ORIGINAL ARTICLE
Extended vertical lower trapezius island myocutaneous flap versus pectoralis major myocutaneous flap for reconstruction in recurrent oral and oropharyngeal cancer Wei-liang Chen, DDS, MD, MBA,* You-yuan Wang, DDS, PhD, Da-ming Zhang, MS, Song Fan, MS, Zhao-yu Lin, MS Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China.
Accepted 16 December 2014 Published online 29 June 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23960
ABSTRACT: Background. The purpose of this study was to compare the use of an extended vertical lower trapezius island myocutaneous flap (TIMF) and a pectoralis major myocutaneous flap (PMMF). Methods. A total of 39 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma (SCC) underwent salvage surgery followed by placement of either an extended lower vertical TIMF or PMMF for reconstruction. Twenty-one patients received extended lower vertical TIMFs, whereas 18 received PMMFs. Results. The pedicle length of the TIMF was longer than that of the PMMF, and the skin paddle of the TIMF was both wider and longer than
the PMMF. No major complication developed in any of the patients. The TIMF group experienced a lower rate of minor flap failure than did the PMMF group. Conclusion. Use of an extended vertical lower TIMF, which has a longer pedicle flap and a larger skin paddle than a PMMF, is optimal for reconC 2015 Wiley Periodicals, Inc. Head Neck 38: struction of major defects. V E159–E164, 2016
INTRODUCTION
PATIENTS AND METHODS
Locoregional recurrence is the most frequent cause of treatment failure in patients with squamous cell carcinoma (SCC) of the oral cavity and oropharynx. Salvage surgery remains the only curative option for those patients who have received prior treatment with primary radiation and/or surgery.1 Reconstruction after extensive resection of SCC of the oral cavity and oropharynx remains a challenge in salvage surgery. The pectoralis major myocutaneous flap (PMMF) based on the thoracoacromial artery was described in 1979 by Ariyan.2 This technique is useful in geographic regions with high incidences of head-and-neck malignancies when microsurgical free-tissue transfer is not possible or when salvage is required.3 Recently, an extended vertical lower trapezius island myocutaneous flap (TIMF) based on the transverse cervical artery has been used to reconstruct large defects arising after salvage surgery in patients with recurrent head-and-neck SCC; the flap is large, simple, and reliable.1,4,5 The purpose of the present study was to compare the use of extended vertical lower TIMFs and PMMFs for reconstruction in patients with advanced recurrent oral and oropharyngeal SCC.
A total of 39 patients with advanced recurrent oral and oropharyngeal SCC who underwent salvage surgery, followed by placement of either an extended lower vertical TIMF or a PMMF for reconstructive purposes, between January 2010 and January 2014 at the Hospital of Sun Yat-sen University were evaluated. The Institutional Review Board of Sun Yat-sen University approved this study. Twenty-one patients (53.8%) received extended lower vertical TIMFs, whereas 18 (46.2%) received PMMFs. We included 25 men and 14 women ranging in age from 39 to 80 years (median 5 58.9 years). The site of the primary tumor was the oral cavity (tongue, buccal mucosa, floor of mouth, palate, or gingiva) in 34 patients (87.2%) and the oropharynx in 5 (12.8%). The clinical stages of recurrence (the rCS scores) were advanced rCS III in 9 patients (23.1%) and rCS IV in 30 (76.9%). Detailed data for both the TIMF and PMMF groups are shown in Tables 1 and 2. As initial treatment, 21 patients in the TIMF group underwent surgery, including ipsilateral radical neck dissection in 16 cases, reconstruction using PMMFs in 5 cases, forearm free flaps in 3 cases, and submental flaps in 2 cases (Table 1). Sixteen patients in the PMMF group were treated with surgery, including ipsilateral radical neck dissection in 10 cases, and reconstruction using a forearm free flap in 3 cases, TIMFs in 2 cases, and a submental flap in 1 case (Table 2). The interval between initial treatment and salvage surgery in patients with advanced recurrent oral and oropharyngeal SCC ranged from 3 to 25 months (median 5 10.0 months) and 3 to 24
*Corresponding author: W. Chen, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang Road, 510120 Guangzhou, China. E-mail:[email protected]
KEY WORDS: trapezius flap, pectoralis major flap, oral cavity, oropharynx, squamous cell carcinoma, recurrence, salvage surgery
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Buccal mucosa, IV
Tongue, III Buccal mucosa, IV
Oropharynx, IV
Floor of mouth, IV
Buccal mucosa, IV
Tongue, IV Buccal mucosa, IV
Floor of mouth, IV
13, 57, F
14, 54, F 15, 63, F
16, 69, F
17, 42, M
18, 60, M
19, 56, M 20, 63, M
21, 53, M
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TR, IND, PMMP TR, IND, FFF TR, IND, fPMMP, TR, IND, fPMMP
TR, IND, PMMP, RT TR, IND, PMMP, RT
TR, IND, RT TR, RT
TR, RT TR, IND, SF TR, IND TR, IND, FFF, RT RT
TR, IND, SF
TR, IND RT TR, IND TR, IND TR, RT TR, IND, FFF TR, IND
Initial treatment
4
16 3
5
18
24
9 18
5
5 8 14 18
10
3
3 7 5 3 5 4
Recurrence time, mo
TR, Man, CND TR, Max, Man, CND TR, Man, CND
TR, Max, Man
TR, Man, CND
TR, Max
TR, Max, Man, IND TR, Man TR, Man, IND
TR, Man, CND TR, Max, IND TR, Man TR, Man, CND
TR, Man, Max
TR, Man, Max
TR, Man TR, Man, IND TR, Man, BND TR, Man, IND TR, Man, BND TR, Man, Max
Salvage surgery
33/9 3 20
36/10 3 (9 1 15)* 33/13 3 25
35/8 3 (11 1 11)*
34/9 3 (10 1 10)*†
26/6 3 14
29/6 3 (7 1 9)* 31/7 3 (7 1 12)*
30/9 3 (7 1 9)*
36/9 3 25 24/6 3 10 22/6 3 7 33/8 3 (7 1 13)*†
32/7 3 20
24/7 3 12
22/8 3 10 34/8 3 (8 1 13)*† 21/6 3 8 29/8 3 16 33/6 3 23 22/6 3 10
PLF/SPF, cm
None
None None
Wound dehiscence in donor site None
Minor flap failure None Orocutaneous fistula None
None None None None
None
None None None None None Orocutaneous fistula None
Complications
-
RT -
RT
-
-
-
CT
RT -
-
Chemo/RT
RT RT -
Adjuvant treatment
7
16 19
12
22
6
14 18
4
16 10 48 12
12
18
16 13 20 33 8 6
Followup, mo
SolD, NS/AND
LD, SS/DOD SofD, NS/AND
SofD, NS/AND
SofD, NS/AWD
SofD, NS/AND
SolD, NS/AND SofD, NS/AND
SofD, SS/AND
SolD, NS/AND SofD, NS/AWD SofD, NS/AND SofD, NS/AND
SofD, IS/AWD
SofD, NS/AND
SofD, NS/AND SofD, NS/AND SofD, NS/AND SofD, NS/AND LD, SS/DOD LD, SS/DOD
Functional outcomes/status
Abbreviations: rCS, clinical staging of recurrence; PLF, pedicle length of the flap; SPF, skin paddle of the flap; TR, tumor resection; IND, ipsilateral radical neck dissection; Man, mandibulotomy; RT, radiotherapy; SofD, soft diet; NS, normal speech; AND, alive (with) no disease; Chemo, chemotherapy; BND, bilateral radical neck dissection; LD, liquid diet; SS, slurred speech; DOD, died of disease; FFF, forearm free flap; Max, maxillotomy; SF, submental flap; IS, intelligible speech; AWD, alive with disease; CND, contralateral radical neck dissection; SolD, solid diet; PMMP, pectoralis major myocutaneous flap; fPMMP, folded pectoralis major myocutaneous flap. * Folded extended vertical lower TIMF. † Titanium bridging plate use to reconstruct a mandibulectomy.
