SURGICAL ONCOLOGY AND RECONSTRUCTION
Pectoralis Major Myocutaneous Flap—Still a Workhorse for Maxillofacial Reconstruction in Developing Countries Kiran Shrikrishna Gadre, MDS,* Pushkar Gadre, MDS,y Vikrant Dilip Sane, MDS,z Rajshekhar Halli, MDS,x Pankaj Doshi, MDS,jj and Sachin Modi, MDS{ Purpose: To retrospectively evaluate the utility of the pectoralis major myocutaneous (PMMC) flap for head, face, and neck (HFN) reconstruction in the Indian population. Materials and Methods:
The hospital records of 496 patients in whom the PMMC flap was used (saving the deltopectoral flap) for reconstruction of HFN defects from January 1991 to December 2010 were reviewed retrospectively. All the patients were followed up for a minimum period of 6 months, and the utility of the PMMC flap was evaluated for HFN reconstruction.
Results: Of the 496 patients, complications developed in 84 patients. The complications included complete flap failure in 12, partial skin paddle loss in 24, wound infection in 12, peripheral wound dehiscence in 16, plate exposure in 12, and donor site morbidity such as infection and a decrease in function in 8. Conclusions:
The PMMC flap or its modification was used in 496 cases of reconstruction after resection surgery for malignancy of the HFN region with minimal morbidity and 1 death. This technique is a useful alternative in places with a high incidence of HFN malignancies and microsurgical free tissue transfer is not possible or as a salvage procedure in selected large, full-thickness, oral cavity lesions. In our 19-year experience, the final functional and cosmetic results were satisfactory with this sturdy flap. Ó 2013 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 71:2005.e1-2005.e10, 2013
The pectoralis major myocutaneous (PMMC) flap can be used as either a pedicled or a free flap. The PMMC flap is still considered a ‘‘workhorse’’ flap for soft tissue reconstruction of the head, face, and neck (HFN) region, particularly in developing and underdeveloped countries. Although the increased use of free tissue transfers to reconstruct complex bony and soft tissue defects has overshadowed the PMMC flap to an extent, it remains a very useful, versatile,
and reliable reconstructive option for many HFN defects of the mucosa or skin, or both.1-4 Moreover, the proximity to the HFN region and the good reach up to the orbit (in selected cases) are additional advantages (Fig 1). Although in many centers, free flap reconstruction has superseded use of the PMMC flap, it still has a very important role as a salvage flap. In many regions in which economic or infrastructural facilities limit the use of microsurgery, the PMMC flap
*Consultant Maxillofacial Surgeon, Ruby Hall Clinic; Professor,
{Resident, Department of Oral and Maxillofacial Surgery, Bharati
Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental College and Hospital, Katraj, Pune, Maharashtra,
Vidyapeeth University Dental College and Hospital, Katraj, Pune, Maharashtra, India.
India.
Address correspondence and reprint requests to Dr Sane: Depart-
yDr Gadre’s Maxillofacial Surgical Centre, Pune, Maharashtra, India.
ment of Oral and Maxillofacial Surgery, Bharati Vidyapeeth Univer-
zConsultant Maxillofacial Surgeon; Assistant Professor, Department
sity Dental College and Hospital, Katraj-Dhankwadi Educational
of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental
Complex, Satara Road, Pune, Maharashtra 411043, India; e-mail:
College and Hospital, Katraj, Pune, Maharashtra, India.
[email protected]
xConsultant Maxillofacial Surgeon; Professor, Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental College and Hospital, Katraj, Pune, Maharashtra, India. jjResident, Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental College and Hospital, Katraj, Pune,
Received May 31 2013 Accepted July 15 2013 Ó 2013 American Association of Oral and Maxillofacial Surgeons 0278-2391/13/00922-1$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.07.016
Maharashtra, India.
2005.e1
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PMMC FLAP STILL USEFUL FOR MAXILLOFACIAL RECONSTRUCTION
FIGURE 1. Pectoralis major myocutaneous flap used for reconstruction of orbital defect. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
is still a primary reconstructive option.5 The amount of coverage and the reach of the flap will be dependent on the individual anatomy and elevation techniques used.
The present review discusses our experience with the PMMC flap for reconstruction of the HFN defects in today’s world of microvascular free tissue transfer.
FIGURE 2. Marking of pectoralis major myocutaneous flap saving deltopectoral flap (red dotted line indicates the line joining the xiphisternum to the acromioclavicular joint, blue dotted line indicates the outline of the clavicle, and black solid line indicates the pedicle of pectoralis major myocutaneous flap). Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
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Materials and Methods
Results
We function as a team of consultant maxillofacial surgeons in many major hospitals in the city of Pune (Maharashtra, India). These tertiary referral centers for specialty cases serve a large area of western Maharashtra. The hospital records of patients in whom the PMMC flap was used for reconstruction of HFN defects from January 1991 to December 2010 were retrospectively reviewed. The respective institutional review boards provided ethical approval for the present study. A total of 496 patients with a minimum follow-up period of 6 months were included in the present study. All patients had undergone an open biopsy. The preoperative assessment included the disease site and stage, and the patients were evaluated by clinical examination assisted by imaging modalities such as computed tomography or magnetic resonance imaging. Cases reported earlier in 20076 were included in the present study. The preoperative medical assessment also included routine complete blood testing, bleeding and coagulation profile, liver and kidney function, electrocardiography, and chest radiography. Additional investigations were performed as needed. The extent of surgery, reconstruction technique, and potential complications were discussed with the patients, and all patients provided written informed consent. All the patients underwent surgery by the same surgeon, saving the deltopectoral flap. The flap design and skin island depended on the site, size, and shape of the defect; however, the skin island was usually below and medial to the nipple, at about the level of the sixth rib (Fig 2). Flap elevation was from a distal to a proximal direction, keeping a divergent muscular plane to include more perforators. During flap elevation, the pectoral fascia and muscle were secured to the skin using 3-0 Vicryl (M/s Ethicon LLC, San Lorenzo, Puerto Rico) to protect the perforator vessel. When the flap was tunneled, subclavicular skeletonization of the pedicle was done. The skin and muscle were elevated from the chest wall, exposing the ribs and intercostal muscles. The flap was elevated up as far as the coracoid process, where the pedicle was narrowed. The lateral pectoral vessels were left intact or divided, depending on the flap volume required and the tension produced. In the women, it was often possible to close the secondary defect by moving the breast tissue. In the men, a skin graft was generally required to cover a defect greater than 6 6 cm. The total operative time, need for blood transfusion, postoperative complications, and total hospital stay were documented. The follow-up protocol in the outpatient clinic involved a thorough clinical examination aided by radiologic assessment for local recurrence and/or distant metastasis at 6-month intervals.
