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The Reliability of Pectoralis Major Myocutaneous Flap in Head and

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					Journal of the Egyptian Nat. Cancer Inst., Vol. 18, No. 1, March: 41-50, 2006




The Reliability of Pectoralis Major Myocutaneous Flap in Head
and Neck Reconstruction
HAMDY H. EL-MARAKBY, M.D. FRCS
Teh Department of Surgery, National Cancer Institute, Cairo University.




                     ABSTRACT                                        patients). Of the 26 PMMPF reconstructions, 22 flaps
                                                                     were carried out as primary reconstructive procedures,
    Background: The pectoralis major myocutaneous                    whereas 4 flaps were "salvage" procedures (reconstruction
pedicle flap (PMMPF) has been considered to be the                   after fistula, free flap failure, coverage of exposed man-
"workhorse" of pedicled flaps in head and neck recon-                dibular prosthesis). Fifteen patients (60%) had complica-
struction. Several series of PMMPF procedures in head                tions such as wound dehiscence, infection, hematoma,
and neck reconstruction have been reported in the literature.        seroma, partial flap failure, total flap failure, fistula, and
Even with the worldwide use of free flaps, the flap is still         donor site complications. A higher complication rates
considered the mainstay head and neck reconstructive                 were associated with the utilization of the flap as a salvage
procedures in many centers. However, the flap is usually             procedure, number of co morbidities, and in oral cavity
associated with a high incidence of complications in                 reconstructions.
addition to its large bulk compared with the free fascio-
cutaneous flaps. Also the final functional and the aesthetic              Conclusion: Although the PMMPF is a versatile flap
results are not comparable to free flaps head and neck               in head and neck reconstruction, being in the proximity
reconstruction.                                                      of the region with good reach to different areas of the
                                                                     face, oral cavity, and the pharynx; the flap is fraught with
     Aim of the Study: The aim of the study is to evaluate           a high complication rate. The wide use and the reliability
the reliability of such flap in selected cases of head and           of free flaps in head and neck reconstruction have super-
neck reconstruction. The indications, technique, compli-             seded the use of the PMMPF flap in comparable circum-
cations and the functional as well as the aesthetic results          stances. However, the flap still has a place in head and
of the flap utilization were evaluated.                              neck reconstruction, particularly after resection of locally
                                                                     advanced tumours. Also the flap can be still used as a
    Patients and Methods: Between May 2002 and May
                                                                     salvage procedure after free flaps failure or when there is
2005 a 26 consecutive head and neck reconstruction
                                                                     a shortage of the microsurgery facility.
procedures using the PMMPF were carried out on 25
patients at the Department of Surgery, National Cancer
                                                                     Key Words: Pectoralis major myocutaneous flaps - Free
Institute, Cairo University. The indications for the flap
                                                                                flaps - Head and neck reconstruction.
use were defects due to resection of stage II-IV cancer in
the head and neck region. The site, stage of the disease
and the presence or absence of distant metastasis were                                INTRODUCTION
assessed. Also preoperative assessment included the fitness
of patients for such an extensive procedure. The total                   Operative treatment of head and neck cancer
operative time, the need for blood transfusion, the post-            requiring a radical resection of the tumor does
operative complications, were all documented. The length
of hospital stay, the follow-up of patients as well as the
                                                                     not only result in severe impairment of important
incidence of local recurrence underneath the flap were all           functions like swallowing, speech, and respira-
evaluated.                                                           tion but also aesthetic mutilation because of the
                                                                     exposed character of the head and neck region.
    Results: Pectoralis major myocutaneous pedicled flap
reconstructions were used to reconstruct defects in the
                                                                     Therefore the rehabilitation from a functional
following sites: oral cavity (10 patients); orophar-                 and cosmetic standpoint is an essential goal of
ynx/hypopharynx, (5 patients); and neck or face (10                  treatment in addition to control of the malignant
                                                                     disease [1].