8, 73, F
7, 50, F
9, 56, F 10, 63, F 11, 80, M 12, 73, F
Tumor site, rCS
Gingiva, IV Tongue, III Tongue, IV Tongue, III Gingiva, IV Buccal mucosa, IV Buccal mucosa, IV Buccal mucosa, IV Floor of mouth, IV Oropharynx, IV Tongue, III Buccal mucosa, IV
1, 61, M 2, 54, F 3, 57, M 4, 66, M 5, 56, F 6, 49, M
Patient #, age, sex
TABLE 1. Tumor origin, initial treatment, salvage surgery, and outcomes of reconstruction using extended lower vertical trapezius island myocutaneous flaps in 21 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma.
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Tongue, III Oropharynx, IV Mandibular gingiva, IV
Buccal mucosa, IV
Buccal mucosa, III Floor of mouth, IV Oropharynx, IV Palate, IV Buccal mucosa, IV Tongue, III Tongue, IV Floor of mouth, IV
Tongue, III Oropharynx, IV Floor of mouth, IV
Palate, IV Tongue, IV Tongue, IV
1, 56, M 2, 57, M 3, 73, M
4, 76, M
5, 63, F 6, 42, M 7, 58, M 10, 52, M 9, 67, M 10, 49, M 11,54, M 12, 52, F
13, 39, F 14, 49, M 15, 62, M
16, 73, M 17, 59, M 18, 61, M
RT HG, IND HG
HG, IND, FFF TR, IND, FFF TR, RT
TR/IND/TIMF TR/IND/RT RT RT TR/IND/TIMF HG, IND, SF HG, IND RT
TR/TR
TR/IND TR/IND/FFF/RT TR/RT
Initial treatment
8 6 7
16 13 5
12 8 5 6 14 9 60 7
6
30 12 5
Recurrence time, mo
Max, IND TG, Man TG, Man, IND
TR, Man TR, Man TR, Man, IND
TR, Max, Man TR, Man, CND TR, BND TR, Max, IND TR, Max, Man TR, Man, CND TR, Man, CND TR, Man, BND
TR, Max, Man, IND
TR TR, CND TR, Man, BND
Salvage treatment
23/7 3 13 22/8 3 (13 1 7)*† 24/6 3 (10 1 5)*
19/6 3 11 24/6 3 (7 1 9)*† 26/8 3 (15 1 7)*
18/5 3 7 24/5 3 15 24/6 3 15 24/7 3 15 25/6 3 (9 1 6)* 24/7 3 (7 1 6)* 23/6 3 12 22/9 3 (10 1 8)*
25/8 3 (9 1 6)*
21/6 3 11 22/6 3 12 23/5 3 14
PLS/SPF, cm
None None Orocutaneous fistula Minor flap failure None None None None None None None Wound dehiscence at donor site, minor flap failure None None Minor flap failure None None None
Complications
RT -
-
RT Chemo RT -
-
RT Chemo -
Adjuvant treatment
9 20 16
36 28 18
18 19 14 8 24 20 13 22
10
24 13 6
Follow-up, mo
SolD, NS/AND SofD, IS/AND SolD, NS/AND
SofD, IS/DOD SolD, NS/AND SolD, NS/AND
SofD, IS/AND LD, IS/AND SolD, NS/AND LD, IS/DOD SolD, NS/AND SolD, NS/AND SofD, IS/DOD SolD, NS/AND
NTF, SS/DWD
SolD, NS/AND SofD, IS/AND LD, IS/AND
Functional outcomes/status
Abbreviations: rCS, clinical staging of recurrence; PLS, pedicle length of the flap; SPF, skin paddle of the flap; TR, tumor resection; IND, ipsilateral radical neck dissection; RT, radiotherapy; SolD, solid diet; NS, normal speech; AND, alive (with) no disease; FFF, forearm free flap; CND, contralateral radical neck dissection; Chemo, chemotherapy; SofD, soft diet; IS, intelligible speech; Man, mandibulotomy; BND, bilateral radical neck dissection; LD, liquid diet; Max, maxillotomy; NTF, nasogastric tube feeding; SS, slurred speech; DWD, alive with disease; TIMF, trapezius island myocutaneous flap; DOD, died of disease; HG, hemiglossectomy; SF, submental flap. * Folded pectoralis major myocutaneous flap. † Titanium bridging plate use to reconstruct a mandibulectomy.
Tumor site, rCS
Patient #, age, sex
TABLE 2. Tumor origins, initial treatment, nature of salvage surgery, and outcomes of reconstruction using pectoralis major myocutaneous flaps in 18 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma.