A total of 496 patients (374 men and 122 women) were treated from January 1991 to December 2010 using the PMMC flap for reconstruction of intra- and extraoral defects. The deltopectoral flap was spared in all cases. The patient age ranged from 32 to 71 years. The PMMC flap was used for 16 patients with recurrent disease and 480 with primary disease. In 450 patients, the PMMC flap was used for primary reconstruction of the defect, and in 46, it was used for salvage (Table 1). Of the 496 patients, 68 needed extraoral reconstruction (Fig 3), 404 needed intraoral reconstruction (Fig 4), and 24 needed both (Table 1). In 27 patients, simultaneous bony reconstruction was used in conjunction with the PMMC flap (4, pedicled rib on the periosteum; 20, free ilium; and 3, free vascularized fibula).
Table 1. PATIENT CHARACTERISTICS
Characteristic Gender Male Female Age (yr) Mean Range Disease status Primary Recurrent Flap procedure Primary Salvage Subsites Intraoral Buccal mucosa Mandibular alveolus Retromandibular triangle and lateral pharynx Cheek Tongue Maxilla Extraoral Ear Maxilla, mandible, neck Both intraoral and extraoral Simultaneous bony reconstruction Rib Ilium Free vascularized fibula Average defect size (cm2) Mucosal Skin cover Average size of entire flap (cm2)
Value
374 122 55 32-71 496 480 16 496 450 46 404 36 222 58 64 12 12 68 2 66 24 27 4 20 3 6 3 to 9 7 4.5 5 to 9 8 10 5 to 15 7
Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
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PMMC FLAP STILL USEFUL FOR MAXILLOFACIAL RECONSTRUCTION
FIGURE 3. Pectoralis major myocutaneous flap used for mandible and cheek defect (white arrow). Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
FIGURE 4. Pectoralis major myocutaneous flap used for maxilla (white arrow). Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
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FIGURE 5. Postavulsion defect showing branches of the facial nerve (white arrows). Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
The intraoral defects involved the mandibular alveolus in 222 patients, retromolar trigone and lateral pharynx in 58 patients, cheek in 64 patients, tongue in 12 patients, maxilla in 12 patients, and buccal mucosa in 36 patients (34 with a skin paddle and 2 without a skin paddle; Table 1). Extraorally, the PMMC flap
was used for reconstruction of maxilla, mandible, and neck defects in 66 and ear defects in 2 (Figs 5-9). The combination of a PMMC flap and free vascularized fibular graft was used in 3 patients. The average size of the mucosal defect repair was 6 3 to 9 7 cm2, the skin coverage was 4.5 5 to 9 8 cm,2 and the
FIGURE 6. Avulsed ear. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
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PMMC FLAP STILL USEFUL FOR MAXILLOFACIAL RECONSTRUCTION
FIGURE 7. Postoperative photograph showing side of a patient after reconstruction with pectoralis major myocutaneous flap. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
average size of the entire flap was 10 5 to 15 7 cm2 to reconstruct 56 stage T2, 304 stage T3, and 136 stage T4 lesions (Table 1). The average estimated blood loss was 300 mL (range 150 to 900). Complications developed in 84 patients, including complete flap failure in 12, partial skin paddle loss in 24, wound infection in 12, peripheral wound dehiscence in 16, plate exposure in 12, and donor site morbidity such as infection and a decrease in function in 8 (Table 2).
