|Year : 2014 | Volume
| Issue : 2 | Page : 88-93
Use of pectoralis major myocutaneous flap for resurfacing the soft tissue defects of head and neck
Rampukar Chaudhary, Md Sohaib Akhtar, Lalit Mohan Bariar, Mohammed Fahud Khurram
Post Graduate Department of Burns, Plastic and Reconstructive Surgery, JNMC, AMU, Aligarh, Uttar Pradesh, India
|Date of Web Publication||16-Oct-2014|
Md Sohaib Akhtar
Post Graduate, Department of Burns, Plastic and Reconstructive Surgery, JNMC, AMU, Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Aims and Objectives: The aim was to evaluate the feasibility of pectoralis major myocutaneous (PMMC) flap in reconstruction of defects in the head and neck region. The study also outlines types of other tissue required, the donor site morbidity and the technical details of the operative procedure. Materials and Methods: This was a retrospective study undertaken on patient of soft tissue defect of head and neck region either traumatic or after resection of the tumor admitted to author's center. A total of 62 patients was included, among them, 59 patients were of malignancy and 3 patients were of traumatic injury to face. All the patients of malignancy underwent wide local excision of the tumor with modified radical neck dissection type III. After resection, the resultant defect was covered with pectoralis major myocutaneus flap (PMMF) with or without deltopectoral (DP) flap or forehead flap (PMMF or PMMF + DP/forehead flap). The operating time was noted from elevation of the flap to completion of flap insetting. Results: All the flaps survived uneventfully except 4, out of this 1 developed total flap necrosis, 1 partial flap necrosis and 2 experienced epidermolysis. Orocutaneous fistula was noted in 3 patients in initial days and after removal of the intraoral suture the fistula spontaneously resolved in all cases. Conclusion: It was concluded that PMMC is the highly versatile and reliable flap with an excellent vascularity, wide arc of rotation, large flap dimension, easy to harvest, economical and with minimal complications.
Keywords: Deltopectoral flap, pectoralis myocutaneous flap, soft tissue defects head and neck region
|How to cite this article:|
Chaudhary R, Akhtar MS, Bariar LM, Khurram MF. Use of pectoralis major myocutaneous flap for resurfacing the soft tissue defects of head and neck
. J Orofac Sci 2014;6:88-93
|How to cite this URL:|
Chaudhary R, Akhtar MS, Bariar LM, Khurram MF. Use of pectoralis major myocutaneous flap for resurfacing the soft tissue defects of head and neck
. J Orofac Sci [serial online] 2014 [cited 2020 Feb 26];6:88-93. Available from: http://www.jofs.in/text.asp?2014/6/2/88/143046
| Introduction|| |
Soft tissue defects head and neck are common problems resulting from excision of head and neck tumors or traumatic insult to the area. It leads to cosmetic and functional deficits with resultant significant impact on patient's quality of life unlike other areas of the body. Reconstruction in this area is of paramount importance to maintain the function and restoring self-deception.  Functional outcomes are measured in terms of integrity of the alimentary tract and to communicate through facial expression. A team approach including oncosurgeon, reconstructive surgeon, trained nursing staffs are required for successful and cosmetically and functionally acceptable results. Various available options for reconstruction are regional pedicle flaps and free flaps. In order to achieve good outcomes, it is important to carefully and systematically analyze these various available methods for reconstruction and its interaction with rehabilitation.  Although reconstruction using free flap would be the ideal option, but it is costly, time consuming, having high-anesthesia risk,  technically demanding  and requires well equipped microsurgical setup.
Hanasono et al. describes the impact of microsurgery in patients with advanced oral cavity cancers. They find that a large number of patients have been reconstructed with local pedicled or regional flaps despite the availability of free tissue transfer. 
Vascularity of regional pedicled flaps has axial pattern. The reach of pedicled flaps is defined by location of the vascular pedicle. It can be a fasciocutaneus or myocutaneus flap. The most common fasciocutaneus flaps used are deltopectoral (DP) flap and common myocutaneus flaps are pectoralis major, latissimus dorsi, trapezius flaps.
