The Pectoralis Major Myofascial Flap for Intraoral and Pharyngeal Reconstruction Maisie L. Shindo, MD; Peter D. Costantino, MD; Craig D. Friedman, MD; Harold J. Pelzer, MD; George A. Sisson, Sr, MD; Fred J. Bressler, MD
\s=b\ The pectoralis myocutaneous flap has been widely used for reconstruction of oral cavity and pharyngeal defects. However, it has several disadvantages, such as chest distortion, hair growth at the reconstructed site, and excessive bulk, all of which can be avoided by the use of the pectoralis myofascial flap. Oral cavities and pharyngeal defects, ranging in size from 4 to 9 cm in largest dimension, in 26 patients were reconstructed with the pectoralis myofascial flap. All but three defects were successfully reconstructed. The surface of the flap was covered by squamous epithelium in 1 month. The flap remained healthy during and after radiotherapy. The pectoralis myofascial flap is ideal for softtissue coverage of small- to medium-size oral cavity and pharyngeal defects. Its major advantages over the pectoralis myocutaneous flap are decreased bulk and improved cosmesis. (Arch Otolaryngol Head Neck Surg. 19 2;1 8:707- 1 )
defects the head and neck region fre¬ reconstructed with the pectoralis major Majorquently The (PMC) in
myocutaneous
are
flap.
straightforward anatomy
of the pectoralis major muscle and its vascular pedicle, ease of dissection of the flap, and proximity of the donor site to the head and neck region makes the PMC flap ideal for re¬ construction of many head and neck defects, particularly those involving the oral cavity and pharynx. Although it is a versatile and fairly reliable flap, it has several signif¬ icant disadvantages. Overall complication rates of 35% to
Accepted
for publication January 3, 1992. From the Departments of Otolaryngology\p=n-\Headand Neck Surgery, University of Southern California, Los Angeles (Dr Shindo); Loyola University Stritch School of Medicine, Maywood, Ill, and Wilford Hall US Air Force Medical Center, Lackland Air Force Base, Tex (Dr Costantino); Yale University Medical School, New Haven, Conn (Dr Friedman); Northwestern University Medical School, Chicago, Ill (Drs Pelzer and Sisson); and University of Texas Health Science Center at Houston (Dr
Bressler).
Presented at the Annual Meeting of the American Academy of Facial Plastic and Reconstructive Surgery, Kansas City, Mo, September 26, 1991.
Reprint requests to University of Southern California Care Consultation Center, 1510 San Pablo St, Suite 201, Los Angeles, CA 90033-4605 (Dr Shindo).
62% have been reported with PMC flaps, the incidence of partial or total flap necrosis ranging from 2% to 33%.15 The flap tends to be bulky due to the adipose tissue between the muscle and skin, and the gravitational pull of a heavy, thick skin paddle may contribute to wound dehiscence. Excessive bulk in the aerodigestive tract may interfere with recovery of swallowing function. Loss of skin from the chest wall results in significant deformity of the chest wall when it is closed primarily, or in an unsightly scar when it is skin grafted. Hair growth in the oral cavity or pharynx can become a problem with hygiene. Some of the disadvantages of the PMC flap can be avoided by using the pectoralis major muscle without its overlying skin paddle. Other muscle flaps using the temporalis or omohyoid muscles have been successfully used for reconstruction of oral cavity defects.6"9 In 1984, Robert¬ son and Robinson10 described the use of the pectoralis muscle flap without its overlying skin for pharyngoesophageal reconstruction. Since then, several articles have ap¬ peared in the literature describing the successful use of this technique for reconstruction of defects in the head and neck region.11"16 Some authors11"13 advocate coverage of the muscle with some form of a graft, such as split-thickness skin or amnion. Others14"16 have described using the mus¬ cle without such coverage. Whether coverage of the mus¬ cle with skin graft yields better results is not certain. In re¬ cent years, mandibular reconstruction plates have been used for bridging a mandibular defect following compos¬ ite resection. In such cases, the PMC flap is generally used to fill the floor of mouth defect and cover the reconstruc¬ tion plate. The feasibility of using the pectoralis muscle flap without the skin paddle in conjunction with a mandibular reconstruction plate has not been addressed in the litera¬ ture. This article describes our experience with using the pectoralis major myofascial (PMF) flap (muscle and over¬ lying fascia only) for reconstruction of oral cavity and pharyngeal defects in 26 patients. To our knowledge, this is the largest series in the literature reporting the use of the PMF for reconstruction of these head and neck regions. The advantages as well as limitations of this technique will be discussed. The efficacy of using this flap for coverage of mandibular reconstruction plates will also be evaluated.