EXTENDED TRAPEZIUS MYOCUTANEOUS VERSUS PECTORALIS MAJOR MYOCUTANEOUS FLAP
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FIGURE 1. A 73-year-old woman presented with advanced recurrent squamous cell carcinoma (SCC) of the left buccal mucosa of grade clinical stages of recurrence (rCS) IV (Table 1, case 12). (A) Outline of the incision line for wide excision of the tumor. (B) Design of the extended lower vertical trapezius island myocutaneous flap (TIMF) featuring a skin paddle measuring 8 3 (7 1 13) cm. (C) and (D) Twelve months postoperatively: an intraoral view and the appearance of the face-and-neck recipient sites, respectively.
months (median 5 8.9 months) in the TIMF and PMMF groups, respectively. All patients were generally in good health, and their tumors were resectable, based on clinical examination, CT scanning, nuclear magnetic resonance data, and/or positron emission tomography-CT. All patients had locoregional recurrences without distant metastases, and all accepted that frozen-section assessment of surgical margins should be used to guide the salvage surgery. Preoperative 3D-CT angiography was performed on the TIMF group to reveal the patency of the transverse cervical artery and its branches. The pedicle length of an extended vertical lower TIMF ranged from 21 to 36 cm (mean 5 29.5 cm) and the skin paddle dimensions from 5 3 7 cm to 13 3 25 cm (average 5 7.7 3 17.0 cm). The PMMFs ranged in length from 18 to 26 cm (mean 5 22.9 cm), with skin paddle dimensions of 6 3 7 cm to 8 3 17 cm (average 5 6.3 3 12.6 cm), and was used to reconstruct major defects. Eight folded extended vertical lower TIMFs (see Figure 1) and 5 folded PMMFs (see Figure 2) were used to reconstruct through-and-through defects. The mean flap harvesting durations in the TIMF and PMMF groups were 58 and 55 minutes, respectively. Seven patients in the TIMF group and 6 in the PMMF group who exhibited positive or close margins after salvage surgery were treated with adjuvant chemotherapy, radiotherapy, or both (Tables 1 and 2). All patients were followed up 3 months postoperatively by a panel of 3 surgeons to evaluate swallowing function (classified as consumption of a solid diet, a soft diet, a liquid diet, or nasogastric tube feeding) and speech function (classified as normal, intelligible, or slurred speech) and the requirement for tracheostomy. The detailed salvage surgical procedures and the outcomes of both groups are shown in Tables 1 and 2. E162
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Statistical analysis SPSS software version 12.0 (SPSS, Chicago, IL) for performing the chi-square test was used to analyze data. Means and SDs were calculated. A p value < .05 was considered to indicate statistical significance.
RESULTS There was no significant difference between the TIMF and PMMF groups in terms of age, primary tumor site, clinical stage of recurrence, time of recurrence, or the initial type of surgery. A much higher proportion of female patients received TIMFs than PMMFs (52.4% vs 16.5%; p 5 .02). There was no significant difference in either mean flap harvesting duration or complication frequency between the groups, but the pedicle length of the TIMF was longer than that of the PMMF (29.48 6 5.13 vs 22.94 6 2.04 cm; p 5 .000), and the skin paddle of the TIMF was both wider (7.71 6 1.76 vs 6.28 6 0.83 cm; p 5 .003) and longer (17.05 6 5.74 vs 12.56 6 2.45 cm; p 5 .004) than that of the PMMF. No major complications developed in any patient. Wound dehiscence at the donor site and orocutaneous fistulas occurred in 3 patients (14.3%) in the TIMF group and 2 patients (11.1%) in the PMMF group, respectively. The TIMF group experienced a lower rate of minor flap failure compared with the PMMF group (4.8% vs 16.7%; p 5 .03). Eighteen patients (85.7%) in the TIMF group and 15 (83.3%) in the PMMF group could manage a solid or soft diet, and no patient required nasogastric tube feeding. Seventeen patients (81.0%) in the TIMF group and 15 (83.3%) in the PMMF group reacquired normal or intelligible speech, and no patient required a permanent tracheostomy. Patients were followed up for 4 to 46 months
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TRAPEZIUS MYOCUTANEOUS VERSUS PECTORALIS MAJOR MYOCUTANEOUS FLAP
FIGURE 2. A 49-year-old man presented with advanced recurrent squamous cell carcinoma (SCC) of the right tongue of grade clinical stages of recurrence (rCS) III (Table 2, case 10). (A) The outline of the incision line for wide excision of the tumor and design of the pectoralis major myocutaneous flap (PMMF) with a skin paddle measuring 7 3 (7 1 6) cm. (B and C) Four months postoperatively: intraoral view and the appearance of the face and neck recipient sites, respectively.
(median 5 16.5 months in the TIMF and 15.1 months in the PMMF group). At final follow-up, 15 patients (71.4%) in the TIMF group and 14 (77.8%) in the PMMF group were alive with no evidence of disease, 3 in the TIMF group and 1 in the PMMF group were alive with disease, and 6 patients in each group died of local recurrence or distant metastases between 6 and 36 months (Tables 1 and 2).
DISCUSSION In the current era of free tissue transfer, the PMMF has been gradually relegated to a secondary role. Free flaps, including free anterolateral thigh flaps and radial forearm flaps, have proven to be very reliable, and success is usually achieved in experienced hands. Recently, a few studies have explored differences between free tissue transfer and pedicle flap reconstruction in the repair of postablative head-and-neck defects.6–10 It was suggested that the reliability of free flaps was higher than that of PMMFs in
patients with extensive tongue defects, suggesting that reconstruction via free soft-tissue transfer should be the first-choice treatment option.6 Patients undergoing reconstruction using free anterolateral thigh flaps had better shoulder but poorer speech functions than those treated using PMMFs.7 The PMMF still provides a durable and safe flap, but use of a radial forearm flap is associated with markedly improved speech performance compared with a PMMF.8 Some studies have claimed that a pedicled PMMF continues to play an important role in headand-neck reconstruction even in the microvascular era, particularly when free flap rescue is required.9,10 The PMMF retains major roles in salvage surgery for patients with recurrent disease or extensive metastatic neck disease, and after free flap failure.9,11,12 There are few comparisons in the literature between the 2 types of pedicled flaps in their use to reconstruct defects arising after salvage surgery. Reconstruction of the (inevitably large) defects arising after wide resection of advanced recurrent oral and HEAD & NECK—DOI 10.1002/HED
