Experience with the modified pectoralis major myocutaneous flap.

Results of 75 reconstructions with a modified pectoralis major myocutaneous flap are described in patients with advanced (stages III and IV) head and neck tumors between 1982 and 1986. The course of the supplying thoracoacromial artery was determined with angiographic studies and was found to follow the middle clavicular line in most cases. The pectoralis major muscle was mobilized up to its acromial attachment, which made the bridging of considerable distances possible between the site of the removed tumor and the donor site. The bulk of the pedicle was reduced at the same time without endangering the safety of the blood supply of the pectoralis major myocutaneous flap. The flaps were viable in the 70 evaluable patients. Partial necroses were observed in three cases. Postoperative fistulas were encountered in 13 patients (surgical closure was necessary in three). Reconstruction with the pectoralis major myocutaneous flap is a safe and versatile procedure, yielding good clinical and functional results in patients with advanced head and neck tumors.     

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.     

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.     

Neurotization of pectoralis major myocutaneous flap by the hypoglossal nerve in tongue reconstruction: clinical and experimental observations

Recently, neurotization has been proposed for providing mobility to the pectoralis major, or other myocutaneous flap in lingual reconstruction following total glossectomy. The development of an active tongue-like structure may offer the patient higher potential for rehabilitation of speech and deglutition. The purpose of this thesis is to report experimental and clinical observations on neurotization of the pectoralis major myocutaneous flap. The pectoralis major myoflap of 16 rats was reinnervated by either a hypoglossal nerve pedicle of hypoglossal-genioglossus muscle neuromuscular pedicle. Functional flap reinnervation was confirmed in eight of the 16 animals. The author's clinical experience with reconstruction of the tongue utilizing neurotized pectoralis major myocutaneous flap is presented.     

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。     

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.     

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.     

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.     

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。     

Utilization of intestinal clamps for precise cutting of the pectoralis major muscle while raising a myocutaneous flap

A variety of approaches have been employed for the reconstruction of head and neck defects and most of the techniques involve the use of arterialized vascular flaps alone, or in conjunction with other regional or local tissues. We frequently use a pectoralis major myocutaneous (PMMC) flap in our hospital in addition to other pedicled or free tissue transfers. A PMMC flap is a reliable flap with acceptable complications, needs a small learning curve, takes less time, and does not require additional investment (i.e. microscopes, loops etc). The disadvantages of the PMMC flap is that it has a restricted arc of rotation, gives a cosmetically unacceptable bulk in the neck, it is difficult in females and causes significant shoulder dysfunction. We have made a small improvization in the flap-raising technique which is helpful for the surgeon. This involves utilization of intestinal clamps to hold and cut the pectoralis major muscle.     

Reconstruction of the laryngopharynx and cervical esophagus

The historical evolution of reconstruction of the cervical esophagus and laryngopharynx over the past 100 years is documented. The impact of these technical achievements is contrasted to the failure to improve the 5-year survival rate of 24%. While the clinician awaits new protocols of treatment to improve survival statistics, the thrust of the surgical oncologist is to develop a reliable method of reconstruction which meets specific minimal criteria. The following objectives should be achieved: Reconstruction should not limit the effectiveness of the ablative technique. Short hospitalization and one stage techniques are superior. Technique mortality and morbidity must be low. A 10-year institutional study using the Montgomery 2-stage technique is presented. In contrast, comparative literature data analysis of all methods of laryngopharyngocervical reconstruction indicates that single stage techniques offer a greater advantage. This study suggests that visceroplasty (stomach), free jejunal transfer, and single stage reconstruction, using the pectoralis myocutaneous flap, approach the previously established criteria more effectively than others. A new technique (1-stage), using partial tubulation of the pectoralis major myocutaneous flap, is recommended for regional reconstruction of the cervical esophagus and pharynx. In order to decrease the pressure and torsion on the vascular pedicle of the pectoralis major myocutaneous flap and increase its predicted length, partial resection of the ipsilateral clavicle is proposed.     

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.     