Discussion The PMMC and other myofacial and myocutaneous flaps have been recognized as important reconstructive methods in head and neck cancer surgery. Even with the worldwide use of free flaps, these have remained the mainstay reconstructive procedures in many cases for a variety of reasons.7 In their series of 491 patients, Hsing et al8 found comparable results in patients who had undergone reconstruction with either a free flap or a PMMC flap. However, the patients who had undergone reconstruction with a free flap had better speech and shoulder function and a better emotional status compared with those patients who had received a PMMC flap. The main advantages were the ease of its technical aspects, the proximity to the HFN region, and the possibility of obtaining a large amount of well-vascularized tissue for reconstruction of wide defects after resection of malignant
tumors of the head and neck in a single-stage procedure.9,10 Other important advantages include the following: 1. Muscle pedicle in the neck effectively covers the exposed carotid vessels after radical neck dissection re-creating the sternomastoid prominence 2. Elevation of the flap does not require any position changes during surgery 3. Effective combinations with other flaps can be used for large defects The reported disadvantages of the PMMC flap concern the thickness of the myocutaneous flap, the functional and cosmetic donor defects, excessive bulk in obese or muscular patients, difficulty using a bipaddled flap in obese patients, and the possibility of hiding the recurrence of the malignant tumor. Another disadvantage of the PMMC flap is its poor vascularity in obese patients and over the random distal end of the rectus abdominis muscle, causing partial dehiscence, fistulation, and infection and resulting in a prolonged hospital stay. Troublesome hair growth in the oral cavity in men is another area of concern.9-11 However, postoperative radiotherapy, when administered, will decrease hair growth. Most of the complications seen in our study, such as complete flap failure and partial skin paddle loss, could be attributed to the use of monopolar cautery
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FIGURE 8. Frontal postoperative photograph of a patient after reconstruction with pectoralis major myocutaneous flap. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
owing to the unavailability of bipolar cautery at many centers in the earlier years. Also, failures were more common in obese and immunocompromised patients. Plate exposure was usually seen in association with wound infection and partial flap loss. Other uncommon complications such as metastatic spread along the myocutaneous flap and autotransplantation or implantation of cancer cells have also been reported.12-15 The technique and design of the flap has been modified by various investigators to increase the utility of this flap. Azevedo16,17 suggested that an island flap with a low skin incision at the donor site and transfer of the flap through a subclavicular tunnel will decrease the functional impairment of the arm and increase the arc of rotation. However, subclavicular passage can compromise the blood supply in obese patients. This was also confirmed by Vartanian et al7 and Kerawala et al.18 Mitchell et al19 modified the design of the PMMC flap into a crescentic PMMC flap to reduce the defect of the donor site. In
a review of 47 cases, Ahmad et al20 suggested the use of a bipaddled PMMC flap for reconstruction of fullthickness skin defects. For women with smaller breasts, it is safe to use an inframammary skin paddle. The planned skin paddle should be designed slightly superior to the inframammary crease. Greater care should be taken to ensure that the skin paddle is completely over the muscle.21 For women with larger breasts, the skin paddle should be designed similar to that for men. However, the flap should be designed medially in the area of less subcutaneous tissue to decrease the distance between the skin and the muscle.21 Inclusion of the nipple areolar complex increases the reliability of the skin paddle.22 Various major and minor complications have been associated with the use of this flap; however, no significantly greater rate of complications has been associated with smoking, preoperative radiotherapy, diabetes, or obesity.7,23,24 One of the major concerns with PMMC flap reconstruction, particularly for the oral cavity, is
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PMMC FLAP STILL USEFUL FOR MAXILLOFACIAL RECONSTRUCTION
FIGURE 9. View after debulking of flap. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
marginal necrosis of the skin paddle, leading to wound dehiscence and salivary leak.7,23,25 This problem can be aggravated if the PMMC flap has been used for repair of the soft and hard palate defects, because the reach of the flap can be compromised; however, minor wound dehiscence can usually be managed conservatively. The weight and pull of gravity can be a cause of concern, particularly when the flap has been used for maxillary reconstruction. In our series, Table 2. COMPLICATIONS (N = 84)
Complication
n
Complete flap failure Partial skin paddle loss Wound infection Peripheral wound dehiscence Plate exposure Donor site morbidity
12 24 12 16 12 8
Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
patients showed dehiscence, particularly at the palatal suture line (at the junction of palatal and PMMC flap). We had used the PMMC flap for reconstruction of the maxilla in 12 patients, and dehiscence was noted in 8, probably resulting from the weight of the flap and gravitational pull. In the successful 4 cases, we had anchored the divergent and broader muscle paddle to the contralateral palate and zygomatic buttress. This decreased the drag on the palatal mucosal suture line. Kekatpure et al,26 from their experience of 147 cases involving reconstruction with the PMMC flap, concluded that the PMMC flap is a safe and reliable flap for reconstruction of a variety of head and neck defects. In the present era of microvascular reconstruction, resource constraints remain the primary indication for selecting the PMMC flap instead of microvascular flaps in developing and underdeveloped countries. In men, one can transpose a skin paddle of approximately 6 6 cm without having to skin graft the chest wall and without significant anatomic distortion of the ventral chest wall after primary closure when developing a PMMC flap. In
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women, one can double the size of skin paddle when developing a PMMC flap because of the greater redundancy of the female breast. The skin paddle can be extended off the most distal aspect of the pectoralis major muscle onto the rectus sheath. The skin paddle in such a situation remains partially axial and becomes random, dependant on the capillary arteriolar connections.27 From our experience, we have suggested various methods that can help minimize the complications and increase the utility of the PMMC flap. A few tips and tricks that can be used while harvesting a PMMC flap are as follows: 1. Ensure easy reach of the paddle to the defect without excessive rotation, kinking, or compression 2. Place only 2 to 3 cm of paddle outside the muscle; incise the skin paddle laterally first, above the nipple in men and below the breast in women 3. The inferior, medial, and lateral incisions should be made through the skin and muscle down to the chest wall; the superior skin incision should be limited to the fascia covering the pectoralis major muscle 4. Large skin paddles diverging in the muscular plane should be used to incorporate more perforators, preserving the lateral thoracic artery whenever possible; placing the flap horizontally with inclusion of the nipple and areola will increase the reach and size of flap 5. While tunneling the paddle either under the clavicle or the skin, preserve the perforators to the deltopectoral flap and always keep the pedicle of PMMC flap in view 6. When the muscle is elevated off the chest wall beneath the deep fascia, complete hemostasis is mandatory; failing to do so will lead to hemothorax because the vessels will retract into the intercostal muscles 7. Sacrificing the lateral thoracic artery (secondary blood supply) will help increase the length of pedicle; skeletonization of the pedicle and sacrificing the middle one third of the clavicle (rarely necessary) will increase the risk of vessel kinking and flap failure 8. Subclavicular tunneling will help to increase the length and arc of rotation of the flap 9. The use of bipolar cautery is recommended to reduce the chances of damage to the skin perforators and thereby maintain the vascularity of the skin paddle 10. When the flap is used for maxillary reconstruction, we recommend that the divergent and broader muscle paddle should be anchored to
the surrounding bony structure with horizontal mattress sutures to overcome the drag due to gravity and weight 11. Using the PMMC flap without a skin paddle will lead to excessive contracture, resulting in trismus and deviation of jaw and, hence, is not recommended
Conclusions The PMMC flap or its modification was used in 496 cases of reconstruction after resection of HFN malignancy with minimal morbidity and 1 death. This technique is a very useful alternative in places with a high incidence of HFN malignancies and where microsurgical free tissue transfer is not possible owing to the lack of infrastructural facilities and poor socioeconomic status. It can be used as a salvage flap in the event of microvascular flap failure. In our 19-year experience, the final functional and cosmetic results were satisfactory to the patients with this reliable and sturdy flap. Thus, it can be concluded that the PMMC flap is still a workhorse in developing and underdeveloped countries.