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Table 1.—Oral Patient No.
Procedures
Results
Surgical
Lateral FOM and tongue
Composite resection,
6X5
No
Anterior FOM and tongue
Composite resection,
7X5
Plate exposure
Lateral FOM and tongue Lateral FOM
Composite resection,
5X4
No
complication
Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection,
8X7
No
complication
6X4
No
complication
6X5
Plate exposure
6X7
No
complication
6X6
No
complication
7X6
Plate exposure
5X5
No
complication
4X6
No
complication
FOM resection,
7X6
No
complication
FOM resection,
9X4
No
complication
3X5
No
9X4
No
Anterior FOM
Lateral FOM Anterior FOM
Anterior FOM
and tongue 10
Anterior FOM
11
Anterior FOM
mandible mandible mandible
mandible
13
Defect Size,
Location of Tumor
Lateral FOM and tongue
12
Cavity Tumors*
Lateral FOM and tongue Lateral FOM and tongue
cm
plate plate
plate
plate
hemiglossectomy
hemiglossectomy RMT 14 Composite resection RMT 15 Composite resection RMT 16 Composite resection RMT 17 Composite resection RMT and palate 18 Composite resection *FOM indicates floor of mouth; RMT, retromolar trigone; and STSG, split-thickness skin graft. PATIENTS AND METHODS Patients This study consists of 26 patients, 21 males and five females who underwent reconstruction of the oral cavity and pharyngeal defects with the PMF flap following resection of squamous cell carcinoma. The location of the tumor, size of the defect, and sur¬ gical procedures are summarized in Tables 1 and 2. The defects were located in the lateral floor of the mouth in seven patients, in the anterior floor of the mouth in six patients, in the tonsillar re¬ gion in six patients, in the retromolar trigone in five patients, and in the hypopharynx in two patients. Twenty-one patients under¬ went composite resection; 12 of the 21 were reconstructed with mandibular reconstruction plates in conjunction with the pecto¬ ralis myofascial flap. Two patients underwent resection of the lateral floor of mouth and tongue without mandibulectomy. The remaining three patients underwent partial pharyngectomy: one patient for a tonsillar carcinoma and two patients for hypopharyngeal lesions. The maximum dimension of the defect in each patient ranged from 4 to 9 cm. Twenty-three patients received ra¬ diotherapy: 19 postoperatively, three preoperatively, and one patient preoperatively and intraoperatively. One patient received
preoperative chemotherapy.
Surgical Technique The skin incision for the pectoralis myofascial flap begins from the anterior axillary crease and extends obliquely toward the sternum at the level of the fifth and sixth ribs (Fig 1, left). In the female patient, the incision is placed just inferior to the infra-
4X5 4X4
4X6
complication
complication complication No complication No complication No complication
mammary crease (Fig 1, right). The dissection is somewhat more tedious with this inframammary incision; however, the resulting scar is much more cosmetically appealing in the female. The in¬ cisions are designed such that the length of the pectoralis muscle can be inspected without disrupting the overlying skin of what would normally be used for a myocutaneous flap. In the event that the pectoralis muscle is too short to reach the defect, the flap can be readily converted to a myocutaneous flap. The skin and subcutaneous tissue are undermined superiorly, laterally, and inferolaterally. During elevation of the superior flap, the skin in¬ cision can be extended into that of a deltopectoral flap, which can be elevated and delayed at the same time. A delayed deltopectoral flap is then available for later use, should a wound complication develop. This approach can be used in patients who are at higher risk for developing wound complications; such risk factors include irradiation, large defects, and severe malnutrition. After elevation of the skin and subcutaneous tissue superiorly and lat¬ erally, the lateral border of the pectoralis muscle is exposed to its inferior edge. The muscle is measured to ensure adequate length for reconstruction of the defect. If adequate length is present, el¬ evation of the skin and subcutaneous tissue is continued medially to the lateral border of the sternum. During this process, extreme care is taken to preserve the fascia overlying the pectoralis major muscle. The muscle is then elevated off the chest wall, preserving the vascular pedicle. The humeral attachments of the pectoralis major muscle are transected. The muscle is then tunneled subcutaneously into the defect and sutured. The muscle paddle of the PMF flap was not skin grafted in any of the patients.
