Experience With the Modified Pectoralis Major Myocutaneous Flap Miklos \s=b\
Results of 75 reconstructions with
Kasler, MD;
Ferenc G.
modified
pectoralis
a
Banhidy, MD; Zoltan Trizna,
Tumor Characteristics
major myocutaneous flap are described in patients with ad-
vanced (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. (Arch Otolaryngol Head Neck Surg. 1992;118:931-932)
Since
its first
neous
description1-2 the pectoralis major myocuta¬
flap (PMMF) has been used extensively for recon¬
structions in head and neck surgery. The original method was modified by many authors for achieving better results. The blood supply of the PMMF was investigated with angiography. On the basis of the angiographie findings and the anatomy of the muscle fibers a modified PMMF was used in patients with advanced head and neck cancer. We describe the modification of the surgical approach and its clinical results. MATERIALS AND METHODS
Seventy-five reconstructions with PMMF were performed in 74
patients with advanced head and neck cancer between 1982 and
1986 (informed consent was obtained after the nature of the pro¬ cedure was explained). The male:female ratio was 72:2, with an age range between 33 and 74 years. The localizations and staging (based on the International Union Against Cancer [UICC] crite¬ ria) are summarized in the Table. Thirteen patients had been treated preoperatively with surgery, radiotherapy or chemother¬ apy, or with a combination of these. Seldinger's selective transfemoral method was used for preop¬ erative angiographie studies of the subclavian artery in 18 cases to determine the exact position of the thoracoacromial artery. The findings were used for modifying the surgical approach for rais¬ ing the PMMF. Extirpation of the primary tumor and neck dissection were performed as a one-stage procedure. Palpable nodes indicated radical neck dissection in 60 cases; in the absence of clinically ev¬ ident cervical métastases elective radical neck dissection was the
Accepted for publication May 6, 1992. From the Department of Head and Neck Surgery, Postgraduate Medical University, National Institute of Oncology, Budapest, Hungary. Reprint requests to Postgraduate Medical University, National Institute of Oncology, Rath Gy.u. 7-9, Budapest H-1122, Hungary (Dr Kasler).
MD
Site
No. of Patients
cavity
33
Oropharynx Hypopharynx (extending to the larynx)
23
Total
74
Oral
Stage 1
III
Stage
IV
32 23
...
18
18 ...
1
73
treatment of choice in the remaining 14. After of the cutaneous island the thoracoacromial ar¬ tery and vein came into view at its distal level, covered by the pectoral fascia. The deep pectoral fascia was incised at a distance of 1 cm medial to and paralleling the vessels. The lateral
outlining
deep
incision followed the muscle fibers along the acromioxyphoideal line. A pedicle of intact muscle fibers with a diameter of approx¬ imately 2 cm was then created by bluntly dissecting the muscle fibers. The pedicle was rotated under the cranial fibers and was positioned on the surface of the major pectoralis muscle through a tunnel in the upper third of the muscle. The flap was advanced through a tunnel between the clavicle and the clavicular part of the muscle bridging the shortest possible distance between the donor site and the defect (Fig 1).
RESULTS Our angiographie studies have shown that the thora¬ coacromial artery had its origin in the plane of the middle clavicular line, with its course being in this plane (Fig 2). However, the site of its origin was lateral to this in some cases. The main stem of the artery could be followed to the level of the seventh and eighth ribs, its collateral system showing variable patterns. Its diameter did not show sig¬ nificant narrowing before the above-mentioned level, thus ensuring a safe blood supply to the PMMF. Our clinical results corroborated these findings, ie, the main vessels came into view immediately after elevating the cutaneous part of the flap from the deep fascia. Pectoralis major myocutaneous flaps were considered vi¬ able if (1) no necroses occurred, or the eventual necrosis was only partial (ie, not involving all layers of the flap), or (2) there were no disruptions at the reconstruction site. Based on these criteria, all PMMFs were viable. However, four pa¬ tients died in the early postoperative phase (one as a result of stroke, two of myocardial infarction, and one of dissem¬ inated intravascular coagulation) before the viability of the flap could have been clinically assessed. Partial necrosis of the PMMF was observed in three cases; however, complete restoration of the necrotic areas occurred in all patients. COMMENT The advantages of the PMMF are well documented. It has found wide applications in head and neck surgery, being a versatile reconstructive procedure following removal of ad¬ vanced oral, mesopharyngeal, and hypopharyngeal, or
esophageal tumors.'"7
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Fig 2.—The angiogram shows the course of the thoracoacromial artery
(arrows) and its origin, both in the plane of the middle clavicular line (A); indicates the acromyoxyphoid line.