References 1. Withers EH, Franklin JD, Madden JJ, et al: Pectoralis major musculocutaneous flap: A new flap in head and neck reconstruction. Am J Surg 138:537, 1979 2. Milenovic A, Virag M, Uglesic V, et al: The pectoralis major flap in head and neck reconstruction: First 500 patients. J Craniomaxillofac Surg 34:340, 2006 3. Sabri A: Oropharyngeal reconstruction: Current state of the art. Curr Opin Otolaryngol Head Neck Surg 11:251, 2003 4. Viros Porcuna D, Leon Vintro X, Lopez Vilas M, et al: Pectoralis major flaps: Evolution of their use in the age of microvascularized flaps. Acta Otorrinolaringol Esp 59:263, 2008 5. EL-Marakby HH: The Reliability of pectoralis major myocutaneous flap in head and neck reconstruction. J Egypt Natl Cancer Inst 18:41, 2006 6. Gadre KS: Utility of pectoralis major myocutaneous flap: Analysis of 124 cases. Int J Oral Maxillofac Surg 36:1054, 2007 7. Vartanian JG, Carvalho AL, Carvalho SMT, et al: Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: Experience with 437 cases at a single institution. Head Neck 26:1018, 2004 8. Hsing C-Y, Wong Y-K, Wang CP, et al: Comparison between free flap and pectoralis major pedicled flap for reconstruction in oral cavity cancer patients—A quality of life analysis. Oral Oncol 47: 522, 2011 9. Biller HF, Baek SM, Lawson W, et al: Pectoralis major myocutaneous island flap in head and neck surgery: Analysis of complications in 42 cases. Arch Otolaryngol 107:23, 1981 10. Schuller DE: Pectoralis myocutaneous flap in head and neck cancer reconstruction. Arch Otolaryngol 109:185, 1983 11. Zbar RIS, Funk GF, McCulloch TM, et al: Pectoralis major myofascial flap: A valuable tool in contemporary head and neck reconstruction. Head Neck 19:412, 1997 12. Badellino F, Berrino P, Campora E, et al: Metastatic spread of the floor of the mouth squamous cell carcinoma via pectoralis major myocutaneous flap. J Surg Oncol 38:45, 1988 13. Bansal R, Patel TS, Bhullar C, et al: Metastases to the donor site of the pectoralis major myocutaneous flap following reconstructive surgery: A rare complication. Plast Reconstr Surg 114:1965, 2004
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14. Robbins TK, Woodson GE: Chest wall metastasis as a complication of myocutaneous flap reconstruction. J Otolaryngol 13:13, 1984 15. Carr RJ, Gilbert PM: Tumour implantation to a temporalis muscle flap donor site. Br J Oral Maxillofac Surg 24:102, 1986 16. Azevedo JF: Modified pectoralis major myocutaneous flap with partial preservation of the muscle: A study of 55 cases. Head Neck Surg 8:327, 1986 17. Azevedo JF: Pectoralis minor flaps: An experimental study and clinical applications of osteomuscular, osteomyocutaneous, and myocutaneous models. Head Neck Surg 9:211, 1987 18. Kerawala CJ, Sun J, Zhang Z, Guoyu Z: The pectoralis major myocutaneous flap: Is the subclavicular route safe? Head Neck 23: 879, 2001 19. Crosher R, Mitchell R, Llewelyn J: A modification of the pectoralis major myocutaneous flap that reduces the defect at the donor site. Ann R Coll Surg Engl 77:389, 1995 20. Ahmad QG, Navadgi S, Agarwal R, et al: Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: A review of 47 cases. J Plast Reconstr Aesthetic Surg 59: 166, 2006
21. Ramakrishnan VR, Yao W, Campana JP: Improved skin paddle survival in pectoralis major myocutaneous flap reconstruction of head and neck defects. Arch Facial Plast Surg 11:306, 2009 22. Coruh A: Pectoralis major musculocutaneous flap with nipple areola complex in head and neck reconstruction: Preliminary results of a new modified method. Ann Plast Surg 56:413, 2006 23. Liu R, Gullane P, Brown D, Irish J: Pectoralis major myocutaneous pedicled flap in head and neck reconstruction: Retrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital. J Otolaryngol 30:34, 2001 24. Von Biberstein SE, Spiro JD: The pectoralis major myocutaneous flap in reconstructive head and neck surgery revisited: A recent experience. Conn Med 58:711, 1994 25. Kroll SS, Goepfert H, Jones M, et al: Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. Ann Plast Surg 25:93, 1990 26. Kekatpure VD, Trivedi NP, Manjula BV, et al: Pectoralis major flap for head and neck reconstruction in era of free flaps. Int J Oral Maxillofac Surg 41:453, 2012 27. Carlson ER: Pectoralis major myocutaneous flap. Oral Maxillofacial Surg Clin North Am 15:565, 2003
Pectoralis Major Myocutaneous Flap—Still a Workhorse for Maxillofacial Reconstruction in Developing Countries Kiran Shrikrishna Gadre, MDS,* Pushkar Gadre, MDS,y Vikrant Dilip Sane, MDS,z Rajshekhar Halli, MDS,x Pankaj Doshi, MDS,jj and Sachin Modi, MDS{ Purpose: To retrospectively evaluate the utility of the pectoralis major myocutaneous (PMMC) flap for head, face, and neck (HFN) reconstruction in the Indian population. Materials and Methods:
The hospital records of 496 patients in whom the PMMC flap was used (saving the deltopectoral flap) for reconstruction of HFN defects from January 1991 to December 2010 were reviewed retrospectively. All the patients were followed up for a minimum period of 6 months, and the utility of the PMMC flap was evaluated for HFN reconstruction.