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oropharyngeal SCC is a major problem. In the present study, we compared 2 pedicled flaps, the extended vertical lower TIMF and PMMF, used for reconstruction in patients with advanced recurrent oral and oropharyngeal SCC. The 2 groups were similar in terms of patient characteristics (age, primary tumor site, clinical staging of recurrence, time of recurrence, and initial surgery), mean flap harvesting time, complications (orocutaneous fistula and wound dehiscence at the donor site), quality of life, and survival time. We believe that both types of flaps retain major roles in salvage surgery and are easy to prepare (thus, the duration of the procedure is reasonably short). An extended vertical lower TIMF may be preferable to reconstruct oral and neck soft-tissue defects after salvage surgery in patients with recurrent oral and neck SCC,4,5 and as a second salvage procedure in patients with advanced re-recurrent oral and neck SCC.1 In the present study, 5 patients (23.8%) and 3 patients (14.3%) in the TIMF group (initial treatment) were reconstructed using PMMFs and forearm free flaps, respectively, and 3 patients (16.7%) and 2 patients (11.1%) in the PMMF group (initial treatment) were reconstructed using forearm free flaps and TIMFs, respectively. This indicated that use of the 2 types of pedicled flaps can be alternated in salvage procedures. The pedicle of the TIMF is longer than that of the PMMF, and the skin paddle of the former flap is both wider and longer than that of the PMMF. The TIMF group experienced a lower rate of minor flap failure compared with the PMMF group. A longer pedicle flap with a larger skin paddle is valuable in the reconstruction of major defects arising after salvage surgery in patients with advanced recurrent oral and oropharyngeal SCC, may be long enough for application to the skull base1,13 and it can be used to prepare folded flaps for reconstruction of through-and-through defects. Eight folded extended vertical lower TIMFs (38.1%) and 5 folded PMMFs (27.8%) were used to reconstruct throughand-through defects. All minor flap failures were in the distal portions of the folded flaps, and the PMMF group experienced a higher rate of minor flap failure than did the TIMF group. The bulkiness of the PMMF causes cramping in the mandibular arch, damaging the paddle, a process exacerbated by postoperative edema. The main bulk of the pectoralis muscle is attached to the skin paddle, and plicature of the pedicle axis increases the risk of skin paddle damage. If the skin paddle is harvested too close to the rectus abdominis muscle, unreliable vascular flow reduces the success rate of flap placement.14 We consider that the PMMF may not be large enough to allow reconstruction of major through-and-through defects and may not be long enough for application to the skull base. Additionally, accidental displacement of a pectoralis major flap by a breast tissue adenocarcinoma and SCC developing in the PMMF donor site have been reported.15,16 A much higher proportion of female patients received TIMFs (52.4%) than PMMFs (16.5%); use of a TIMF is preferred in women when myocutaneous flaps are not ideal. We did not detect any major complications after flap use. Wound dehiscence at the donor site and orocutaneous
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fistulas occurred and were treated successfully using debridement. At the last follow-up, 15 patients (71.4%) in the TIMF group and 14 patients (77.8%) in the PMMF group were alive with no evidence of disease; 3 patients in the TIMF group and 1 in the PMMF group were alive with disease, and 6 in either group had died of local recurrence or distant metastases after 6 to 36 months. We believe that salvage surgery remains an effective treatment modality for selected patients with advanced recurrent oral and oropharyngeal SCCs without major complications. Extended vertical lower TIMFs and PMMFs may be the preferred options for repair of oral and oropharyngeal soft-tissue defects after salvage surgery in patients with recurrent oral and oropharyngeal SCC. The extended vertical lower TIMF, featuring a long pedicled flap with a large skin paddle, is useful to reconstruct major defects arising after salvage surgery in such patients, and folded flaps are optimal when reconstructing through-andthrough defects.
REFERENCES 1. Chen W, Yang Z, Zhang D, Wang Y, Fan S, Huang Z. Second salvage surgery with extended vertical lower trapezius island myocutaneous flap reconstruction for advanced re-recurrent oral and oropharyngeal squamous cell carcinoma. Int J Oral Maxillofac Surg 2014;43:531–538. 2. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73–81. 3. Gadre KS, Gadre P, Sane VD, Halli R, Doshi P, Modi S. Pectoralis major myocutaneous flap–still a workhorse for maxillofacial reconstruction in developing countries. J Oral Maxillofac Surg 2013;71:2005.e1–2005.e10. 4. Chen WL, Li J, Yang Z, Huang Z, Wang J, Zhang B. Extended vertical lower trapezius island myocutaneous flap in reconstruction of oral and maxillofacial defects after salvage surgery for recurrent oral carcinoma. J Oral Maxillofac Surg 2007;65:205–211. 5. Chen WL, Zhang B, Wang JG, Yang ZH, Huang ZQ, Zhang DM. Reconstruction of large defects of the neck using an extended vertical lower trapezius island myocutaneous flap following salvage surgery for neck recurrence of oral carcinoma. J Plast Reconstr Aesthet Surg 2011;64:319– 322. 6. Mallet Y, El Bedoui S, Penel N, Ton VanJ, Fournier C, Lefebvre JL. The free vascularized flap and the pectoralis major pedicled flap options: comparative results of reconstruction of the tongue. Oral Oncol 2009;45:1028– 1031. 7. Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014;25:868–871. 8. O’Neill JP, Shine N, Eadie PA, Beausang E, Timon C. Free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects. Ir J Med Sci 2010;179:337–343. 9. Avery CM, Crank ST, Neal CP, Hayter JP, Elton C. The use of the pectoralis major flap for advanced and recurrent head and neck malignancy in the medically compromised patient. Oral Oncol 2010;46:829–833. 10. Schneider DS, Wu V, Wax MK. Indications for pedicled pectoralis major flap in a free tissue transfer practice. Head Neck 2012;34:1106–1110. 11. 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;41:453–457. 12. Avery CM, Gandhi N, Peel D, Neal CP. Indications and outcomes for 100 patients managed with a pectoralis major flap within a UK maxillofacial unit. Int J Oral Maxillofac Surg 2014;43:546–554. 13. Chen WL, Deng YF, Peng GG, et al. Extended vertical lower trapezius island myocutaneous flap for reconstruction of cranio-maxillofacial defects. Int J Oral Maxillofac Surg 2007;36:165–170. 14. Koh KS, Eom JS, Kirk I, Kim SY, Nam S. Pectoralis major musculocutaneous flap in oropharyngeal reconstruction: revisited. Plast Reconstr Surg 2006;118:1145–1149; discussion 1150. 15. Depprich RA, Handschel JG, Braunstein S, K€ ubler NR. Breast carcinoma in a pectoralis major myocutaneous flap used for reconstruction of the oral cavity: a case report and review of the literature. Oral Oncol Extra 2005; 41:238–241. 16. Mohan AM, Balaguhan B, Krishna V, Nagarjuna M. Squamous cell carcinoma of the pectoralis major myocutaneous flap donor site. J Oral Maxillofac Surg 2014;72:1425–1431.
Extended vertical lower trapezius island myocutaneous flap versus pectoralis major myocutaneous flap for reconstruction in recurrent oral and oropharyngeal cancer Wei-liang Chen, DDS, MD, MBA,* You-yuan Wang, DDS, PhD, Da-ming Zhang, MS, Song Fan, MS, Zhao-yu Lin, MS Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, Guangzhou, China.