Correspondence: Dr Hamdy H. El-Marakby, Department                      In modern multi-disciplinary cancer treat-
of Surgery, National Cancer Institute, Fom El-Khlig,                 ment, rehabilitation and functional results rep-
hamdyelmrakby@hotmail.com                                            resent utmost intent in reconstructive surgery

                                                                41
42                                                                               The Reliability of PMMF

of the oral cavity. Even in cases where the stage       tool for extending the limits of resectability and
of disease is advanced and the perspective of           reconstruction [11]. The versatility of the flap
survival is limited, it is possible to achieve an       in head and neck reconstruction exceeded its
acceptable quality of life [2]. In previous years,      utilization for the oral cavity and in covering a
the pedicled myocutaneous e.g. pectoralis major         soft tissue defects in the face. A combination
and latissmus dorsi flaps were used for head            of a pectoralis flap with a gastric transposition
and neck reconstruction, but the arc of rotation        was used to reconstruct the cervical esophagus
and the huge bulk of these 2 flaps were consid-         as an alternative for cases in which a gastric
ered limiting factors for the indication of these       flap alone was insufficient. With this combina-
techniques [1].                                         tion virtually any defect of the upper aero-
                                                        digestive tract can be successfully reconstructed
    The PMMPF is considered the mainstay of             [15]. Also the tubed PMM flap is a reliable tech-
pedicled flap reconstruction in the head and            nique for pharyng-oesophageal reconstruction
neck region; however it is associated with a            that is particularly useful in elderly and debili-
relatively high complications rate. The overall         tated patients [15]. The pectorals major myocu-
complication rate in a very recent study was            taneous flap is not only a versatile flap but also
36.1%, with 2.4% of cases involving total flap          a very reliable and robust one for single stage
necrosis [3]. Although the operation time of this       immediate head and neck reconstruction [16].
reconstructive method was shorter compared              Although the use of micro vascular free flaps
with free flap reconstruction [4], the relatively       is a reliable procedure, the pectoralis major
high complications rate and the inferior func-          myocutaneous flap is still applicable for selected
tional and aesthetic results limit its indication.      cases of hypo-pharyngeal reconstruction [18].
     Other series have also reported variable but            The utilization of the PMMPF has been
high incidence of complications, 58% [5], 63%           compared with 2 alternative methods of head
[6]. In spite of the higher overall rate of compli-     and neck reconstruction namely the free forearm
cations most of these complications were self-          flap, and the nasolabial flap. The morbidity
limited, and the rate of total flap loss was only       showed an extremely low rate of flap loss in
2.4% [6].                                               all the groups, but "minor" complications, such
    Others analyzed some of the individual com-         as fistulas and leakages, were significantly more
plications such as wound dehiscence, infection,         frequent in the myocutaneous flaps group [2,
partial flap failure, total flap failure, and fistula   17] . Functional evaluation for speech and de-
in addition to the donor site complications and         glutition showed good results in most patients.
reported it in over a third of patients [7]. The        In particular, the pectoralis major flap showed
higher complication rates were associated with          its best functional performance in patients who
salvage procedures, number of risk factors,             have undergone total or subtotal glossectomies
number of cigarettes packs smoked, and in oral          with a sacrifice of the muscles of the oral floor.
cavity reconstructions [8]. The high incidence          The free forearm flap was reliable and safe with
of postoperative complications in some reports          its low thickness and pliability, especially for
was attributed to previous radiation therapy.           partial glossectomies. On the other hand, the
Half of these complications were felt to be             nasolabial flap was confirmed to be the first
major because they prolonged the hospital stay,         reconstructive choice for selected limited resec-
or they required secondary reconstructive pro-          tions of the tongue and of the antero-lateral
cedures [9].                                            floor of the mouth [2].