Arlyan and Cuono et al. first described the clinical application of pectoralis major myocutaneous (PMMC) flap in head and neck reconstruction.  Since its description, it continues to be the workhorse of pedicled flaps for head and neck reconstruction with acceptable morbidity. 
The main advantages of this flap are its reliable vascularity and good viability,  protection of carotid artery and acceptable cosmetic appearance in cases where bulk of tissue is required. In addition, this flap can easily be used in irradiated areas and even a large cutaneus island of donor site closed primarily. 
In this series, we have clinically applied the PMMC flap in the resurfacing the full thickness defect of head and neck regions.
| Materials and methods|| |
This was a retrospective study undertaken on patient of soft tissue defect of head and neck region either traumatic or after resection of the tumor; admitted to author's center between August 2010 and July 2013. A total of 62 patients were included in the study fulfilling the following criteria:
- resectable facial malignant tumor with defect having upper limits the zygomatic arch area externally and the superior tonsillar pole internally and
- any posttraumatic soft tissue defect in above mentioned region.
Among 62 patients that were studied, 56 were male, and 6 were female with male to female ratio of 9:1 with an average age 42.15 year (25-85 year).
Among these, 59 Patients were of malignancy and 3 patients were of traumatic injury to face [Table 1].
Distribution of site of malignancy among 59 patients was as follows; lower lip (n = 6), buccal mucosa (n = 6), buccal mucosa + gingiva (n = 12), retromolar trigone (n = 6), buccal mucosa + gingiva + retromolar trigone (n = 29) [Table 2].
All the patients of malignancy underwent wide local excision of the tumor with modified radical neck dissection type III. After resection, the resultant defect was covered with either pectoralis major myocutaneus flap (PMMF) with or without DP or forehead flap (PMMF or PMMF + DP/forehead flap). The type of tissue required for reconstruction was as follows [Figure 1], [Figure 2] and [Table 3].
|Figure 1: (a) Preoperative photograph of the patient with carcinoma buccal mucosa showing skin involvement. (b) Intraoral photograph of same patient. (c) Intraoperative photograph showing elevation of pectoralis major myocutaneous (PMMC) flap. (d) PMMC flap for inner lining and outer line was formed by deltopectoral (DP) flap. (e) Follow-up photograph after DP flap detachment|
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|Figure 2: (a) Preoperative photograph showing carcinoma left cheek. (b) Postoperative follow-up photograph showing good uptake|
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The operating time was noted from elevation of the flap to completion of flap in setting; in case of two flaps the time of 2 nd flap harvest was deducted from the total time to get an accurate time of PMMF.
All the patients were operated under endotracheal intubation. The ipsilateral chest was prepared and draped.
Marking of flap
- Landmarks: First of all acromion, xyphoid and medial end of the clavicle was marked. Then the line was drawn from the xyphoid to the acromion. A second line is drawn perpendicular to this line that bisects the clavicle. The course of the Thoracoacromial artery corresponds to the line drawn from the midpoint of the clavicle continuing to the medial portion of the acromion to xyphoid line [Figure 3].
- Skin paddle: Size and location of the skin paddle depends on the soft tissue defect. The skin paddle was designed at the infero-medial border of the pectoralis major muscle that is inserting on the lateral border of the sternum and the second to sixth costal cartilage. Skin paddle was extended as a random-pattern flap beyond the inferior edge of the muscle belly, including the anterior rectus sheath getting the extra length of the flap depending upon the requirement.
- Flap elevation: The size and location of the skin paddle over the pectoralis major muscle was designed following basic principles of plastic surgery that is, planning in reverse. First incision was made from the lateral edge of designed skin paddle toward the anterior axillary line. This incision can be made above or below the nipple depending upon gender of the patient. The incision was deepened down to the pectoralis major muscle so that medial and inferior extents of the muscle could be identified. All the incisions were made through the fascia, muscle up to the chest wall except superior one which is made down to the muscle fibers. Once the skin paddle has been isolated and remaining skin lying over the muscle has been separated, the muscle is divided distally and dissection performed proximally towards the clavicle up to the dominant pedicle which can be visualized in the deep surface of muscle. The perforators of internal mammary artery must be preserved during cutting the muscle fibers along the sternal borders to preserve the supply of DP flap. When DP along with PMMF was needed for reconstruction, DP was harvested first. When forehead flap was planned along with the PMMC flap; PMMC flap is harvested first. Donor defects were primarily closed when only PMMC was harvested, or skin grafted when both PMMC and DP was raised. The suction drains were used in all cases.