Results: Of the 496 patients, complications developed in 84 patients. The complications included complete flap failure in 12, partial skin paddle loss in 24, wound infection in 12, peripheral wound dehiscence in 16, plate exposure in 12, and donor site morbidity such as infection and a decrease in function in 8. Conclusions:
The PMMC flap or its modification was used in 496 cases of reconstruction after resection surgery for malignancy of the HFN region with minimal morbidity and 1 death. This technique is a useful alternative in places with a high incidence of HFN malignancies and microsurgical free tissue transfer is not possible or as a salvage procedure in selected large, full-thickness, oral cavity lesions. In our 19-year experience, the final functional and cosmetic results were satisfactory with this sturdy flap. Ó 2013 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 71:2005.e1-2005.e10, 2013
The pectoralis major myocutaneous (PMMC) flap can be used as either a pedicled or a free flap. The PMMC flap is still considered a ‘‘workhorse’’ flap for soft tissue reconstruction of the head, face, and neck (HFN) region, particularly in developing and underdeveloped countries. Although the increased use of free tissue transfers to reconstruct complex bony and soft tissue defects has overshadowed the PMMC flap to an extent, it remains a very useful, versatile,
and reliable reconstructive option for many HFN defects of the mucosa or skin, or both.1-4 Moreover, the proximity to the HFN region and the good reach up to the orbit (in selected cases) are additional advantages (Fig 1). Although in many centers, free flap reconstruction has superseded use of the PMMC flap, it still has a very important role as a salvage flap. In many regions in which economic or infrastructural facilities limit the use of microsurgery, the PMMC flap
*Consultant Maxillofacial Surgeon, Ruby Hall Clinic; Professor,
{Resident, Department of Oral and Maxillofacial Surgery, Bharati
Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental College and Hospital, Katraj, Pune, Maharashtra,
Vidyapeeth University Dental College and Hospital, Katraj, Pune, Maharashtra, India.
India.
Address correspondence and reprint requests to Dr Sane: Depart-
yDr Gadre’s Maxillofacial Surgical Centre, Pune, Maharashtra, India.
ment of Oral and Maxillofacial Surgery, Bharati Vidyapeeth Univer-
zConsultant Maxillofacial Surgeon; Assistant Professor, Department
sity Dental College and Hospital, Katraj-Dhankwadi Educational
of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental
Complex, Satara Road, Pune, Maharashtra 411043, India; e-mail:
College and Hospital, Katraj, Pune, Maharashtra, India.
[email protected]
xConsultant Maxillofacial Surgeon; Professor, Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental College and Hospital, Katraj, Pune, Maharashtra, India. jjResident, Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth University Dental College and Hospital, Katraj, Pune,
Received May 31 2013 Accepted July 15 2013 Ó 2013 American Association of Oral and Maxillofacial Surgeons 0278-2391/13/00922-1$36.00/0 http://dx.doi.org/10.1016/j.joms.2013.07.016
Maharashtra, India.
2005.e1
2005.e2
PMMC FLAP STILL USEFUL FOR MAXILLOFACIAL RECONSTRUCTION
FIGURE 1. Pectoralis major myocutaneous flap used for reconstruction of orbital defect. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
is still a primary reconstructive option.5 The amount of coverage and the reach of the flap will be dependent on the individual anatomy and elevation techniques used.
The present review discusses our experience with the PMMC flap for reconstruction of the HFN defects in today’s world of microvascular free tissue transfer.
FIGURE 2. Marking of pectoralis major myocutaneous flap saving deltopectoral flap (red dotted line indicates the line joining the xiphisternum to the acromioclavicular joint, blue dotted line indicates the outline of the clavicle, and black solid line indicates the pedicle of pectoralis major myocutaneous flap). Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
2005.e3
GADRE ET AL
Materials and Methods
Results
We function as a team of consultant maxillofacial surgeons in many major hospitals in the city of Pune (Maharashtra, India). These tertiary referral centers for specialty cases serve a large area of western Maharashtra. The hospital records of patients in whom the PMMC flap was used for reconstruction of HFN defects from January 1991 to December 2010 were retrospectively reviewed. The respective institutional review boards provided ethical approval for the present study. A total of 496 patients with a minimum follow-up period of 6 months were included in the present study. All patients had undergone an open biopsy. The preoperative assessment included the disease site and stage, and the patients were evaluated by clinical examination assisted by imaging modalities such as computed tomography or magnetic resonance imaging. Cases reported earlier in 20076 were included in the present study. The preoperative medical assessment also included routine complete blood testing, bleeding and coagulation profile, liver and kidney function, electrocardiography, and chest radiography. Additional investigations were performed as needed. The extent of surgery, reconstruction technique, and potential complications were discussed with the patients, and all patients provided written informed consent. All the patients underwent surgery by the same surgeon, saving the deltopectoral flap. The flap design and skin island depended on the site, size, and shape of the defect; however, the skin island was usually below and medial to the nipple, at about the level of the sixth rib (Fig 2). Flap elevation was from a distal to a proximal direction, keeping a divergent muscular plane to include more perforators. During flap elevation, the pectoral fascia and muscle were secured to the skin using 3-0 Vicryl (M/s Ethicon LLC, San Lorenzo, Puerto Rico) to protect the perforator vessel. When the flap was tunneled, subclavicular skeletonization of the pedicle was done. The skin and muscle were elevated from the chest wall, exposing the ribs and intercostal muscles. The flap was elevated up as far as the coracoid process, where the pedicle was narrowed. The lateral pectoral vessels were left intact or divided, depending on the flap volume required and the tension produced. In the women, it was often possible to close the secondary defect by moving the breast tissue. In the men, a skin graft was generally required to cover a defect greater than 6 6 cm. The total operative time, need for blood transfusion, postoperative complications, and total hospital stay were documented. The follow-up protocol in the outpatient clinic involved a thorough clinical examination aided by radiologic assessment for local recurrence and/or distant metastasis at 6-month intervals.