    Despite the increasing use of micro vascular            With regard to the risk of developing com-
flaps, the pectoralis major flap remains an ex-         plication with the PMMPF it was found that
cellent reconstructive choice for large soft tissue     there was slight increase in patients who smoke
defects in the oral cavity [10].                        cigarettes and in patients with larger tumors
                                                        resection [12]. However, obesity and previous
    With the exception of the problem of hidden         radiotherapy were found to have no effect on
recurrence, the pectoralis major myocutaneous           the complication rates. On the other hand women
flap compares favorably with other methods of           who underwent pectoralis major myocutaneous
reconstruction of head and neck defects. Its            flaps had a higher rate of flap necrosis than did
size, viability, and versatility make it a valuable     men, presumably because of the interposition
Hamdy H. El-Marakby                                                                                 43

of breast tissue between the muscle and the skin     were discussed with the patients. Consent for
paddle [13].                                         the operation was signed by the patient and then
                                                     countersigned by the surgeon performing the
    The use of the pectoralis myo fascial flap       operation.
(PMMF) (with no skin island) as compared to
the PMMPF was reported with lower incidence              A two team approach was adopted in the
of complications with avoidance of some of the       entire patients group, where one team carried
limitations of the PMMP flap [19]. The overall       out the excision of the tumour or the neck nodes
rate of flap complications in one series was         and the other team undertook the procedure of
only 22%, and the incidence of major flap            reconstruction. The technique of reconstruction
complications requiring surgical revision was        is shown in Fig. (1:A-E). The flap design and
only 11% [12,14]. On the other hand, understand-     the skin island depend on the site, size and
ing the hemodynamics of the pectoralis major         shape of the defects but the skin island was
myocutaneous flap by including the 4th inter-        usually below and medial to the nipple about
costals perforator in the skin island's central      the level of the 6th rib. The flap elevation
axis has been reported with an improvement in        normally starts from a distal to a proximal
the vascularity with no total flap loss and very     direction. The perfusion of the sources of the
limited cases with partial flap necrosis [20].       flap is the pectoral branch of the acromio-
                                                     thorathic artery and the lateral thoracic artery.
    In the current study we will assess the ver-     The pectoral vessels emerge from the clavipec-
satility and the reliability of the flap in head     toral fascia 2-3 cm medial to the coracoid pro-
and neck reconstruction. The relatively high         cess. During the flap elevation the pectoral
complications rate will be tested against the        fascia and the muscle are secured to the skin to
versatility of the flap. Also the final functional   protect the perforator vessels and the muscle is
and aesthetic results will be evaluated.             exposed over the length and the breadth of the
                                                     pedicle. The skin and muscle are elevated from
        PATIENTS AND METHODS
                                                     the chest wall exposing the ribs and the inter-
    This study was carried out between May           costals muscles. The flap is elevated up as far
2002 and May 2005 based on 26 consecutive            as the coracoid process where the pedicle can
head and neck reconstruction procedures using        be narrowed. As the lateral pectoral vessels
the PMMPF were carried out on 25 patients at         became visible they may be left intact or divided
the Department of Surgery, National Cancer           depending on the volume of the flap required
Institute, Cairo University. Preoperative assess-    and the tension produced if the vessels are left
ment included the site, stage of the disease. An     intact. In females it is often possible to close
open biopsy from the tumour was undertaken           the secondary defect by moving the breast tis-
for all cases. The stage of the disease was eval-    sues. In males a skin graft is generally required
uated by clinical examination assisted by radio-     to cover the secondary defect.
logical (CT or MRI) examination. To assess the           The total operative time, the need of blood
presence of distant metastasis, a routine chest      transfusion, the postoperative complications,
x-ray, and abdominal sonar were carried out.         and the total hospital stay were all documented.
Patients who received preoperative neo-adjuvant      Follow-up of patients in the outpatient clinic
radiotherapy or chemotherapy were documented.        involved a thorough clinical examination aided
    Preoperative medical assessment included         by radiological assessment for the local recur-
routine complete blood picture, bleeding and         rence and /or distant metastasis.
coagulation profile, liver and kidney functions,         Postoperative photos (Figs. 2-5) were used
ECG. An echo cardiography was done for pa-           to assess the final aesthetic and functional re-
tients presented with a past history of cardiac      sults. Swallowing, deglutition, speech and aes-
problems and in all patients who were over 50        thetic appearance were subjectively evaluated
years at the time of surgery.                        to assess the final outcome of the reconstruction.
    The indications for the flap use and the flap                      RESULTS
design to fit the defect were planned preopera-
tively. The extent of surgery, the technique of         A group of 25 patients with cancer in the
reconstruction and the potential complications       head and neck region who underwent radical
44                                                                              The Reliability of PMMF