|Figure 3: Markings of the pectoralis major myocutaneous flap with skin Island|
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Postoperatively patients were kept in appropriate positions to minimize the tensile strength, pressure points or torsion on the pedicle. Flaps were regularly monitored in terms viability.
| Results|| |
All the patients were evaluated in terms of viability of the flap, restoring form and function, donor site morbidity and formation of orocutaneus fistula as shown below:
- Flap related complications: All the PMMC flap survived well except 4, out of which 1 developed total flap necrosis, 1 partial flap necrosis and 2 experienced epidermolysis [Table 4]. No complications were noted in any of DP or forehead flap.
- Orocutaneous fistula: This was noted in 3 patients in initial days and it was found that the vicryl was one of the reasons for it and after removal of the intraoral suture the fistula spontaneously resolved in all cases.
- Intraoral hair growth: This was one of the distressing problems noted in all male patients which took 2-4 months to resolve.
- Donor site morbidity: No seroma or hematoma formation was noted at donor site because we used suction drain at donor as well recipient site. The defect was closed primarily when only PMMF was taken from chest, but the donor site was covered with split thickness skin graft when PMMF + DP were harvested. The donor site complications have been shown in [Table 5].
The average operating time was 90 min (75-110 min). The average amount of blood transfusion was 1 unit (0-2units).
| Discussion|| |
Reconstruction of full thickness soft tissue defect in the head and neck regions remain a challenging task to the plastic surgeons. Currently, free tissue transfer is considered to be the gold standard for soft tissue coverage in the head neck regions. However, due to its limited availability in most of the centers and various disadvantages described above, it cannot be used widely especially in developing countries. This has led to the wide application of pedicled and regional flaps. Among the pedicled flaps, PMMF is considered to be a reliable option for the coverage of these regions.
In developing countries, patients with head and neck cancers usually presents late to the clinicians leading to critical weight loss.  This has led the wide application of PMMC flap by various researchers. ,,,
In this series, we have successfully used PMMC flap in the reconstruction of soft tissue defect in head and neck regions following cancer excision in 59 patients and trauma in 3 patients.
Pinto et al.  describes the use of PMMC flaps in postcancer resection soft tissue defect in head and neck region. They identified the factors causing various complications and outcome of reconstruction. They concluded that PMMC flap is a reliable and versatile flap for head neck reconstruction.
El-Marakby  evaluates the indications, technique, reliability, complications and the functional and aesthetic outcomes of PMMC flap head and neck reconstruction in 25 selected patients. They have used the flap in the reconstruction of the oral cavity, oropharynx, hypopharynx and neck or face. They conclude that despite the wide use and the reliability of free flaps in head and neck reconstruction, PMMC is a good option when facility of microsurgery is lacking and as a salvage procedure after free flaps failure.
Kekatpure et al.  evaluate different factors affecting the selection of pectoralis major flap in the era of free tissue reconstruction for postablative head and neck defects. They also outlined different flap associated complications. A total of 147 reconstructive procedures was performed including 79 free flaps and 58 pectoralis major flaps were performed. The indications for pectoralis flap selection were resource constrains (36%), associated co morbidities (20%), extended/salvage neck dissection (19%), vessel depleted neck and free flap failure salvage surgery. All the flaps survived with 41% of patients had flap related complications majority of which were self-limiting and managed conservatively. They conclude that pectoralis major flap is a reliable option for head and neck reconstruction and has a significant role even in this era of free flaps.
Brusati et al.  performed PMMC flap was for reconstruction after surgical ablation of advanced malignant tumors in the head and neck. They find a low complication rate and confirm the reliability of the PMMC flap that offers the possibility of providing large cutaneous islands and a simple, reliable method which may be used in the reconstruction of the cervico-maxillo-facial area.