sively mobilized muscular pedicle can sufficiently protect the supplying vessels even with its reduced bulk. Our PMMF made it possible to bridge substantial dis¬ tances between the donor site and the defect caused by re¬ 1.—The pectoralis major myocutaneous flap bridges the shortest possible distance between the donor site and the defect.
Fig
Our angiographie studies showed that the course of the thoracoacromial artery was in the plane of the middle clavicular line or in that of a plane lateral to it. The main stem could be followed to the level of the seventh and eighth ribs without demonstrating any significant narrow¬ ing in its diameter. These findings were, to some extent, contrary to those of other studies where the course of the artery followed the acromioxyphoid line.1-3-8'9 The modification in raising the PMMF was based on the angiographie results and the anatomic structure of the mus¬ cle. It should be emphasized that, during the preparation of the pedicle, the muscle fibers were not cut (in contrast to other methods) as this would have incurred the risk that the entire flap would have been suspended on its supplying ves¬ sels. In this latter case the flaccid pedicle, consisting of dis¬ sected incomplete fibers, could not protect the vessels from kinking, overextension, or eventual occlusion. The pedicle, consisting of intact muscle fibers, preserves its tone while bridging the distance between the humérus and the de¬ fect. This feature ensures the protection of the vessels
against damage. The viability of the PMMFs has been proven clinically by the fact that no significant necroses were observed in the 70 évaluable
patients.
This demonstrated that the exten-
moval of the primary tumor. Thus, the PMMF could be used extensively even for closing tonsillolingual defects or de¬ fects extending into the tissues of the soft palate. The effi¬ cacy of the procedure was preserved. At the same time the muscular bulk of the pedicle was reduced resulting in cosmetically good neck contours in our patients. We found that, in addition to good viability, both functional and aes¬ thetic results were improved by using our modified PMMF. References S. The
Ariyan pectoralis major myocutaneous flap. Plast Reconstr Surg. 1979;63:73-81. 2. Baek S, Biller HF, Krespi YP, Lawson W. The pectoralis major myocu1.
taneous
island flap for reconstruction of the head and neck. Head Neck Surg.
1979;1:293-300. 3. Maisel RH, Liston SI. Pectoralis major myocutaneous flap. Laryngoscope. 1980;90:2051-6. 4. Theogaraj SD, Merritt WH, Acharyr G, Cohen G. The pectoralis major musculocutaneous island flap in single-stage reconstruction of the pharyngoesophageal region. Plast Reconstr Surg. 1980;65:267-276.
5. Goldstein RD, Komisar A, Silver C, Strauch B. Management of necrotic neck wounds with a 'sandwich' pectoralis myocutaneous flap. Head Neck
Surg. 1988;10:246-251. 6. Joseph CE, Gregor RT, Davidge-Pitts KJ, Waner M. The versatility of the pectoralis major myocutaneous flap. Head Neck Surg. 1985;7:365-368. 7. Cusumano
RJ, Silver CE, Brauer RJ, Strauch B. Pectoralis myocutaneous
flap for replacement of cervical esophagus. Head Neck Surg. 1988;11:450-456. 8. Eitschberger E, Rossalan A, Weidenbecker M. Gefaess-system und Praeparationstechnik des pektoralen myokutanen Insellappens. HNO. 1981;29:79-82.
9. Mann W. Grenzen und Anwendungsbereiche myokutaner Insellappen in der rekonstruktiven Kopf-Hals-Chirurgie. Laryngol Rhinol Otol. 1983;62: 29-32.