Accepted 16 December 2014 Published online 29 June 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23960
ABSTRACT: Background. The purpose of this study was to compare the use of an extended vertical lower trapezius island myocutaneous flap (TIMF) and a pectoralis major myocutaneous flap (PMMF). Methods. A total of 39 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma (SCC) underwent salvage surgery followed by placement of either an extended lower vertical TIMF or PMMF for reconstruction. Twenty-one patients received extended lower vertical TIMFs, whereas 18 received PMMFs. Results. The pedicle length of the TIMF was longer than that of the PMMF, and the skin paddle of the TIMF was both wider and longer than
the PMMF. No major complication developed in any of the patients. The TIMF group experienced a lower rate of minor flap failure than did the PMMF group. Conclusion. Use of an extended vertical lower TIMF, which has a longer pedicle flap and a larger skin paddle than a PMMF, is optimal for reconC 2015 Wiley Periodicals, Inc. Head Neck 38: struction of major defects. V E159–E164, 2016
INTRODUCTION
PATIENTS AND METHODS
Locoregional recurrence is the most frequent cause of treatment failure in patients with squamous cell carcinoma (SCC) of the oral cavity and oropharynx. Salvage surgery remains the only curative option for those patients who have received prior treatment with primary radiation and/or surgery.1 Reconstruction after extensive resection of SCC of the oral cavity and oropharynx remains a challenge in salvage surgery. The pectoralis major myocutaneous flap (PMMF) based on the thoracoacromial artery was described in 1979 by Ariyan.2 This technique is useful in geographic regions with high incidences of head-and-neck malignancies when microsurgical free-tissue transfer is not possible or when salvage is required.3 Recently, an extended vertical lower trapezius island myocutaneous flap (TIMF) based on the transverse cervical artery has been used to reconstruct large defects arising after salvage surgery in patients with recurrent head-and-neck SCC; the flap is large, simple, and reliable.1,4,5 The purpose of the present study was to compare the use of extended vertical lower TIMFs and PMMFs for reconstruction in patients with advanced recurrent oral and oropharyngeal SCC.
A total of 39 patients with advanced recurrent oral and oropharyngeal SCC who underwent salvage surgery, followed by placement of either an extended lower vertical TIMF or a PMMF for reconstructive purposes, between January 2010 and January 2014 at the Hospital of Sun Yat-sen University were evaluated. The Institutional Review Board of Sun Yat-sen University approved this study. Twenty-one patients (53.8%) received extended lower vertical TIMFs, whereas 18 (46.2%) received PMMFs. We included 25 men and 14 women ranging in age from 39 to 80 years (median 5 58.9 years). The site of the primary tumor was the oral cavity (tongue, buccal mucosa, floor of mouth, palate, or gingiva) in 34 patients (87.2%) and the oropharynx in 5 (12.8%). The clinical stages of recurrence (the rCS scores) were advanced rCS III in 9 patients (23.1%) and rCS IV in 30 (76.9%). Detailed data for both the TIMF and PMMF groups are shown in Tables 1 and 2. As initial treatment, 21 patients in the TIMF group underwent surgery, including ipsilateral radical neck dissection in 16 cases, reconstruction using PMMFs in 5 cases, forearm free flaps in 3 cases, and submental flaps in 2 cases (Table 1). Sixteen patients in the PMMF group were treated with surgery, including ipsilateral radical neck dissection in 10 cases, and reconstruction using a forearm free flap in 3 cases, TIMFs in 2 cases, and a submental flap in 1 case (Table 2). The interval between initial treatment and salvage surgery in patients with advanced recurrent oral and oropharyngeal SCC ranged from 3 to 25 months (median 5 10.0 months) and 3 to 24
*Corresponding author: W. Chen, Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital of Sun Yat-sen University, 107 Yanjiang Road, 510120 Guangzhou, China. E-mail:[email protected]
KEY WORDS: trapezius flap, pectoralis major flap, oral cavity, oropharynx, squamous cell carcinoma, recurrence, salvage surgery
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Buccal mucosa, IV
Tongue, III Buccal mucosa, IV
Oropharynx, IV
Floor of mouth, IV
Buccal mucosa, IV
Tongue, IV Buccal mucosa, IV
Floor of mouth, IV
13, 57, F
14, 54, F 15, 63, F
16, 69, F
17, 42, M
18, 60, M
19, 56, M 20, 63, M
21, 53, M
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TR, IND, PMMP TR, IND, FFF TR, IND, fPMMP, TR, IND, fPMMP
TR, IND, PMMP, RT TR, IND, PMMP, RT
TR, IND, RT TR, RT
TR, RT TR, IND, SF TR, IND TR, IND, FFF, RT RT
TR, IND, SF
TR, IND RT TR, IND TR, IND TR, RT TR, IND, FFF TR, IND
Initial treatment
4
16 3
5
18
24
9 18
5
5 8 14 18
10
3
3 7 5 3 5 4
Recurrence time, mo
TR, Man, CND TR, Max, Man, CND TR, Man, CND
TR, Max, Man
TR, Man, CND
TR, Max
TR, Max, Man, IND TR, Man TR, Man, IND
TR, Man, CND TR, Max, IND TR, Man TR, Man, CND
TR, Man, Max
TR, Man, Max
TR, Man TR, Man, IND TR, Man, BND TR, Man, IND TR, Man, BND TR, Man, Max
Salvage surgery
33/9 3 20
36/10 3 (9 1 15)* 33/13 3 25
35/8 3 (11 1 11)*
34/9 3 (10 1 10)*†
26/6 3 14
29/6 3 (7 1 9)* 31/7 3 (7 1 12)*
30/9 3 (7 1 9)*
36/9 3 25 24/6 3 10 22/6 3 7 33/8 3 (7 1 13)*†
32/7 3 20
24/7 3 12
22/8 3 10 34/8 3 (8 1 13)*† 21/6 3 8 29/8 3 16 33/6 3 23 22/6 3 10
PLF/SPF, cm
None
None None
Wound dehiscence in donor site None
Minor flap failure None Orocutaneous fistula None
None None None None
None
None None None None None Orocutaneous fistula None
Complications
-
RT -
RT
-
-
-
CT
RT -
-
Chemo/RT
RT RT -
Adjuvant treatment
7
16 19
12
22
6
14 18
4
16 10 48 12
12
18
16 13 20 33 8 6
Followup, mo
SolD, NS/AND
LD, SS/DOD SofD, NS/AND
SofD, NS/AND
SofD, NS/AWD
SofD, NS/AND
SolD, NS/AND SofD, NS/AND
SofD, SS/AND
SolD, NS/AND SofD, NS/AWD SofD, NS/AND SofD, NS/AND
SofD, IS/AWD
SofD, NS/AND
SofD, NS/AND SofD, NS/AND SofD, NS/AND SofD, NS/AND LD, SS/DOD LD, SS/DOD
Functional outcomes/status
Abbreviations: rCS, clinical staging of recurrence; PLF, pedicle length of the flap; SPF, skin paddle of the flap; TR, tumor resection; IND, ipsilateral radical neck dissection; Man, mandibulotomy; RT, radiotherapy; SofD, soft diet; NS, normal speech; AND, alive (with) no disease; Chemo, chemotherapy; BND, bilateral radical neck dissection; LD, liquid diet; SS, slurred speech; DOD, died of disease; FFF, forearm free flap; Max, maxillotomy; SF, submental flap; IS, intelligible speech; AWD, alive with disease; CND, contralateral radical neck dissection; SolD, solid diet; PMMP, pectoralis major myocutaneous flap; fPMMP, folded pectoralis major myocutaneous flap. * Folded extended vertical lower TIMF. † Titanium bridging plate use to reconstruct a mandibulectomy.