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Table Patient No.
Location of Tumor
Surgical
Procedures
Defect Size,
resection
Tonsil
Nasopharynx
2.—Pharyngeal Tumors
and tonsil
Tonsil and tongue
Tonsil Tonsil Tonsil
Hypopharynx Hypopharynx
Composite Composite resection Pharyngectomy, partial glossectomy Composite resection Composite resection Composite resection, mandible plate Partial pharyngectomy Total laryngectomy, subtotal pharyngectomy
Results
cm
7X7
complication complication No complication
4X4
No
4X5
No
5X6
No
7X6.5
No
7X4
complication complication No complication
6X5
No
8X7
No
complication complication
patients, the surface area of the muscle contracted by 41 % and 45%. The degree of contraction in the remaining patients was estimated to be one third to one half by gross inspection. The appearance of the flap postoperatively fol¬ lowed a consistent pattern for all patients.
Fig 1.—Skin incisions for pectoralis major myofascial flap in male (left)
(right) patient. Skin flaps are initially elevated laterally and superiorly (shaded area), and then inferomedially (dashed area) after ensuring that the length of the muscle is adequate for reconstruction. and female
Postoperative Evaluation The flaps were inspected daily during the first 7 to 10 postop¬ erative days, then weekly for 2 months, and monthly for 1 year. If a complication developed, the wounds were checked more fre¬ quently. The size of the muscle paddle and the gross appearance on the surface of the muscle were noted. Biopsy specimens from the center of the flap were taken at 2 weeks, 1 month, 2 months, 3 months, 6 months, and 9 months. Barium swallow videofluoroscopy was performed by the speech and swallowing team in 15 of the 26 patients between 7 days and 1 month postoperatively to assess the patient's swallowing function.
RESULTS Flap necrosis was not seen in any of the patients. Three of the 12 patients who underwent mandibular reconstruc¬ tion with the myofascial flap and mandibular reconstruc¬ tion plate developed wound dehiscence with exposure of the plate. Those three patients had large defects, 5 to 7 cm, resulting from resection of the anterior mandibular arch and floor of the mouth. One of those three patients died with recurrent disease at the primary site. The second pa¬ tient developed distant metastasis, and no further recon¬ structive attempts were made. The third patient required removal of the plate. The flaps healed without any complications in the remaining 23 patients. The flap remained viable during and after radiation therapy. The degree of flap contracture was measured with tat¬ too marks in two patients. Such measurements were not possible in all of the patients because the flaps were not in readily accessible locations for measurement. In those two
The surface of the myofascial flap was covered with a fibrinous exúdate at 1 week postoperatively. At 2 weeks, granulation tissue was seen on the surface of the flap. Af¬ ter 1 month, the surface of the flap appeared to be covered with mucosa (Fig 2). A biopsy specimen taken from the central portion of the flap at this time showed that the flap was covered with a thin layer of squamous mucosa. With time, this layer progressively increased in thickness (Fig 3). These changes were the same regardless of whether the patients underwent postoperative radiation. All of the patients were able to resume the swallowing function postoperatively. In the 15 patients who under¬ went barium swallow videofluoroscopy, the grade of their initial swallowing attempt was categorized as normal, fair, or good; the majority of the patients were graded good. Those with a fair grade improved with therapy over time. All donor sites healed without complication. There was no significant distortion of the chest wall (Fig 4). COMMENT The fact that various muscles in the head and neck re¬ gion, such as the temporalis and omohyoid muscles, have been successfully used without overlying skin to recon¬ struct mucosal defects demonstrates the effectiveness of myogenous or myofascial flaps. The pectoralis major muscle flap without the overlying skin paddle has been used to reconstruct head and neck defects since the early 1980s. Its early uses were for reconstruction of pharyngeal and/or esophageal defects. Since then, several authors have described the use of the PMF flap for reconstruction of various defects in the head and neck region. Some au¬ thors reported 100% success rate with this technique, the number of cases in each series ranging from three to 12 cases. However, in one5 of the larger series consisting of 24 cases, the minor complication rate was 46%, and the inci¬ dence of major flap loss was 4%. In another large series,12 consisting of 23 patients, the complication rate was not specified. The only type of complication in our series was wound dehiscence with resultant exposure of the mandib¬ ular reconstruction plate, which occurred in three (12%) of the patients. All three cases involved large anterior floor of mouth and mandibular arch defects. The results suggest
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Fig 2.—Smooth, mucosa-covered appearance of the pectoralis myofas¬ flap at 3 months postoperatively. The flap right mandible and floor of mouth defect.