Several modifications of PMMC flaps have been introduced by various authors. One of the important and useful modifications was reported by Ahmad et al.  They performed bipaddle PMMC flap in 47 patients with large full thickness cheek defects secondary to cancer ablative surgery. This modification was based on anatomical location of perforators to ensure good blood supply to both the skin paddles of flap. The flap was placed horizontally with nipple and areola included leading to increased reach and size of the available flap. They conclude that this modification is a useful alternative where free tissue transfer is not possible or as a salvage procedure in selected large full thickness oral cavity lesions.
In our series, due to limited availability of microsurgical facility, we performed PMMC flap in all the cases. We required additional tissue in the form of DP and forehead flap for other lining. We have used this flap in a wide spectrum of soft tissue defects, including lower lip, buccal mucosa, gingival and retromolar trigone in various combinations. This correspond to other studies by various investigators. ,,,
We observed a high-success rate using PMMFs (1/62; 98.5%) that is, 1.5% failure, and this rate compares favorably described in the literature by various researchers. Mehrhof et al.  in a series of 73 patients reports total flap necrosis of 4%, Brusati et al. in series of 100 patients reported total flap necrosis (2%).
Castelli et al.  describe in their study the effects of old age and systemic diseases on use of a PMMF related complications for reconstruction in head and neck surgery. They find the overall complications occurred more frequently in patients with underlying pathologies. They recommend the use of PMMF in patients who suffer concomitantly with various medical problems known to increase complication rates. Wei et al.  in a review of 1235 flaps in the head and neck finds 42 failures (3.4%).
The partial flap necrosis in our study was 1.5% as comparable to other studies. Schuller  noted partial flap necrosis 6.6%, Mehrhof et al. found it to be 12.3% and Brusati et al. reports partial necrosis of 9%. Our results were contrary to those of Nagral et al.  who reports partial necrosis of 32% in 19 patients and Saito et al. noted partial flap loss in 4 patients (33%) when they performed PMMF in 12 patients.
In terms of orocutaneus fistula, it was noted in 3 patients in initial days and it was found that the vicryl was one of the reasons for it and after removal of the intraoral suture, the fistula spontaneously resolved in all cases. This was contrary to the findings of Saito et al. who finds 3 recurrent fistulae following reconstruction with PMMC flaps.
In this study, no seroma or hematoma formation was noted at donor site because we used suction drain at donor as well recipient site. Wound dehiscence was observed in 1 patient which healed by regular dressings and in 3 patients partial graft loss occurred who required regrafting [Table 5].
| Conclusion|| |
It was concluded that PMMC is the highly versatile and reliable flap with an excellent vascularity, wide arc of rotation, large flap dimension, easy to harvest, economical and with minimal donor site morbidity and limited complications.
| References|| |
Vos JD, Burkey BB. Functional outcomes after free flap reconstruction of the upper aerodigestive tract. Curr Opin Otolaryngol Head Neck Surg 2004;12:305-10.
Gal TJ, Futran ND. Outcomes research in head and neck reconstruction. Facial Plast Surg 2002;18:113-7.
Petruzzelli GJ, Brockenbrough JM, Vandevender D, Creech SD. The influence of reconstructive modality on cost of care in head and neck oncologic surgery. Arch Otolaryngol Head Neck Surg 2002;128:1377-80.
Smeele LE, Goldstein D, Tsai V, Gullane PJ, Neligan P, Brown DH, et al.
Morbidity and cost differences between free flap reconstruction and pedicled flap reconstruction in oral and oropharyngeal cancer : M0 atched control study. J Otolaryngol 2006;35:102-7.
Hanasono MM, Friel MT, Klem C, Hsu PW, Robb GL, Weber RS, et al.
Impact of reconstructive microsurgery in patients with advanced oral cavity cancers. Head Neck 2009;31:1289-96.
Arlyan S, Cuono CB. Use of the pectoralis major myocutaneous flap for reconstruction of large cervical, facial or cranial defects. Am J Surg 1980;140:503-6.
Milenovic A, Virag M, Uglesic V, Aljinovic-Ratkovic N. The pectoralis major flap in head and neck reconstruction : f0 irst 500 patients. J Craniomaxillofac Surg 2006;34:340-3.
Schuller DE. Pectoralis myocutaneous flap in head and neck cancer reconstruction. Arch Otolaryngol 1983;109:185-9.