A total of 496 patients (374 men and 122 women) were treated from January 1991 to December 2010 using the PMMC flap for reconstruction of intra- and extraoral defects. The deltopectoral flap was spared in all cases. The patient age ranged from 32 to 71 years. The PMMC flap was used for 16 patients with recurrent disease and 480 with primary disease. In 450 patients, the PMMC flap was used for primary reconstruction of the defect, and in 46, it was used for salvage (Table 1). Of the 496 patients, 68 needed extraoral reconstruction (Fig 3), 404 needed intraoral reconstruction (Fig 4), and 24 needed both (Table 1). In 27 patients, simultaneous bony reconstruction was used in conjunction with the PMMC flap (4, pedicled rib on the periosteum; 20, free ilium; and 3, free vascularized fibula).
Table 1. PATIENT CHARACTERISTICS
Characteristic Gender Male Female Age (yr) Mean Range Disease status Primary Recurrent Flap procedure Primary Salvage Subsites Intraoral Buccal mucosa Mandibular alveolus Retromandibular triangle and lateral pharynx Cheek Tongue Maxilla Extraoral Ear Maxilla, mandible, neck Both intraoral and extraoral Simultaneous bony reconstruction Rib Ilium Free vascularized fibula Average defect size (cm2) Mucosal Skin cover Average size of entire flap (cm2)
Value
374 122 55 32-71 496 480 16 496 450 46 404 36 222 58 64 12 12 68 2 66 24 27 4 20 3 6 3 to 9 7 4.5 5 to 9 8 10 5 to 15 7
Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
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FIGURE 3. Pectoralis major myocutaneous flap used for mandible and cheek defect (white arrow). Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
FIGURE 4. Pectoralis major myocutaneous flap used for maxilla (white arrow). Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
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FIGURE 5. Postavulsion defect showing branches of the facial nerve (white arrows). Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
The intraoral defects involved the mandibular alveolus in 222 patients, retromolar trigone and lateral pharynx in 58 patients, cheek in 64 patients, tongue in 12 patients, maxilla in 12 patients, and buccal mucosa in 36 patients (34 with a skin paddle and 2 without a skin paddle; Table 1). Extraorally, the PMMC flap
was used for reconstruction of maxilla, mandible, and neck defects in 66 and ear defects in 2 (Figs 5-9). The combination of a PMMC flap and free vascularized fibular graft was used in 3 patients. The average size of the mucosal defect repair was 6 3 to 9 7 cm2, the skin coverage was 4.5 5 to 9 8 cm,2 and the
FIGURE 6. Avulsed ear. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
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FIGURE 7. Postoperative photograph showing side of a patient after reconstruction with pectoralis major myocutaneous flap. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
average size of the entire flap was 10 5 to 15 7 cm2 to reconstruct 56 stage T2, 304 stage T3, and 136 stage T4 lesions (Table 1). The average estimated blood loss was 300 mL (range 150 to 900). Complications developed in 84 patients, including complete flap failure in 12, partial skin paddle loss in 24, wound infection in 12, peripheral wound dehiscence in 16, plate exposure in 12, and donor site morbidity such as infection and a decrease in function in 8 (Table 2).