cial a
was
used
to reconstruct
Fig 4.—Appearance of the donor site at 6 weeks postoperatively. healed, cosmetically acceptable incisions (bottom) patient.
Fig 3.—Biopsy specimen from central portion of pectoralis major myo¬ fascial flap at 6 weeks postoperatively, showing squamous epithelium on the surface (hematoxylin-eosin, X400). that patients with large, combined anterior floor of mouth and mandibular arch defects are not ideal candidates for reconstruction with the PMF flap and mandible plates. However, the technique appears to be feasible for recon¬ struction of small defects in this location, ie, less than 5 cm in diameter. The contraction rate of the muscle paddle of the PMF flap has been reported to be 60% to 75% of the original surface area.14 The degree of contracture in our series was
in the male
Well-
(top) and female
estimated to be approximately one third to one half. To ac¬ count for this contraction, it is extremely important to use a muscle paddle that is at least twice the size of the defect. Meticulous dissection and preservation of the fascia over¬ lying the muscle cannot be overemphasized, as we believe that it minimizes contraction. Furthermore, placing su¬ tures through both muscle and fascia rather than through only muscle results in a more "secure" closure, minimiz¬ ing the chance of suture line separation. We do not believe that there is any added advantage to placement of some form of graft, such as split-thickness skin or amnion, as advocated in several articles.11"13 A previous article14 on the PMF flap indicated that the flap is most useful for intermediate-size defects of approx¬ imately 6X6 cm. The fact that defects as large as 9X4 cm were successfully reconstructed in our series suggests that the size of the defect is not necessarily a limiting factor. We found it useful for defects of various sizes. Smaller defects in the oral cavity or oropharynx can potentially be closed primarily. However, this can ultimately result in tethering of the tongue and limitation of its motion. Reconstruction of such defects with the PMF flap can avoid some of these problems with wound contracture in the oral cavity and oropharynx. Large defects can also be reconstructed with judicious selection of the cases. An important determina¬ tion is the "relative" length of the pectoralis muscle; when rotated, the length must be sufficient to reach well beyond the most distal portion of the defect so that the muscle paddle that is laid into the defect is approximately twice the size of the defect. Thus, in individuals with a long pec-
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toralis major muscle and a short neck, large defects can be easily reconstructed. Due to individual variations in the length of the upper torso, no specific rule can be made re¬ garding the limits of the defect size that can be recon¬ structed. The feasibility of using a PMF flap can be deter¬ mined prior to elevation of the skin flap over the entire anterior part of the chest, as described in the "Surgical Technique" section. In the event that the pectoralis muscle is too short, the flap can be readily converted to a PMC flap, and greater length can be obtained from the skin paddle. In summary, the PMF flap is an excellent alternative to the PMC flap for soft-tissue coverage of oral cavity and pharyngeal defects. The success rate is comparable to that of the myocutaneous flap, with advantages of decreased bulk and improved cosmesis. The authors thank Jerilyn A. Logemann, PhD, for her assistance in the evaluation and analysis of the patients' swallowing function. References 1. Biller
HF, Baek S, Lawson W, Krespi YP, Blaugrund SM. Pectoralis major myocutaneous island flap in head and neck surgery: analysis of complications in 42 cases. Arch Otolaryngol. 1981;107:23-26. 2. Baek S, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast Reconstr Surg. 1982;69:460-467. 3. Maisel RH, Lisyon SL, Adams L. Complications of pectoralis myocutaneous flaps. Laryngoscope. 1983;93:928-930.