Shank EC, Patow CA. The pectoralis major flap. Ear Nose Throat J 1992;71:161-5.
Jager-Wittenaar H, Dijkstra PU, Vissink A, van der Laan BF, van Oort RP, Roodenburg JL. Critical weight loss in head and neck cancer - prevalence and risk factors at diagnosis : a0 n explorative study. Support Care Cancer 2007;15:1045-50.
Vartanian JG, Carvalho AL, Carvalho SM, Mizobe L, Magrin J, Kowalski LP. Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction : e0 xperience with 437 cases at a single institution. Head Neck 2004;26:1018-23.
Croce A, Moretti A, D'Agostino L, Neri G. Continuing validity of pectoralis major muscle flap 25 years after its first application. Acta Otorhinolaryngol Ital 2003;23:297-304.
Liu R, Gullane P, Brown D, Irish J. Pectoralis major myocutaneous pedicled flap in head and neck reconstruction : r0 etrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital. J Otolaryngol 2001;30:34-40.
Pinto FR, Malena CR, Vanni CM, Capelli Fde A, Matos LL, Kanda JL. Pectoralis major myocutaneous flaps for head and neck reconstruction : f0 actors influencing occurrences of complications and the final outcome. Sao Paulo Med J 2010;128:336-41.
El-Marakby HH. The reliability of pectoralis major myocutaneous flap in head and neck reconstruction. J Egypt Natl Canc Inst 2006;18:41-50.
Kekatpure VD, Trivedi NP, Manjula BV, Mathan Mohan A, Shetkar G, Kuriakose MA. Pectoralis major flap for head and neck reconstruction in era of free flaps. Int J Oral Maxillofac Surg 2012;41:453-7.
Brusati R, Collini M, Bozzetti A, Chiapasco M, Galioto S. The pectoralis major myocutaneous flap. Experience in 100 consecutive cases. J Craniomaxillofac Surg 1988;16:35-9.
Ahmad QG, Navadgi S, Agarwal R, Kanhere H, Shetty KP, Prasad R. Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek : a0 review of 47 cases. J Plast Reconstr Aesthet Surg 2006;59:166-73.
Ariyan S. Further experiences with the pectoralis major myocutaneous flap for the immediate repair of defects from excisions of head and neck cancers. Plast Reconstr Surg 1979; 64:605-12.
Baek SM, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast Reconstr Surg 1982;69:460-9.
Chew CT, Stanley R, Peck R, Chew SC. Pectoralis major myocutaneous flap reconstruction in head and neck surgery - Experience with 60 cases. Ann Acad Med Singapore 1991; 20:570-80.
Vendrell Marqués JB, Zapater Latorre E, Ferrandis Perepérez E, Estellés Ferriol E, Brotons Durbán S. Pedicled pectoralis major musculocutaneous flaps. Acta Otorrinolaringol Esp 2002;53:39-45.
Mehrhof AI Jr, Rosenstock A, Neifeld JP, Merritt WH, Theogaraj SD, Cohen IK. The pectoralis major myocutaneous flap in head and neck reconstruction. Analysis of complications. Am J Surg 1983;146:478-82.
Castelli ML, Pecorari G, Succo G, Bena A, Andreis M, Sartoris A. Pectoralis major myocutaneous flap : a0 nalysis of complications in difficult patients. Eur Arch Otorhinolaryngol 2001;258:542-5.
Wei FC, Demirkan F, Chen HC, Chuang DC, Chen SH, Lin CH, et al.
The outcome of failed free flaps in head and neck and extremity reconstruction : w0 hat is next in the reconstructive ladder? Plast Reconstr Surg 2001;108:1154-60.
Schuller DE. Limitations of the pectoralis major myocutaneous flap in head and neck cancer reconstruction. Arch Otolaryngol 1980;106:709-14.
Nagral S, Sankhe M, Patel CV. Experience with the pectoralis major myocutaneous flap for head and neck reconstruction in a general surgical unit. J Postgrad Med 1992;38:119-23.
Saito A, Minakawa H, Saito N, Nagahashi T. Indications and outcomes for pedicled pectoralis major myocutaneous flaps at a primary microvascular head and neck reconstructive center. Mod Plast Surg 2012;2:103-7.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]