resection and PMMPF reconstructions were               required 2-3 units of blood transfusion during
prospectively evaluated during the last 3 years        the whole operation e.g. tunour resection and
(May 2002-May 2005). They were 15 males                reconstruction. The mean hospital stay was 16
and 10 females with a mean of age 52±12 SD             day and the range was (8-24 days).
years, and a range of 26-67 years. The inclusion
criteria were stage II-IV extirpation, reconstruc-         Fifteen patients (60%) had been affected by
tion with skin and soft-tissue defect, or a defect     complications such as wound dehiscence (5),
involving the upper aero digestive tract.              infection (5), hematoma (2), seroma (2), partial
                                                       flap failure (3), total flap failure (2), oro-
    The pathology of the disease included squa-        cutaneous fistula (10), Pharyngo-cutaneous
mous cell carcinoma in the majority of cases           fistula (2) and donor site healing problems (5).
(20) (80%). The rest of the cases were fungating       All the minor complications were treated con-
sub-mandibular mucoepidermpoid ca, metastatic          servatively with no resulting functional morbid-
fungating undifferentiated carcinoma in cervical       ity. On the other hand Major complications
lymph nodes, 2 advanced mucoepidermpoid                requiring latissmus dorsi flap salvage was un-
parotid cancer and a fungating mandibular soft         dertaken in the 2 flap failures (Table 3). A
tissue sarcoma.                                        higher complication rates were associated with
    Pectoralis major myocutaneous pedicled             the utilization of the flap as a salvage procedures
flap reconstructions were completed after ab-          (100%), the presence of more than one risk
lation of cancer in 15 patients with carcinoma         factor, heavy smokers (15-20 cigarettes per day)
of the oral cavities (3 tongues, 3 floors of           (70%), and in oral cavity reconstructions (80%).
mouth, 3 alveolar margins, 5 retro molar and
                                                          However, the complications rate was not
one recurrent squamous cell carcinoma of the
                                                       significantly associated with smoking, old age
lip involving the buccal mucosa) (Figs. 2,4);
                                                       above 60 years, diabetes mellitus, prior radio-
oropharynx/ hypopharynx in 5 patients (Fig.
                                                       therapy or obesity.
5) and neck or face in 5 patients (Fig. 3) (2
parotid, 2 mandible, and one neck defect). Eight           Most complications were minor and did not
reconstructions were carried out after resection
                                                       require a second salvage procedure. Only in
of primary tumours were stage 2, and 12 were
                                                       cases who suffered total flap loss, a latissmus
stage 3, where the other 5 cases were stage 4
                                                       dorsi flap was used as salvage procedure. On
who presented with fungating ulcers (Table 1,
                                                       the other hand a secondary revision surgery was
Fig. 2).
                                                       required in the majority of cases (60%) after 6
    Of the 26 PMMPF, 22 were carried out as            months to reduce the bulk of the flap in 10
primary reconstructive procedures, whereas 4           (40%), or to release a contracture scar in 2 (8%)
flaps were done as "salvage" procedures (2             and to treat a donor site scarring in 3 (12%).
reconstructions after fistula, one after free flap
failure, and 2 for coverage of mandibular pros-            The Functional results were satisfactory in
thesis,). The flap was carried out bilaterally in      the majority of patients (60%). However, pa-
one patient where the first procedure was a            tients who suffered a degree of flap loss (20%)
primary reconstruction and the second was used         suffered from a variable degree of trismus and
to cover an exposed procedure 6 months after           thereby the final functional out come was not
the primary reconstruction. The radical surgery        satisfactory. All the poor functional results were
was carried out as a salvage procedure after           oral cavity reconstruction.
preoperative radiotherapy in 4 patients (Table
2). A metal plate prothesis was used to restore            Six out of the 10 patients in whom a metal
the manidbular continuity in conjunction with          appliance was placed to restore mandibular
PMMPF in 10 (40%) of patients who suffered             continuity required the removal of that appliance
stage II to III disease of the oral cavity involving   due to flap necrosis, fistula formation, or plate
the mandible.                                          exposure. The final aesthetic results were either
                                                       poor in 3 (12%); all were oral cavity, fair in 12
   The average operative time for the flap             (48%), good in 6 (24%) and excellent in 4 (16%)
harvest and insetting was 80± 29 minutes (range        patients; all were skin and soft tissue reconstruc-
45-120 minutes). Ninety percent of patients            tion of the neck and the face.
Hamdy H. El-Marakby                                                                                                         45