8, 73, F
7, 50, F
9, 56, F 10, 63, F 11, 80, M 12, 73, F
Tumor site, rCS
Gingiva, IV Tongue, III Tongue, IV Tongue, III Gingiva, IV Buccal mucosa, IV Buccal mucosa, IV Buccal mucosa, IV Floor of mouth, IV Oropharynx, IV Tongue, III Buccal mucosa, IV
1, 61, M 2, 54, F 3, 57, M 4, 66, M 5, 56, F 6, 49, M
Patient #, age, sex
TABLE 1. Tumor origin, initial treatment, salvage surgery, and outcomes of reconstruction using extended lower vertical trapezius island myocutaneous flaps in 21 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma.
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Tongue, III Oropharynx, IV Mandibular gingiva, IV
Buccal mucosa, IV
Buccal mucosa, III Floor of mouth, IV Oropharynx, IV Palate, IV Buccal mucosa, IV Tongue, III Tongue, IV Floor of mouth, IV
Tongue, III Oropharynx, IV Floor of mouth, IV
Palate, IV Tongue, IV Tongue, IV
1, 56, M 2, 57, M 3, 73, M
4, 76, M
5, 63, F 6, 42, M 7, 58, M 10, 52, M 9, 67, M 10, 49, M 11,54, M 12, 52, F
13, 39, F 14, 49, M 15, 62, M
16, 73, M 17, 59, M 18, 61, M
RT HG, IND HG
HG, IND, FFF TR, IND, FFF TR, RT
TR/IND/TIMF TR/IND/RT RT RT TR/IND/TIMF HG, IND, SF HG, IND RT
TR/TR
TR/IND TR/IND/FFF/RT TR/RT
Initial treatment
8 6 7
16 13 5
12 8 5 6 14 9 60 7
6
30 12 5
Recurrence time, mo
Max, IND TG, Man TG, Man, IND
TR, Man TR, Man TR, Man, IND
TR, Max, Man TR, Man, CND TR, BND TR, Max, IND TR, Max, Man TR, Man, CND TR, Man, CND TR, Man, BND
TR, Max, Man, IND
TR TR, CND TR, Man, BND
Salvage treatment
23/7 3 13 22/8 3 (13 1 7)*† 24/6 3 (10 1 5)*
19/6 3 11 24/6 3 (7 1 9)*† 26/8 3 (15 1 7)*
18/5 3 7 24/5 3 15 24/6 3 15 24/7 3 15 25/6 3 (9 1 6)* 24/7 3 (7 1 6)* 23/6 3 12 22/9 3 (10 1 8)*
25/8 3 (9 1 6)*
21/6 3 11 22/6 3 12 23/5 3 14
PLS/SPF, cm
None None Orocutaneous fistula Minor flap failure None None None None None None None Wound dehiscence at donor site, minor flap failure None None Minor flap failure None None None
Complications
RT -
-
RT Chemo RT -
-
RT Chemo -
Adjuvant treatment
9 20 16
36 28 18
18 19 14 8 24 20 13 22
10
24 13 6
Follow-up, mo
SolD, NS/AND SofD, IS/AND SolD, NS/AND
SofD, IS/DOD SolD, NS/AND SolD, NS/AND
SofD, IS/AND LD, IS/AND SolD, NS/AND LD, IS/DOD SolD, NS/AND SolD, NS/AND SofD, IS/DOD SolD, NS/AND
NTF, SS/DWD
SolD, NS/AND SofD, IS/AND LD, IS/AND
Functional outcomes/status
Abbreviations: rCS, clinical staging of recurrence; PLS, pedicle length of the flap; SPF, skin paddle of the flap; TR, tumor resection; IND, ipsilateral radical neck dissection; RT, radiotherapy; SolD, solid diet; NS, normal speech; AND, alive (with) no disease; FFF, forearm free flap; CND, contralateral radical neck dissection; Chemo, chemotherapy; SofD, soft diet; IS, intelligible speech; Man, mandibulotomy; BND, bilateral radical neck dissection; LD, liquid diet; Max, maxillotomy; NTF, nasogastric tube feeding; SS, slurred speech; DWD, alive with disease; TIMF, trapezius island myocutaneous flap; DOD, died of disease; HG, hemiglossectomy; SF, submental flap. * Folded pectoralis major myocutaneous flap. † Titanium bridging plate use to reconstruct a mandibulectomy.
Tumor site, rCS
Patient #, age, sex
TABLE 2. Tumor origins, initial treatment, nature of salvage surgery, and outcomes of reconstruction using pectoralis major myocutaneous flaps in 18 patients with advanced recurrent oral and oropharyngeal squamous cell carcinoma.