4. de Azevedo JF. Modified pectoralis major myocutaneous flap with partial preservation of the muscle: a study of 55 cases. Head Neck Surg. 1986;
8:327-331. 5. Kroll SS,
Goepfert H, Jones M, Guillamondegui O, Schusterman M. Analysis of complications in 168 pectoralis major myocutaneous flaps used
for head and neck reconstruction. Ann Plast Surg. 1990;25:93-97. 6. Bradley P, Brockbank J. The temporalis muscle flap in oral reconstruction. J Maxillofac Surg. 1981;9:139-145. 7. Birt BD, Antonyshyn O, Gruss JS. The temporalis muscle flap for head and neck reconstruction. J Otolaryngol. 1987;16:179-194. 8. Koranda FC, McMahon MF, Jernstrom VR. The temporalis muscle flap for intraoral reconstruction. Arch Otolaryngol Head Neck Surg. 1987;113:
740-743. 9. Calcaterra TC: Bilateral omohyoid muscle flap reconstruction for anterior commissure cancer. Laryngoscope. 1987;97:810-813. 10. Robertson MS, Robinson JM. Immediate pharyngoesophageal reconstruction: use of a 'quilted' skin-grafted pectoralis major muscle flap. Arch
Otolaryngol Head Neck Surg. 1984;110:386-387.
11. Robertson MS, Robinson JM. Pectoralis major muscle flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1986;112:297-301. 12. Robertson MS, Allison RS. The pectoralis major muscle in head and neck reconstruction. Aust N Z J Surg. 1986:56:753-757. 13. Lawson VG. Oral cavity reconstruction using pectoralis major muscle and amnion. Arch Otolaryngol Head Neck Surg. 1985;111:230-233. 14. Moloy PJ. Reconstruction of intermediate sized mucosal defects with the pectoralis major myofascial flap. J Otolaryngol. 1989;18:32-35. 15. Phillips JG, Postlethwaite K, Peckitt N. The pectoralis major muscle flap without skin in intra-oral reconstruction. Br J Oral Maxillofac Surg.
1988;26:479-485. 16. Johnson MA, Langdon JD. Is skin necessary for intraoral reconstruction with myocutaneous flaps? Br J Oral Maxillofac Surg. 1990;28:299-301.
NEWS AND COMMENT Fourth Annual
Meeting of the North American Skull Base Soci¬
ety. —The fourth annual meeting of the North American Skull Base Society will be held at the Camelback Inn, Scottsdale, Ariz, from February 12 through 14,1993. For further information, contact Pe¬ ter G. Smith, MD, PhD, Midwest Otologie Group, 621 S New Ballas Rd, St Louis, MO 63141; (314) 569-6873; fax: (314) 432-8795.
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\s=b\ The pectoralis myocutaneous flap has been widely used for reconstruction of oral cavity and pharyngeal defects. However, it has several disadvantages, such as chest distortion, hair growth at the reconstructed site, and excessive bulk, all of which can be avoided by the use of the pectoralis myofascial flap. Oral cavities and pharyngeal defects, ranging in size from 4 to 9 cm in largest dimension, in 26 patients were reconstructed with the pectoralis myofascial flap. All but three defects were successfully reconstructed. The surface of the flap was covered by squamous epithelium in 1 month. The flap remained healthy during and after radiotherapy. The pectoralis myofascial flap is ideal for softtissue coverage of small- to medium-size oral cavity and pharyngeal defects. Its major advantages over the pectoralis myocutaneous flap are decreased bulk and improved cosmesis. (Arch Otolaryngol Head Neck Surg. 19 2;1 8:707- 1 )
defects the head and neck region fre¬ reconstructed with the pectoralis major Majorquently The (PMC) in
myocutaneous
are
flap.
