a landmark in the development of head and neck reconstructive surgery. After Stephan Ariyan first described its use for head and neck reconstruction in 1979, it has become tremendously popular and has revolutionised head and neck cancer surgery. Here, we present our initial experience with fourteen PMMC flaps in head and neck reconstruction. In most of the instances it was used for oral or oropharyngeal reconstruction. It was used for five other reconstructive tasks as well. Wound infection was the most common complication. There was no case of total flap loss. It has proven to be a reliable method of reconstuction in the head and neck.     

Simultaneous reconstruction of large skin and mucosal defect following head and neck surgery with a single skin paddle pectoralis major myocutaneous flap

The pectoralis major myocutaneous (PMMC) flap is commonly used for head and neck reconstruction especially in impoverished nations. PMMC is a sturdy pedicled flap with relatively fewer complications, the learning curve is short and no specialized training in microvascular surgery is needed in order to use this flap. In a defect that requires a large skin and mucosal lining the authors routinely use either a bi-paddle PMMC or a combination of PMMC (for the mucosal lining) and a delto-pectoral flap (for the skin defect). It is indisputable that free tissue transfer is a better way of reconstruction for the majority of most such defects. Unfortunately, not all patients can be offered this form of reconstruction due to the cost, time, expertise and infrastructural constraints in high volume centres such as ours. Bi-paddling of PMMC is hazardous in obese males and most female patients. In such patients the skin defect is reconstructed usually by the delto-pectoral (DP) flap but this, for obvious reasons, is less welcomed by the patients. The authors suggest a technique wherein mucosal lining is created by the myofascial lining (inner surface) of the flap and the skin defect is reconstructed by the skin paddle of the single paddle PMMC. It should be considered wherever a DP flap is unacceptable, or bi-paddling or free tissue transfer is not possible.     

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.     

Post-operative complications of salvage total laryngectomy forpost-radiotherapy recurrent laryngeal cancer using pectoralis major myocutaneous flaps

Background: Salvage surgery for laryngeal cancer recurring after radiotherapy is difficult and complications readily occur. Our institution has adopted the pharyngeal interposition graft (PIG) using a pectoralis major myocutaneous (PMMC) flap, which has copious blood flow, for preventing post-irradiation pharyngocutaneous fistula.

Aims/objectives: The purpose of this study was to examine the incidence of post-operative complications of salvage total laryngectomy (STL) using the PMMC flap for post-radiotherapy recurrent laryngeal cancer at our institution.

Material and methods: From among 162 patients with laryngeal cancer who had been treated at Tokyo Medical University Hospital between January 2014 and March 2018, we enrolled 11 patients who had undergone STL applying a PMMC flap. We examined patient backgrounds (age, gender, subtype, stage), initial therapy (radiotherapy/chemoradiotherapy), radiation dose, irradiation area, surgery type (with/without neck dissection) and postoperative complications.

Results: No severe systemic complications were encountered. Pharyngocutaneous fistula occurred as a severe local complication in one patient (8.3%) and wound infection as a mild local complication in one patient (8.3%).

Conclusions: Rates of post-operative complications following STL tended to be lower at our institution than those reported for other institutions.

Significance: PIG may be a useful surgical procedure in STL.     

Partial laryngopharyngectomy for piriform sinus carcinoma. Technique and preliminary results

This paper presents a technique for partial laryngopharyngectomy followed by a one-stage reconstruction and its preliminary results. This surgery is indicated for carefully selected cases in which the lesion is confined to the ipsilateral piriform sinus, aryepiglottic fold, arytenoid eminence and paraglottic space at the level of the false fold. The hyoid bone, thyroid ala, arytenoid cartilage, epiglottis, aryepiglottic fold, arytenoid eminence and false fold are removed on the affected side. Reconstruction is performed with the use of a pectoralis major myocutaneous (PMMC) flap. The surgery was performed on four cases: two were successful; one suffered from persistent postsurgical aspiration because the reconstructed hypopharynx was too wide; and one developed necrosis of PMMC flap and a secondary reconstruction procedure was performed.     

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.     

The pectoralis major myocutaneous flap: An angiographic study

A new era in head and neck reconstruction has been opened with the use of myocutaneous flaps. The pectoralis major myocutaneous flap is considered the most reliable of its kind but flap failures still occur secondary to tension and infection. Our standard procedure has been to follow the acromioxiphoid line as a guide to the location of the blood supply of the pectoralis major muscle. We have noticed in the operating room and during cadaver dissection that the vascular supply is sometimes more laterally located than usually described. A review of the vascular supply of this anatomic area using angiographic studies of the subclavian and its branches is presented, with important findings critical to the surgical technique used to protect the flap's blood supply.     