EXTENDED TRAPEZIUS MYOCUTANEOUS VERSUS PECTORALIS MAJOR MYOCUTANEOUS FLAP
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FIGURE 1. A 73-year-old woman presented with advanced recurrent squamous cell carcinoma (SCC) of the left buccal mucosa of grade clinical stages of recurrence (rCS) IV (Table 1, case 12). (A) Outline of the incision line for wide excision of the tumor. (B) Design of the extended lower vertical trapezius island myocutaneous flap (TIMF) featuring a skin paddle measuring 8 3 (7 1 13) cm. (C) and (D) Twelve months postoperatively: an intraoral view and the appearance of the face-and-neck recipient sites, respectively.
months (median 5 8.9 months) in the TIMF and PMMF groups, respectively. All patients were generally in good health, and their tumors were resectable, based on clinical examination, CT scanning, nuclear magnetic resonance data, and/or positron emission tomography-CT. All patients had locoregional recurrences without distant metastases, and all accepted that frozen-section assessment of surgical margins should be used to guide the salvage surgery. Preoperative 3D-CT angiography was performed on the TIMF group to reveal the patency of the transverse cervical artery and its branches. The pedicle length of an extended vertical lower TIMF ranged from 21 to 36 cm (mean 5 29.5 cm) and the skin paddle dimensions from 5 3 7 cm to 13 3 25 cm (average 5 7.7 3 17.0 cm). The PMMFs ranged in length from 18 to 26 cm (mean 5 22.9 cm), with skin paddle dimensions of 6 3 7 cm to 8 3 17 cm (average 5 6.3 3 12.6 cm), and was used to reconstruct major defects. Eight folded extended vertical lower TIMFs (see Figure 1) and 5 folded PMMFs (see Figure 2) were used to reconstruct through-and-through defects. The mean flap harvesting durations in the TIMF and PMMF groups were 58 and 55 minutes, respectively. Seven patients in the TIMF group and 6 in the PMMF group who exhibited positive or close margins after salvage surgery were treated with adjuvant chemotherapy, radiotherapy, or both (Tables 1 and 2). All patients were followed up 3 months postoperatively by a panel of 3 surgeons to evaluate swallowing function (classified as consumption of a solid diet, a soft diet, a liquid diet, or nasogastric tube feeding) and speech function (classified as normal, intelligible, or slurred speech) and the requirement for tracheostomy. The detailed salvage surgical procedures and the outcomes of both groups are shown in Tables 1 and 2. E162
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Statistical analysis SPSS software version 12.0 (SPSS, Chicago, IL) for performing the chi-square test was used to analyze data. Means and SDs were calculated. A p value < .05 was considered to indicate statistical significance.
RESULTS There was no significant difference between the TIMF and PMMF groups in terms of age, primary tumor site, clinical stage of recurrence, time of recurrence, or the initial type of surgery. A much higher proportion of female patients received TIMFs than PMMFs (52.4% vs 16.5%; p 5 .02). There was no significant difference in either mean flap harvesting duration or complication frequency between the groups, but the pedicle length of the TIMF was longer than that of the PMMF (29.48 6 5.13 vs 22.94 6 2.04 cm; p 5 .000), and the skin paddle of the TIMF was both wider (7.71 6 1.76 vs 6.28 6 0.83 cm; p 5 .003) and longer (17.05 6 5.74 vs 12.56 6 2.45 cm; p 5 .004) than that of the PMMF. No major complications developed in any patient. Wound dehiscence at the donor site and orocutaneous fistulas occurred in 3 patients (14.3%) in the TIMF group and 2 patients (11.1%) in the PMMF group, respectively. The TIMF group experienced a lower rate of minor flap failure compared with the PMMF group (4.8% vs 16.7%; p 5 .03). Eighteen patients (85.7%) in the TIMF group and 15 (83.3%) in the PMMF group could manage a solid or soft diet, and no patient required nasogastric tube feeding. Seventeen patients (81.0%) in the TIMF group and 15 (83.3%) in the PMMF group reacquired normal or intelligible speech, and no patient required a permanent tracheostomy. Patients were followed up for 4 to 46 months
EXTENDED
TRAPEZIUS MYOCUTANEOUS VERSUS PECTORALIS MAJOR MYOCUTANEOUS FLAP
FIGURE 2. A 49-year-old man presented with advanced recurrent squamous cell carcinoma (SCC) of the right tongue of grade clinical stages of recurrence (rCS) III (Table 2, case 10). (A) The outline of the incision line for wide excision of the tumor and design of the pectoralis major myocutaneous flap (PMMF) with a skin paddle measuring 7 3 (7 1 6) cm. (B and C) Four months postoperatively: intraoral view and the appearance of the face and neck recipient sites, respectively.
(median 5 16.5 months in the TIMF and 15.1 months in the PMMF group). At final follow-up, 15 patients (71.4%) in the TIMF group and 14 (77.8%) in the PMMF group were alive with no evidence of disease, 3 in the TIMF group and 1 in the PMMF group were alive with disease, and 6 patients in each group died of local recurrence or distant metastases between 6 and 36 months (Tables 1 and 2).
DISCUSSION In the current era of free tissue transfer, the PMMF has been gradually relegated to a secondary role. Free flaps, including free anterolateral thigh flaps and radial forearm flaps, have proven to be very reliable, and success is usually achieved in experienced hands. Recently, a few studies have explored differences between free tissue transfer and pedicle flap reconstruction in the repair of postablative head-and-neck defects.6–10 It was suggested that the reliability of free flaps was higher than that of PMMFs in
patients with extensive tongue defects, suggesting that reconstruction via free soft-tissue transfer should be the first-choice treatment option.6 Patients undergoing reconstruction using free anterolateral thigh flaps had better shoulder but poorer speech functions than those treated using PMMFs.7 The PMMF still provides a durable and safe flap, but use of a radial forearm flap is associated with markedly improved speech performance compared with a PMMF.8 Some studies have claimed that a pedicled PMMF continues to play an important role in headand-neck reconstruction even in the microvascular era, particularly when free flap rescue is required.9,10 The PMMF retains major roles in salvage surgery for patients with recurrent disease or extensive metastatic neck disease, and after free flap failure.9,11,12 There are few comparisons in the literature between the 2 types of pedicled flaps in their use to reconstruct defects arising after salvage surgery. Reconstruction of the (inevitably large) defects arising after wide resection of advanced recurrent oral and HEAD & NECK—DOI 10.1002/HED