straightforward anatomy
of the pectoralis major muscle and its vascular pedicle, ease of dissection of the flap, and proximity of the donor site to the head and neck region makes the PMC flap ideal for re¬ construction of many head and neck defects, particularly those involving the oral cavity and pharynx. Although it is a versatile and fairly reliable flap, it has several signif¬ icant disadvantages. Overall complication rates of 35% to
Accepted
for publication January 3, 1992. From the Departments of Otolaryngology\p=n-\Headand Neck Surgery, University of Southern California, Los Angeles (Dr Shindo); Loyola University Stritch School of Medicine, Maywood, Ill, and Wilford Hall US Air Force Medical Center, Lackland Air Force Base, Tex (Dr Costantino); Yale University Medical School, New Haven, Conn (Dr Friedman); Northwestern University Medical School, Chicago, Ill (Drs Pelzer and Sisson); and University of Texas Health Science Center at Houston (Dr
Bressler).
Presented at the Annual Meeting of the American Academy of Facial Plastic and Reconstructive Surgery, Kansas City, Mo, September 26, 1991.
Reprint requests to University of Southern California Care Consultation Center, 1510 San Pablo St, Suite 201, Los Angeles, CA 90033-4605 (Dr Shindo).
62% have been reported with PMC flaps, the incidence of partial or total flap necrosis ranging from 2% to 33%.15 The flap tends to be bulky due to the adipose tissue between the muscle and skin, and the gravitational pull of a heavy, thick skin paddle may contribute to wound dehiscence. Excessive bulk in the aerodigestive tract may interfere with recovery of swallowing function. Loss of skin from the chest wall results in significant deformity of the chest wall when it is closed primarily, or in an unsightly scar when it is skin grafted. Hair growth in the oral cavity or pharynx can become a problem with hygiene. Some of the disadvantages of the PMC flap can be avoided by using the pectoralis major muscle without its overlying skin paddle. Other muscle flaps using the temporalis or omohyoid muscles have been successfully used for reconstruction of oral cavity defects.6"9 In 1984, Robert¬ son and Robinson10 described the use of the pectoralis muscle flap without its overlying skin for pharyngoesophageal reconstruction. Since then, several articles have ap¬ peared in the literature describing the successful use of this technique for reconstruction of defects in the head and neck region.11"16 Some authors11"13 advocate coverage of the muscle with some form of a graft, such as split-thickness skin or amnion. Others14"16 have described using the mus¬ cle without such coverage. Whether coverage of the mus¬ cle with skin graft yields better results is not certain. In re¬ cent years, mandibular reconstruction plates have been used for bridging a mandibular defect following compos¬ ite resection. In such cases, the PMC flap is generally used to fill the floor of mouth defect and cover the reconstruc¬ tion plate. The feasibility of using the pectoralis muscle flap without the skin paddle in conjunction with a mandibular reconstruction plate has not been addressed in the litera¬ ture. This article describes our experience with using the pectoralis major myofascial (PMF) flap (muscle and over¬ lying fascia only) for reconstruction of oral cavity and pharyngeal defects in 26 patients. To our knowledge, this is the largest series in the literature reporting the use of the PMF for reconstruction of these head and neck regions. The advantages as well as limitations of this technique will be discussed. The efficacy of using this flap for coverage of mandibular reconstruction plates will also be evaluated.
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Table 1.—Oral Patient No.