Discussion The PMMC and other myofacial and myocutaneous flaps have been recognized as important reconstructive methods in head and neck cancer surgery. Even with the worldwide use of free flaps, these have remained the mainstay reconstructive procedures in many cases for a variety of reasons.7 In their series of 491 patients, Hsing et al8 found comparable results in patients who had undergone reconstruction with either a free flap or a PMMC flap. However, the patients who had undergone reconstruction with a free flap had better speech and shoulder function and a better emotional status compared with those patients who had received a PMMC flap. The main advantages were the ease of its technical aspects, the proximity to the HFN region, and the possibility of obtaining a large amount of well-vascularized tissue for reconstruction of wide defects after resection of malignant
tumors of the head and neck in a single-stage procedure.9,10 Other important advantages include the following: 1. Muscle pedicle in the neck effectively covers the exposed carotid vessels after radical neck dissection re-creating the sternomastoid prominence 2. Elevation of the flap does not require any position changes during surgery 3. Effective combinations with other flaps can be used for large defects The reported disadvantages of the PMMC flap concern the thickness of the myocutaneous flap, the functional and cosmetic donor defects, excessive bulk in obese or muscular patients, difficulty using a bipaddled flap in obese patients, and the possibility of hiding the recurrence of the malignant tumor. Another disadvantage of the PMMC flap is its poor vascularity in obese patients and over the random distal end of the rectus abdominis muscle, causing partial dehiscence, fistulation, and infection and resulting in a prolonged hospital stay. Troublesome hair growth in the oral cavity in men is another area of concern.9-11 However, postoperative radiotherapy, when administered, will decrease hair growth. Most of the complications seen in our study, such as complete flap failure and partial skin paddle loss, could be attributed to the use of monopolar cautery
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FIGURE 8. Frontal postoperative photograph of a patient after reconstruction with pectoralis major myocutaneous flap. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
owing to the unavailability of bipolar cautery at many centers in the earlier years. Also, failures were more common in obese and immunocompromised patients. Plate exposure was usually seen in association with wound infection and partial flap loss. Other uncommon complications such as metastatic spread along the myocutaneous flap and autotransplantation or implantation of cancer cells have also been reported.12-15 The technique and design of the flap has been modified by various investigators to increase the utility of this flap. Azevedo16,17 suggested that an island flap with a low skin incision at the donor site and transfer of the flap through a subclavicular tunnel will decrease the functional impairment of the arm and increase the arc of rotation. However, subclavicular passage can compromise the blood supply in obese patients. This was also confirmed by Vartanian et al7 and Kerawala et al.18 Mitchell et al19 modified the design of the PMMC flap into a crescentic PMMC flap to reduce the defect of the donor site. In
a review of 47 cases, Ahmad et al20 suggested the use of a bipaddled PMMC flap for reconstruction of fullthickness skin defects. For women with smaller breasts, it is safe to use an inframammary skin paddle. The planned skin paddle should be designed slightly superior to the inframammary crease. Greater care should be taken to ensure that the skin paddle is completely over the muscle.21 For women with larger breasts, the skin paddle should be designed similar to that for men. However, the flap should be designed medially in the area of less subcutaneous tissue to decrease the distance between the skin and the muscle.21 Inclusion of the nipple areolar complex increases the reliability of the skin paddle.22 Various major and minor complications have been associated with the use of this flap; however, no significantly greater rate of complications has been associated with smoking, preoperative radiotherapy, diabetes, or obesity.7,23,24 One of the major concerns with PMMC flap reconstruction, particularly for the oral cavity, is
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FIGURE 9. View after debulking of flap. Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
marginal necrosis of the skin paddle, leading to wound dehiscence and salivary leak.7,23,25 This problem can be aggravated if the PMMC flap has been used for repair of the soft and hard palate defects, because the reach of the flap can be compromised; however, minor wound dehiscence can usually be managed conservatively. The weight and pull of gravity can be a cause of concern, particularly when the flap has been used for maxillary reconstruction. In our series, Table 2. COMPLICATIONS (N = 84)
Complication
n
Complete flap failure Partial skin paddle loss Wound infection Peripheral wound dehiscence Plate exposure Donor site morbidity
12 24 12 16 12 8
Gadre et al. PMMC Flap Still Useful for Maxillofacial Reconstruction. J Oral Maxillofac Surg 2013.
patients showed dehiscence, particularly at the palatal suture line (at the junction of palatal and PMMC flap). We had used the PMMC flap for reconstruction of the maxilla in 12 patients, and dehiscence was noted in 8, probably resulting from the weight of the flap and gravitational pull. In the successful 4 cases, we had anchored the divergent and broader muscle paddle to the contralateral palate and zygomatic buttress. This decreased the drag on the palatal mucosal suture line. Kekatpure et al,26 from their experience of 147 cases involving reconstruction with the PMMC flap, concluded that the PMMC flap is a safe and reliable flap for reconstruction of a variety of head and neck defects. In the present era of microvascular reconstruction, resource constraints remain the primary indication for selecting the PMMC flap instead of microvascular flaps in developing and underdeveloped countries. In men, one can transpose a skin paddle of approximately 6 6 cm without having to skin graft the chest wall and without significant anatomic distortion of the ventral chest wall after primary closure when developing a PMMC flap. In
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women, one can double the size of skin paddle when developing a PMMC flap because of the greater redundancy of the female breast. The skin paddle can be extended off the most distal aspect of the pectoralis major muscle onto the rectus sheath. The skin paddle in such a situation remains partially axial and becomes random, dependant on the capillary arteriolar connections.27 From our experience, we have suggested various methods that can help minimize the complications and increase the utility of the PMMC flap. A few tips and tricks that can be used while harvesting a PMMC flap are as follows: 1. Ensure easy reach of the paddle to the defect without excessive rotation, kinking, or compression 2. Place only 2 to 3 cm of paddle outside the muscle; incise the skin paddle laterally first, above the nipple in men and below the breast in women 3. The inferior, medial, and lateral incisions should be made through the skin and muscle down to the chest wall; the superior skin incision should be limited to the fascia covering the pectoralis major muscle 4. Large skin paddles diverging in the muscular plane should be used to incorporate more perforators, preserving the lateral thoracic artery whenever possible; placing the flap horizontally with inclusion of the nipple and areola will increase the reach and size of flap 5. While tunneling the paddle either under the clavicle or the skin, preserve the perforators to the deltopectoral flap and always keep the pedicle of PMMC flap in view 6. When the muscle is elevated off the chest wall beneath the deep fascia, complete hemostasis is mandatory; failing to do so will lead to hemothorax because the vessels will retract into the intercostal muscles 7. Sacrificing the lateral thoracic artery (secondary blood supply) will help increase the length of pedicle; skeletonization of the pedicle and sacrificing the middle one third of the clavicle (rarely necessary) will increase the risk of vessel kinking and flap failure 8. Subclavicular tunneling will help to increase the length and arc of rotation of the flap 9. The use of bipolar cautery is recommended to reduce the chances of damage to the skin perforators and thereby maintain the vascularity of the skin paddle 10. When the flap is used for maxillary reconstruction, we recommend that the divergent and broader muscle paddle should be anchored to
the surrounding bony structure with horizontal mattress sutures to overcome the drag due to gravity and weight 11. Using the PMMC flap without a skin paddle will lead to excessive contracture, resulting in trismus and deviation of jaw and, hence, is not recommended
Conclusions The PMMC flap or its modification was used in 496 cases of reconstruction after resection of HFN malignancy with minimal morbidity and 1 death. This technique is a very useful alternative in places with a high incidence of HFN malignancies and where microsurgical free tissue transfer is not possible owing to the lack of infrastructural facilities and poor socioeconomic status. It can be used as a salvage flap in the event of microvascular flap failure. In our 19-year experience, the final functional and cosmetic results were satisfactory to the patients with this reliable and sturdy flap. Thus, it can be concluded that the PMMC flap is still a workhorse in developing and underdeveloped countries.