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oropharyngeal SCC is a major problem. In the present study, we compared 2 pedicled flaps, the extended vertical lower TIMF and PMMF, used for reconstruction in patients with advanced recurrent oral and oropharyngeal SCC. The 2 groups were similar in terms of patient characteristics (age, primary tumor site, clinical staging of recurrence, time of recurrence, and initial surgery), mean flap harvesting time, complications (orocutaneous fistula and wound dehiscence at the donor site), quality of life, and survival time. We believe that both types of flaps retain major roles in salvage surgery and are easy to prepare (thus, the duration of the procedure is reasonably short). An extended vertical lower TIMF may be preferable to reconstruct oral and neck soft-tissue defects after salvage surgery in patients with recurrent oral and neck SCC,4,5 and as a second salvage procedure in patients with advanced re-recurrent oral and neck SCC.1 In the present study, 5 patients (23.8%) and 3 patients (14.3%) in the TIMF group (initial treatment) were reconstructed using PMMFs and forearm free flaps, respectively, and 3 patients (16.7%) and 2 patients (11.1%) in the PMMF group (initial treatment) were reconstructed using forearm free flaps and TIMFs, respectively. This indicated that use of the 2 types of pedicled flaps can be alternated in salvage procedures. The pedicle of the TIMF is longer than that of the PMMF, and the skin paddle of the former flap is both wider and longer than that of the PMMF. The TIMF group experienced a lower rate of minor flap failure compared with the PMMF group. A longer pedicle flap with a larger skin paddle is valuable in the reconstruction of major defects arising after salvage surgery in patients with advanced recurrent oral and oropharyngeal SCC, may be long enough for application to the skull base1,13 and it can be used to prepare folded flaps for reconstruction of through-and-through defects. Eight folded extended vertical lower TIMFs (38.1%) and 5 folded PMMFs (27.8%) were used to reconstruct throughand-through defects. All minor flap failures were in the distal portions of the folded flaps, and the PMMF group experienced a higher rate of minor flap failure than did the TIMF group. The bulkiness of the PMMF causes cramping in the mandibular arch, damaging the paddle, a process exacerbated by postoperative edema. The main bulk of the pectoralis muscle is attached to the skin paddle, and plicature of the pedicle axis increases the risk of skin paddle damage. If the skin paddle is harvested too close to the rectus abdominis muscle, unreliable vascular flow reduces the success rate of flap placement.14 We consider that the PMMF may not be large enough to allow reconstruction of major through-and-through defects and may not be long enough for application to the skull base. Additionally, accidental displacement of a pectoralis major flap by a breast tissue adenocarcinoma and SCC developing in the PMMF donor site have been reported.15,16 A much higher proportion of female patients received TIMFs (52.4%) than PMMFs (16.5%); use of a TIMF is preferred in women when myocutaneous flaps are not ideal. We did not detect any major complications after flap use. Wound dehiscence at the donor site and orocutaneous
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fistulas occurred and were treated successfully using debridement. At the last follow-up, 15 patients (71.4%) in the TIMF group and 14 patients (77.8%) in the PMMF group were alive with no evidence of disease; 3 patients in the TIMF group and 1 in the PMMF group were alive with disease, and 6 in either group had died of local recurrence or distant metastases after 6 to 36 months. We believe that salvage surgery remains an effective treatment modality for selected patients with advanced recurrent oral and oropharyngeal SCCs without major complications. Extended vertical lower TIMFs and PMMFs may be the preferred options for repair of oral and oropharyngeal soft-tissue defects after salvage surgery in patients with recurrent oral and oropharyngeal SCC. The extended vertical lower TIMF, featuring a long pedicled flap with a large skin paddle, is useful to reconstruct major defects arising after salvage surgery in such patients, and folded flaps are optimal when reconstructing through-andthrough defects.
REFERENCES 1. Chen W, Yang Z, Zhang D, Wang Y, Fan S, Huang Z. Second salvage surgery with extended vertical lower trapezius island myocutaneous flap reconstruction for advanced re-recurrent oral and oropharyngeal squamous cell carcinoma. Int J Oral Maxillofac Surg 2014;43:531–538. 2. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73–81. 3. Gadre KS, Gadre P, Sane VD, Halli R, Doshi P, Modi S. Pectoralis major myocutaneous flap–still a workhorse for maxillofacial reconstruction in developing countries. J Oral Maxillofac Surg 2013;71:2005.e1–2005.e10. 4. Chen WL, Li J, Yang Z, Huang Z, Wang J, Zhang B. Extended vertical lower trapezius island myocutaneous flap in reconstruction of oral and maxillofacial defects after salvage surgery for recurrent oral carcinoma. J Oral Maxillofac Surg 2007;65:205–211. 5. Chen WL, Zhang B, Wang JG, Yang ZH, Huang ZQ, Zhang DM. Reconstruction of large defects of the neck using an extended vertical lower trapezius island myocutaneous flap following salvage surgery for neck recurrence of oral carcinoma. J Plast Reconstr Aesthet Surg 2011;64:319– 322. 6. Mallet Y, El Bedoui S, Penel N, Ton VanJ, Fournier C, Lefebvre JL. The free vascularized flap and the pectoralis major pedicled flap options: comparative results of reconstruction of the tongue. Oral Oncol 2009;45:1028– 1031. 7. Zhang X, Li MJ, Fang QG, Sun CF. A comparison between the pectoralis major myocutaneous flap and the free anterolateral thigh perforator flap for reconstruction in head and neck cancer patients: assessment of the quality of life. J Craniofac Surg 2014;25:868–871. 8. O’Neill JP, Shine N, Eadie PA, Beausang E, Timon C. Free tissue transfer versus pedicled flap reconstruction of head and neck malignancy defects. Ir J Med Sci 2010;179:337–343. 9. Avery CM, Crank ST, Neal CP, Hayter JP, Elton C. The use of the pectoralis major flap for advanced and recurrent head and neck malignancy in the medically compromised patient. Oral Oncol 2010;46:829–833. 10. Schneider DS, Wu V, Wax MK. Indications for pedicled pectoralis major flap in a free tissue transfer practice. Head Neck 2012;34:1106–1110. 11. 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;41:453–457. 12. Avery CM, Gandhi N, Peel D, Neal CP. Indications and outcomes for 100 patients managed with a pectoralis major flap within a UK maxillofacial unit. Int J Oral Maxillofac Surg 2014;43:546–554. 13. Chen WL, Deng YF, Peng GG, et al. Extended vertical lower trapezius island myocutaneous flap for reconstruction of cranio-maxillofacial defects. Int J Oral Maxillofac Surg 2007;36:165–170. 14. Koh KS, Eom JS, Kirk I, Kim SY, Nam S. Pectoralis major musculocutaneous flap in oropharyngeal reconstruction: revisited. Plast Reconstr Surg 2006;118:1145–1149; discussion 1150. 15. Depprich RA, Handschel JG, Braunstein S, K€ ubler NR. Breast carcinoma in a pectoralis major myocutaneous flap used for reconstruction of the oral cavity: a case report and review of the literature. Oral Oncol Extra 2005; 41:238–241. 16. Mohan AM, Balaguhan B, Krishna V, Nagarjuna M. Squamous cell carcinoma of the pectoralis major myocutaneous flap donor site. J Oral Maxillofac Surg 2014;72:1425–1431.