   Fig. (1-A): Large skin island including the nipple.            Fig. (1-B): The flap harvest starting inferior to the nipple.




                          (C)                                                                 (D)
Fig. (1-C,D): The pedicle is shown on the ventral aspect of the pectoralis major that have divided inferiorly, medially
              and laterally.




                                       Fig. (1-E): Flap insetting in the oral cavity.
46                                                                                          The Reliability of PMMF




Fig. (2-A): A fungating squamous cell carcinoma of the         Fig. (2-B): Immediate postoperative picture following
           mandible.                                                       reconstruction.




         Fig. (2-C): Late postoperative picture.                              Fig. (2-D): The donor site.




Fig. (3-A): A defect in the neck that          Fig. (3-B): Early postoperative picture following reconstruction
            was created by excision                        with the pectoralis major myocutaneous flap.
            of fungating metastatic
            cervical lymph node.
Hamdy H. El-Marakby                                                                                                        47




     Fig. (4-A): A complete lower lip and mandible destruction              Fig. (4-B): The defect after excision of the
                 by squamous cell carcinoma.                                            tumour and the central mandible.




Fig. (4-C): The mandible was restored by using titanium prosthesis               Fig. (4-D): The PMMPF covering the prosthe-
            and the lip was reconstructed with a double island pectoralis                    sis and the defect.
            major myocuataneous flap.




Fig. (5-A): Anterior pharyngeal wall disruption following                       Fig. (5-B): Repair by using PMMCF.
            total laryngectomy.
48                                                                                     The Reliability of PMMF