References 1. Withers EH, Franklin JD, Madden JJ, et al: Pectoralis major musculocutaneous flap: A new flap in head and neck reconstruction. Am J Surg 138:537, 1979 2. Milenovic A, Virag M, Uglesic V, et al: The pectoralis major flap in head and neck reconstruction: First 500 patients. J Craniomaxillofac Surg 34:340, 2006 3. Sabri A: Oropharyngeal reconstruction: Current state of the art. Curr Opin Otolaryngol Head Neck Surg 11:251, 2003 4. Viros Porcuna D, Leon Vintro X, Lopez Vilas M, et al: Pectoralis major flaps: Evolution of their use in the age of microvascularized flaps. Acta Otorrinolaringol Esp 59:263, 2008 5. EL-Marakby HH: The Reliability of pectoralis major myocutaneous flap in head and neck reconstruction. J Egypt Natl Cancer Inst 18:41, 2006 6. Gadre KS: Utility of pectoralis major myocutaneous flap: Analysis of 124 cases. Int J Oral Maxillofac Surg 36:1054, 2007 7. Vartanian JG, Carvalho AL, Carvalho SMT, et al: Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: Experience with 437 cases at a single institution. Head Neck 26:1018, 2004 8. Hsing C-Y, Wong Y-K, Wang CP, et al: Comparison between free flap and pectoralis major pedicled flap for reconstruction in oral cavity cancer patients—A quality of life analysis. Oral Oncol 47: 522, 2011 9. Biller HF, Baek SM, Lawson W, et al: Pectoralis major myocutaneous island flap in head and neck surgery: Analysis of complications in 42 cases. Arch Otolaryngol 107:23, 1981 10. Schuller DE: Pectoralis myocutaneous flap in head and neck cancer reconstruction. Arch Otolaryngol 109:185, 1983 11. Zbar RIS, Funk GF, McCulloch TM, et al: Pectoralis major myofascial flap: A valuable tool in contemporary head and neck reconstruction. Head Neck 19:412, 1997 12. Badellino F, Berrino P, Campora E, et al: Metastatic spread of the floor of the mouth squamous cell carcinoma via pectoralis major myocutaneous flap. J Surg Oncol 38:45, 1988 13. Bansal R, Patel TS, Bhullar C, et al: Metastases to the donor site of the pectoralis major myocutaneous flap following reconstructive surgery: A rare complication. Plast Reconstr Surg 114:1965, 2004
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14. Robbins TK, Woodson GE: Chest wall metastasis as a complication of myocutaneous flap reconstruction. J Otolaryngol 13:13, 1984 15. Carr RJ, Gilbert PM: Tumour implantation to a temporalis muscle flap donor site. Br J Oral Maxillofac Surg 24:102, 1986 16. Azevedo JF: Modified pectoralis major myocutaneous flap with partial preservation of the muscle: A study of 55 cases. Head Neck Surg 8:327, 1986 17. Azevedo JF: Pectoralis minor flaps: An experimental study and clinical applications of osteomuscular, osteomyocutaneous, and myocutaneous models. Head Neck Surg 9:211, 1987 18. Kerawala CJ, Sun J, Zhang Z, Guoyu Z: The pectoralis major myocutaneous flap: Is the subclavicular route safe? Head Neck 23: 879, 2001 19. Crosher R, Mitchell R, Llewelyn J: A modification of the pectoralis major myocutaneous flap that reduces the defect at the donor site. Ann R Coll Surg Engl 77:389, 1995 20. Ahmad QG, Navadgi S, Agarwal R, et al: Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: A review of 47 cases. J Plast Reconstr Aesthetic Surg 59: 166, 2006
21. Ramakrishnan VR, Yao W, Campana JP: Improved skin paddle survival in pectoralis major myocutaneous flap reconstruction of head and neck defects. Arch Facial Plast Surg 11:306, 2009 22. Coruh A: Pectoralis major musculocutaneous flap with nipple areola complex in head and neck reconstruction: Preliminary results of a new modified method. Ann Plast Surg 56:413, 2006 23. Liu R, Gullane P, Brown D, Irish J: Pectoralis major myocutaneous pedicled flap in head and neck reconstruction: Retrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital. J Otolaryngol 30:34, 2001 24. Von Biberstein SE, Spiro JD: The pectoralis major myocutaneous flap in reconstructive head and neck surgery revisited: A recent experience. Conn Med 58:711, 1994 25. Kroll SS, Goepfert H, Jones M, et al: Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. Ann Plast Surg 25:93, 1990 26. Kekatpure VD, Trivedi NP, Manjula BV, et al: Pectoralis major flap for head and neck reconstruction in era of free flaps. Int J Oral Maxillofac Surg 41:453, 2012 27. Carlson ER: Pectoralis major myocutaneous flap. Oral Maxillofacial Surg Clin North Am 15:565, 2003