Downloaded From: http://archotol.jamanetwork.com/ by a University of California - San Diego User on 06/10/2015
Results of 75 reconstructions with
Kasler, MD;
Ferenc G.
modified
pectoralis
a
Banhidy, MD; Zoltan Trizna,
Tumor Characteristics
major myocutaneous flap are described in patients with ad-
vanced (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. (Arch Otolaryngol Head Neck Surg. 1992;118:931-932)
Since
its first
neous
description1-2 the pectoralis major myocuta¬
flap (PMMF) has been used extensively for recon¬
structions in head and neck surgery. The original method was modified by many authors for achieving better results. The blood supply of the PMMF was investigated with angiography. On the basis of the angiographie findings and the anatomy of the muscle fibers a modified PMMF was used in patients with advanced head and neck cancer. We describe the modification of the surgical approach and its clinical results. MATERIALS AND METHODS
Seventy-five reconstructions with PMMF were performed in 74
patients with advanced head and neck cancer between 1982 and
1986 (informed consent was obtained after the nature of the pro¬ cedure was explained). The male:female ratio was 72:2, with an age range between 33 and 74 years. The localizations and staging (based on the International Union Against Cancer [UICC] crite¬ ria) are summarized in the Table. Thirteen patients had been treated preoperatively with surgery, radiotherapy or chemother¬ apy, or with a combination of these. Seldinger's selective transfemoral method was used for preop¬ erative angiographie studies of the subclavian artery in 18 cases to determine the exact position of the thoracoacromial artery. The findings were used for modifying the surgical approach for rais¬ ing the PMMF. Extirpation of the primary tumor and neck dissection were performed as a one-stage procedure. Palpable nodes indicated radical neck dissection in 60 cases; in the absence of clinically ev¬ ident cervical métastases elective radical neck dissection was the
Accepted for publication May 6, 1992. From the Department of Head and Neck Surgery, Postgraduate Medical University, National Institute of Oncology, Budapest, Hungary. Reprint requests to Postgraduate Medical University, National Institute of Oncology, Rath Gy.u. 7-9, Budapest H-1122, Hungary (Dr Kasler).
MD
Site
No. of Patients
cavity
33
Oropharynx Hypopharynx (extending to the larynx)
23
Total
74
Oral
Stage 1
III
Stage
IV
32 23
...
18
18 ...
1
73
treatment of choice in the remaining 14. After of the cutaneous island the thoracoacromial ar¬ tery and vein came into view at its distal level, covered by the pectoral fascia. The deep pectoral fascia was incised at a distance of 1 cm medial to and paralleling the vessels. The lateral
outlining
deep
incision followed the muscle fibers along the acromioxyphoideal line. A pedicle of intact muscle fibers with a diameter of approx¬ imately 2 cm was then created by bluntly dissecting the muscle fibers. The pedicle was rotated under the cranial fibers and was positioned on the surface of the major pectoralis muscle through a tunnel in the upper third of the muscle. The flap was advanced through a tunnel between the clavicle and the clavicular part of the muscle bridging the shortest possible distance between the donor site and the defect (Fig 1).
RESULTS Our angiographie studies have shown that the thora¬ coacromial artery had its origin in the plane of the middle clavicular line, with its course being in this plane (Fig 2). However, the site of its origin was lateral to this in some cases. The main stem of the artery could be followed to the level of the seventh and eighth ribs, its collateral system showing variable patterns. Its diameter did not show sig¬ nificant narrowing before the above-mentioned level, thus ensuring a safe blood supply to the PMMF. Our clinical results corroborated these findings, ie, the main vessels came into view immediately after elevating the cutaneous part of the flap from the deep fascia. Pectoralis major myocutaneous flaps were considered vi¬ able if (1) no necroses occurred, or the eventual necrosis was only partial (ie, not involving all layers of the flap), or (2) there were no disruptions at the reconstruction site. Based on these criteria, all PMMFs were viable. However, four pa¬ tients died in the early postoperative phase (one as a result of stroke, two of myocardial infarction, and one of dissem¬ inated intravascular coagulation) before the viability of the flap could have been clinically assessed. Partial necrosis of the PMMF was observed in three cases; however, complete restoration of the necrotic areas occurred in all patients. COMMENT The advantages of the PMMF are well documented. It has found wide applications in head and neck surgery, being a versatile reconstructive procedure following removal of ad¬ vanced oral, mesopharyngeal, and hypopharyngeal, or
esophageal tumors.'"7
Downloaded From: http://archotol.jamanetwork.com/ by a University of California - San Diego User on 06/10/2015
Fig 2.—The angiogram shows the course of the thoracoacromial artery
(arrows) and its origin, both in the plane of the middle clavicular line (A); indicates the acromyoxyphoid line.