Parietal occipital nape of neck flap. A myocutaneous flap for selected head and neck reconstruction

Reconstruction in head and neck surgery has been greatly advanced with the use of the pectoralis major and trapezius myocutaneous flaps. Most surgical defects can be repaired with one of these flaps alone, or in conjunction with cutaneous flaps. Specific problems, however, occur that cannot be successfully reconstructed by these standard flaps. The traditional scalp flaps are cutaneous flaps. Use of these flaps is limited because of their shortened arc of rotation and accompanying forehead deformity. Three patients underwent reconstruction with a parietal occipital nape of neck myocutaneous flap. Its advantages include the following: large segments of hairless skin from the contralateral side of the neck can be used, an extensive arc of rotation and distance can be achieved with excellent vascularity in the overlying skin, and cosmetic results are superior. Angiographic studies were used to demonstrate the vascular pattern and supply to this flap. Cadaver dissections were performed to determine the pattern of distribution of the perforating vessels to the skin from underlying muscle.     

Delayed failure of myocutaneous flaps in head and neck reconstruction

Since the concept of myocutaneous flap reconstruction of the head and neck region was introduced it has opened a new approach to surgical management in this area. This flap not only reduced the number of operations as compared to "staged procedure", but also reduced the costs of medical care. We are, however, experiencing significant failures as the applications of this flap are extended. This paper reviews our experience with myocutaneous flaps in 15 partial and total failures. An evaluation of these failures reveals that most occurred 1 1/2 to 3 weeks after reconstruction. The factors predisposing to failure seem related more to technical errors rather than to general factors. Diabetes, peripheral vascular disease, malnutrition and low hemoglobin, and low blood pressure were not major contributors to the failures in our series. Local factors predisposing to failure of myocutaneous flaps can be divided into two large categories--arterial failure and venous failure. In our series of unsuccessful myocutaneous flaps, the major factors appeared to be venous stasis leading to arterial insufficiency. All failures had developed after the initial critical period of flap survival (7-10 days). The following techniques showed an especially high rate of failure: 1. SCM--myocutaneous flap to resurface floor of mouth. 2. Tubed pectoralis myocutaneous flap to reconstruct pharynx and esophagus. 3. Flaps developed with very narrow vascular pedicles. Individual cases representing delayed failure are presented.     

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.     

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.     

头颈部岛状肌皮瓣和皮瓣的改良设计及临床应用

目的　探讨制作单一血管为蒂的头颈部局部带蒂肌皮瓣或皮瓣的安全性。方法　解剖学观察20例胸肩峰动脉分支,观察最远入肌点走行特征。通过术前超声观察和术中透视法观察定位最远入肌点,在最远入肌点上方1～2 cm断离肌肉,形成单纯动静脉血管为蒂的胸大肌岛状肌肌皮瓣。利用同样的技术方法,设计岛状的胸锁乳突肌、下位斜方肌的岛状肌皮瓣。结果　解剖学观察胸肩峰动脉分支分为单支型12.5%（5/40）,双支型67.5%（27/40）,多支型20%（8/40）。术前超声定位胸大肌皮瓣的最远入肌点成功率为29.1%（14/48）,DSA成功显影乳内动脉穿支66.7%（12/18）,共完成胸大肌岛状肌皮瓣48例,乳内动脉岛状皮瓣12例,颏瓣18例,下位斜方肌岛状肌皮瓣4例,胸锁乳突肌岛状肌皮瓣4例,颈横血管岛状皮瓣3例,胸肩峰动脉穿支的岛状皮瓣3例。失败2例,1例为胸大肌肌皮瓣的岛状设计中电刀误伤胸肩峰动脉胸肌支;1例为颈横血管浅支,术中修复扁桃体癌咽侧壁缺损。3例胸大肌部分坏死,清理完坏死组织,换药后痊愈。结论　在头颈部设计单一血管为蒂的岛状肌皮瓣（皮瓣）的改良设计安全可行,在受区皮瓣容易塑形固定,供区不仅外形美观且功能保全。     

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.