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.     

Reconstruction of oropharyngeal defects with lateral arm flap

The lateral arm flap, is a fasciocutaneous flap with great versatility, but underused in head and neck reconstruction. Its qualities include a intermediate thickness between the radial forearm flap and the pectoralis major, ideal to reconstruct oropharyngeal defect, a consistent vascular pedicle, a pliable soft tissue and a low donor site morbidity. Use of this flap does not require the sacrificing of a major feeding vessel to the arm. We have chosen this technique to reconstruct four cases with surgical defects in oral cavity and oropharynx. The anatomic and functional results have been satisfactory and the complications rate is comparable to other microvascular techniques. We think that the lateral arm free flap is a useful reconstructive technique in specific areas of head and neck.     

The pectoralis major flap.

The pectoralis major myocutaneous flap (PMC) is a major flap for reconstruction of large head and neck defects. Its principle advantages are its dependability and ability to cover large defects. It is, however, a bulky flap, preventing its use for delicate reconstruction. The PMC flap is justifiably a popular flap that will continue to command an important place in the head and neck surgeon's reconstructive armamentarium.     

The pectoralis major myocutaneous flap. Use in surgery of the lower neck and superior mediastinum

Surgery of the lower neck and superior mediastinum is most frequently performed for parastomal recurrence of laryngeal carcinoma. It has been associated with a high incidence of complications, often leading to fatal innominate artery rupture. The use of the pectoralis major myocutaneous flap has permitted wide en bloc resections of the superior mediastinum in ten patients without a major complication. Several technical innovations add versatility to the pectoralis major myocutaneous flap, including tailor fitting each skin paddle and incorporating the pectoralis minor into the muscular pedicle. Superior mediastinal resection should be performed in conjunction with laryngectomy and cervical lymph node dissection in patients who are at high risk for parastomal recurrence. We also recommend that patients with parastomal recurrence undergo this procedure for salvage.     

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.     

Caustic soda ingestion -- a case presentation and review of the literature

We present a case report of a 2-year-old child with a hypopharyngeal stricture secondary to caustic soda ingestion. We discuss the initial and long-term management of caustic soda ingestion. In this case the hypopharynx was successfully reconstructed using a pedicled pectoralis major flap. We demonstrate the versatility of this flap, which is traditionally known for its use in adult head and neck surgery.     

Enhanced Reliability and Renewed Applications of the Deltopectoral Flap in Head and Neck Reconstruction

Bakamjian introduced the deltopectoral skin flap in 1965, and thereafter it was used extensively for reconstructive surgery of the head and neck. Flap failure rates of 10% to 25% were reported, necessitating the development of alternative methods of reconstruction and eventually relegating the flap to historical references. Since 1991, we have used the deltopectoral flap in 24 patients for reconstruction after head and neck tumor surgery. Simple technical modifications have been used to enhance the reliability of this flap, with no observed failures or even partial flap loss. The deltopectoral flap remains a versatile and reliable tissue source that can be used simultaneously with the pectoralis major myocutaneous flap for a variety of complex head and neck reconstructions. Laryngoscope, 106:1230-1233, 1996     

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.     

Jejunum transplantation. Therapeutic progress?

Either the musculocutaneous island flap (especially the pectoralis major flap) or the free jejunal transplant are used for large mucosal defects of the oro- and hypopharynx. As a jejunal transplant is more time consuming than the use of a musculocutaneous flap, its use must be justified. A review of the literature and our own experience show that the jejunal transplant should be preferred because (1) it is more versatile, (2) it can easily be handled, (3) it provides better functional results, (4) it avoids the functional and aesthetic morbidity of the donor site defect and (5) it has a lower complication rate than the pectoralis major flap.     

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.     

带蒂胸大肌皮瓣在头颈部肿瘤术后缺损修复中的应用

目的:探讨运用带蒂胸大肌皮瓣修复头颈部肿瘤切除术后缺损的效果及优点。方法:13例晚期头颈部肿瘤患者,行肿瘤切除术后以带蒂胸大肌皮瓣修复术后缺损。结果:术后11例愈合良好;1例出现腮腺瘘,加压包扎后愈合;1例自动出院后失访。结论:胸大肌皮瓣修复头颈部肿瘤切除术后缺损,具有血供丰富、可修复较大面积缺损、术后愈合较好等优点。对延长患者生命,减轻病痛有重要作用。     

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.     

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.