Table (1): Site, stage and pathology of the disease in the   larity and the proximity to various defects in
           study group.                                      the region has made it the standard reconstruc-
                                           No. & %           tive procedure for deep defects in the head and
                                                             neck area. However, since the introduction of
     Site of the disease:                                    the free fasciocutaneous flaps; the flap has lost
       Oral cavity                          15 (60)
       Neck                                 5 (20)
                                                             much of its reputation in reconstruction of the
       Pharynx                              5 (20)           head and neck region, particularity the oral
                                                             cavity. The pliability and the less bulk of the
     Stage of the disease:                                   free flaps have superseded the utilization of the
       Stage 1                              0
       Stage 2                              8 (32)
                                                             PMMPF in the reconstruction of oral defects
       Stage 3                              12 (48)          [2,17].
       Stage 4                              5 (20)
                                                                 During the last 2 decades, the utilization of
     Pathology:                                              the PMMPF flap has been restricted to extensive
       Squamous cell ca.                    20 (80)          deep defects that have resulted from resection
       Mucoepidermioid ca.                  3 (12)
       Poorly differentiated ca.            1 (4)            of stage III- IV cancer (18 in our series). The
       Sarcoma                              1 (4)            advanced or the recurrent disease at presentation
                                                             has made it the first choice in the reconstructive
                                                             ladder in these circumstances being much sim-
                                                             pler to harvest and less time consuming as
Table (2): Type of reconstruction.
                                                             compared to the free flaps [4,8,11].
     Type of reconstruction                No. & %
                                                                 The other indication of flap utilization is for
     Primary reconstruction:                20 (80)          the secondary reconstruction after free flaps
       Oral cavity                          12 (48)          failure. This was tested in one of our patients
       Neck and face                        5 (20)           where the flap was used as a salvage procedure
       Pharynx                              3 (12)
                                                             after free radial forearm flap failure in oral
     Salvage procedure:                     5   (20)         cavity reconstruction.
       Pharyngo cutaneous fistula           2   (8)
       Free flap failure                    1   (4)              Because of the reported relatively high inci-
       Exposed prosthesis                   2   (8)          dence of complications with the use of PMMPF
                                                             (60% in the current series); attention to flap
                                                             design, operative technique, and post-operative
Table (3): Post operative complications.                     management are mandatory in reducing the
                                                             incidence of these complications [20]. The high
     Complications                         No. & %           incidence of oro-cuatnous fistula in our series
                                                             was due to the fact that the majority of our cases
     Major:                                 5 (20)
      Partial flap necrosis                 3 (12)           had either oral cavity defects (100% fistula)
      Total flap necrosis                   2 (8)            and/or pharyngeal esophageal defects (60%
                                                             fistula rate). These results are comparable to
     Minor:                                 10 (40)          other series [3,5,6,7] and all have been conserva-
      Haematoma                             2 (8)
      Wound dehiscence                      5 (20)           tively treated with satisfactory functional results.
      Wound Infection                       5 (20)           In spite of the reported high incidence of sec-
      Seroma                                2 (8)            ondary surgery for the flap complications 36%,
      Fistulas                              12 (48)          50% in recent reports [9,12] a secondary surgery
      Donor site healing problems           5 (20)
                                                             was only required in 20% of our cases to salvage
                                                             a major complication such as partial or total
                                                             flap failure.
                     DISCUSSION
                                                                 On the other hand, because of the minor
    The pectoralis major myocutaneous pedicled               complications, the length of hospital stay was
flap (PMMPF) has been long utilized in restoring             relatively long (an average of 16 days). This
various defects in the head and neck region. The             was also significantly longer than the free fascio-
versatility, reliability of the flap, the robust vascu-      cutanouss flaps in other series (12 days) [7,9].
Hamdy H. El-Marakby                                                                                              49

    There were no significantly higher compli-          struct defects in the pharynx and the cervical
cations rate associated with smoking,                   oesphagous. Although the overall incidence of
preoperative radiotherapy, diabetes and obesity         complications of the PMMPF was high, the
[7,9,13] , using a univariate or multivariate re-       actual incidence of flaps failing to accomplish
gression analysis. This is supported by the             their intended purpose and requiring secondary
results of the current study, however, this can         repair was acceptable. The pectoralis major
by attributed to the small number of patients in        myocutaneous flap is reliable in the reconstruc-
this series. A larger series and or multicentre         tion of defects in the head and neck region, and
analysis are required to confirm this trend.            in agreement with the literature, we believe that
                                                        the free fasciocuatnous flaps are not routinely
    The bulk of the flap is considered a disad-         the substitute of PMMPF in head and neck
vantage to its utilization for small superficial        reconstruction. Larger series of patients could
defects [1]. This usually affects the final cosmetic    be useful in evaluating the final functional and
appearance of the neck after reconstruction and         the aesthetic results as well as the effect of risk
hence reflects in the overall patients' satisfaction.   factors in the flap survival as compared to the
The ideal situation occur when the muscle is            free flaps.
used to cover a neck defect after extirpation of
cancer in the neck nodes (radical neck dissec-
tion), whether this is associated with a large                             REFERENCES
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                                                        2- Pompei S, Caravelli G, Vigili MG, Ducci M, Marzetti
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50                                                                                           The Reliability of PMMF

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