sively mobilized muscular pedicle can sufficiently protect the supplying vessels even with its reduced bulk. Our PMMF made it possible to bridge substantial dis¬ tances between the donor site and the defect caused by re¬ 1.—The pectoralis major myocutaneous flap bridges the shortest possible distance between the donor site and the defect.
Fig
Our angiographie studies showed that the course of the thoracoacromial artery was in the plane of the middle clavicular line or in that of a plane lateral to it. The main stem could be followed to the level of the seventh and eighth ribs without demonstrating any significant narrow¬ ing in its diameter. These findings were, to some extent, contrary to those of other studies where the course of the artery followed the acromioxyphoid line.1-3-8'9 The modification in raising the PMMF was based on the angiographie results and the anatomic structure of the mus¬ cle. It should be emphasized that, during the preparation of the pedicle, the muscle fibers were not cut (in contrast to other methods) as this would have incurred the risk that the entire flap would have been suspended on its supplying ves¬ sels. In this latter case the flaccid pedicle, consisting of dis¬ sected incomplete fibers, could not protect the vessels from kinking, overextension, or eventual occlusion. The pedicle, consisting of intact muscle fibers, preserves its tone while bridging the distance between the humérus and the de¬ fect. This feature ensures the protection of the vessels
against damage. The viability of the PMMFs has been proven clinically by the fact that no significant necroses were observed in the 70 évaluable
patients.
This demonstrated that the exten-
moval of the primary tumor. Thus, the PMMF could be used extensively even for closing tonsillolingual defects or de¬ fects extending into the tissues of the soft palate. The effi¬ cacy of the procedure was preserved. At the same time the muscular bulk of the pedicle was reduced resulting in cosmetically good neck contours in our patients. We found that, in addition to good viability, both functional and aes¬ thetic results were improved by using our modified PMMF. References S. The
Ariyan pectoralis major myocutaneous flap. Plast Reconstr Surg. 1979;63:73-81. 2. Baek S, Biller HF, Krespi YP, Lawson W. The pectoralis major myocu1.
taneous
island flap for reconstruction of the head and neck. Head Neck Surg.
1979;1:293-300. 3. Maisel RH, Liston SI. Pectoralis major myocutaneous flap. Laryngoscope. 1980;90:2051-6. 4. Theogaraj SD, Merritt WH, Acharyr G, Cohen G. The pectoralis major musculocutaneous island flap in single-stage reconstruction of the pharyngoesophageal region. Plast Reconstr Surg. 1980;65:267-276.
5. Goldstein RD, Komisar A, Silver C, Strauch B. Management of necrotic neck wounds with a 'sandwich' pectoralis myocutaneous flap. Head Neck
Surg. 1988;10:246-251. 6. Joseph CE, Gregor RT, Davidge-Pitts KJ, Waner M. The versatility of the pectoralis major myocutaneous flap. Head Neck Surg. 1985;7:365-368. 7. Cusumano
RJ, Silver CE, Brauer RJ, Strauch B. Pectoralis myocutaneous
flap for replacement of cervical esophagus. Head Neck Surg. 1988;11:450-456. 8. Eitschberger E, Rossalan A, Weidenbecker M. Gefaess-system und Praeparationstechnik des pektoralen myokutanen Insellappens. HNO. 1981;29:79-82.
9. Mann W. Grenzen und Anwendungsbereiche myokutaner Insellappen in der rekonstruktiven Kopf-Hals-Chirurgie. Laryngol Rhinol Otol. 1983;62: 29-32.
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