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Pectoralis Major Myocutaneous Flap for Head and Neck Defects in the Era of Free Flaps: Harvesting Technique and Indications

View Article: PubMed Central - PubMed

ABSTRACT

The role of the pectoralis major myocutaneous flap (PMMF) in head and neck reconstruction is challenged recently due to its natural drawbacks and the popularity of free flaps. This study was designed to evaluate the indications and reliability of using a PMMF in the current free flap era based on a single center experience. The PMMF was harvested as a pedicle-skeletonized flap, with its skin paddle caudally and medially to the areola, including the third intercostal perforator, preserving the upper one third of the pectoralis major muscle. The harvested flap was passed via a submuscular tunnel over the clavicle. One hundred eighteen PMMFs were used in 114 patients, of which 76 were high-risk candidates for a free flap; 8 patients underwent total glossectomy, and 30 underwent salvage or emergency reconstruction. Major complications occurred in 4 patients and minor complications developed in 10. Tracheal extubation was possible in all cases, while oral intake was possible in all but 1 case. These techniques used in harvesting a PMMF significantly overcome its natural pitfalls. PMMFs can safely be used in head and neck cancer patients who need salvage reconstruction, who are high risk for free flaps, and who need large volume soft-tissue flaps.

No MeSH data available.


Related in: MedlinePlus

A partial circumferential defect of the hypopharynx resulted following ablative surgery for the recurrent hypopharyngeal squamous cell carcinoma after radical chemoradiation. The skin paddle was designed medially to the areola.
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f1: A partial circumferential defect of the hypopharynx resulted following ablative surgery for the recurrent hypopharyngeal squamous cell carcinoma after radical chemoradiation. The skin paddle was designed medially to the areola.

Mentions: All patients underwent general anesthesia; tracheotomy was performed as indicated. The skin paddle was designed and marked over the chest wall caudally-medially to the nipple with sparing of the areola. The shape of the skin paddle matched the defect, mainly elliptically (Fig. 1). The inferior, medial, and lateral incision was made and the surrounding cutaneous flap was elevated to expose the pectoralis major. The attachment of the pectoralis major to the costa and the lower part of the sternum was detached and the space between the pectoralis major and minor was reached, keeping in mind that the third intercostal perforating branch of the internal thoracic artery was included and divided at the point where it derives from the chest wall (Fig. 2). Blunt dissection was performed to identify the pectoral branch of the thoracoacromial artery (Fig. 3). After extending the skin incision upward, the sternal attachment was divided. Then the pectoralis major was transected horizontally along the muscular fiber axis at the level where the terminal pectoral branch could be identified, commonly at the level of the second costa, leaving the upper one third (clavicle portion and part of the sternocostal portion) of the pectoralis major intact (Fig. 4). Vascular pedicle dissection was performed beneath the muscular fascia toward its origin, during which the external pectoral branches were sacrificed to skeletonize and elongate the vascular pedicle. The length of the pedicle reaches 8 to 10 cm (Fig. 5). After ligation of the perforator to the clavicular portion of the pectoralis major, the clavipectoral fascia was divided to create a tunnel. The flap was then passed to the defect region via the submuscular tunnel over the clavicle and beneath the platysma flap (Figs 6 and 7). The donor site defect can easily be closed in all the cases.


Pectoralis Major Myocutaneous Flap for Head and Neck Defects in the Era of Free Flaps: Harvesting Technique and Indications
A partial circumferential defect of the hypopharynx resulted following ablative surgery for the recurrent hypopharyngeal squamous cell carcinoma after radical chemoradiation. The skin paddle was designed medially to the areola.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5384233&req=5

f1: A partial circumferential defect of the hypopharynx resulted following ablative surgery for the recurrent hypopharyngeal squamous cell carcinoma after radical chemoradiation. The skin paddle was designed medially to the areola.
Mentions: All patients underwent general anesthesia; tracheotomy was performed as indicated. The skin paddle was designed and marked over the chest wall caudally-medially to the nipple with sparing of the areola. The shape of the skin paddle matched the defect, mainly elliptically (Fig. 1). The inferior, medial, and lateral incision was made and the surrounding cutaneous flap was elevated to expose the pectoralis major. The attachment of the pectoralis major to the costa and the lower part of the sternum was detached and the space between the pectoralis major and minor was reached, keeping in mind that the third intercostal perforating branch of the internal thoracic artery was included and divided at the point where it derives from the chest wall (Fig. 2). Blunt dissection was performed to identify the pectoral branch of the thoracoacromial artery (Fig. 3). After extending the skin incision upward, the sternal attachment was divided. Then the pectoralis major was transected horizontally along the muscular fiber axis at the level where the terminal pectoral branch could be identified, commonly at the level of the second costa, leaving the upper one third (clavicle portion and part of the sternocostal portion) of the pectoralis major intact (Fig. 4). Vascular pedicle dissection was performed beneath the muscular fascia toward its origin, during which the external pectoral branches were sacrificed to skeletonize and elongate the vascular pedicle. The length of the pedicle reaches 8 to 10 cm (Fig. 5). After ligation of the perforator to the clavicular portion of the pectoralis major, the clavipectoral fascia was divided to create a tunnel. The flap was then passed to the defect region via the submuscular tunnel over the clavicle and beneath the platysma flap (Figs 6 and 7). The donor site defect can easily be closed in all the cases.

View Article: PubMed Central - PubMed

ABSTRACT

The role of the pectoralis major myocutaneous flap (PMMF) in head and neck reconstruction is challenged recently due to its natural drawbacks and the popularity of free flaps. This study was designed to evaluate the indications and reliability of using a PMMF in the current free flap era based on a single center experience. The PMMF was harvested as a pedicle-skeletonized flap, with its skin paddle caudally and medially to the areola, including the third intercostal perforator, preserving the upper one third of the pectoralis major muscle. The harvested flap was passed via a submuscular tunnel over the clavicle. One hundred eighteen PMMFs were used in 114 patients, of which 76 were high-risk candidates for a free flap; 8 patients underwent total glossectomy, and 30 underwent salvage or emergency reconstruction. Major complications occurred in 4 patients and minor complications developed in 10. Tracheal extubation was possible in all cases, while oral intake was possible in all but 1 case. These techniques used in harvesting a PMMF significantly overcome its natural pitfalls. PMMFs can safely be used in head and neck cancer patients who need salvage reconstruction, who are high risk for free flaps, and who need large volume soft-tissue flaps.

No MeSH data available.


Related in: MedlinePlus