Procedures
Results
Surgical
Lateral FOM and tongue
Composite resection,
6X5
No
Anterior FOM and tongue
Composite resection,
7X5
Plate exposure
Lateral FOM and tongue Lateral FOM
Composite resection,
5X4
No
complication
Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection, mandible plate Composite resection,
8X7
No
complication
6X4
No
complication
6X5
Plate exposure
6X7
No
complication
6X6
No
complication
7X6
Plate exposure
5X5
No
complication
4X6
No
complication
FOM resection,
7X6
No
complication
FOM resection,
9X4
No
complication
3X5
No
9X4
No
Anterior FOM
Lateral FOM Anterior FOM
Anterior FOM
and tongue 10
Anterior FOM
11
Anterior FOM
mandible mandible mandible
mandible
13
Defect Size,
Location of Tumor
Lateral FOM and tongue
12
Cavity Tumors*
Lateral FOM and tongue Lateral FOM and tongue
cm
plate plate
plate
plate
hemiglossectomy
hemiglossectomy RMT 14 Composite resection RMT 15 Composite resection RMT 16 Composite resection RMT 17 Composite resection RMT and palate 18 Composite resection *FOM indicates floor of mouth; RMT, retromolar trigone; and STSG, split-thickness skin graft. PATIENTS AND METHODS Patients This study consists of 26 patients, 21 males and five females who underwent reconstruction of the oral cavity and pharyngeal defects with the PMF flap following resection of squamous cell carcinoma. The location of the tumor, size of the defect, and sur¬ gical procedures are summarized in Tables 1 and 2. The defects were located in the lateral floor of the mouth in seven patients, in the anterior floor of the mouth in six patients, in the tonsillar re¬ gion in six patients, in the retromolar trigone in five patients, and in the hypopharynx in two patients. Twenty-one patients under¬ went composite resection; 12 of the 21 were reconstructed with mandibular reconstruction plates in conjunction with the pecto¬ ralis myofascial flap. Two patients underwent resection of the lateral floor of mouth and tongue without mandibulectomy. The remaining three patients underwent partial pharyngectomy: one patient for a tonsillar carcinoma and two patients for hypopharyngeal lesions. The maximum dimension of the defect in each patient ranged from 4 to 9 cm. Twenty-three patients received ra¬ diotherapy: 19 postoperatively, three preoperatively, and one patient preoperatively and intraoperatively. One patient received
preoperative chemotherapy.
Surgical Technique The skin incision for the pectoralis myofascial flap begins from the anterior axillary crease and extends obliquely toward the sternum at the level of the fifth and sixth ribs (Fig 1, left). In the female patient, the incision is placed just inferior to the infra-
4X5 4X4
4X6
complication
complication complication No complication No complication No complication
mammary crease (Fig 1, right). The dissection is somewhat more tedious with this inframammary incision; however, the resulting scar is much more cosmetically appealing in the female. The in¬ cisions are designed such that the length of the pectoralis muscle can be inspected without disrupting the overlying skin of what would normally be used for a myocutaneous flap. In the event that the pectoralis muscle is too short to reach the defect, the flap can be readily converted to a myocutaneous flap. The skin and subcutaneous tissue are undermined superiorly, laterally, and inferolaterally. During elevation of the superior flap, the skin in¬ cision can be extended into that of a deltopectoral flap, which can be elevated and delayed at the same time. A delayed deltopectoral flap is then available for later use, should a wound complication develop. This approach can be used in patients who are at higher risk for developing wound complications; such risk factors include irradiation, large defects, and severe malnutrition. After elevation of the skin and subcutaneous tissue superiorly and lat¬ erally, the lateral border of the pectoralis muscle is exposed to its inferior edge. The muscle is measured to ensure adequate length for reconstruction of the defect. If adequate length is present, el¬ evation of the skin and subcutaneous tissue is continued medially to the lateral border of the sternum. During this process, extreme care is taken to preserve the fascia overlying the pectoralis major muscle. The muscle is then elevated off the chest wall, preserving the vascular pedicle. The humeral attachments of the pectoralis major muscle are transected. The muscle is then tunneled subcutaneously into the defect and sutured. The muscle paddle of the PMF flap was not skin grafted in any of the patients.
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Table Patient No.
Location of Tumor
Surgical
Procedures
Defect Size,
resection
Tonsil
Nasopharynx
2.—Pharyngeal Tumors
and tonsil
Tonsil and tongue
Tonsil Tonsil Tonsil
Hypopharynx Hypopharynx
Composite Composite resection Pharyngectomy, partial glossectomy Composite resection Composite resection Composite resection, mandible plate Partial pharyngectomy Total laryngectomy, subtotal pharyngectomy
Results
cm
7X7
complication complication No complication
4X4
No
4X5
No
5X6
No
7X6.5
No
7X4
complication complication No complication
6X5
No
8X7
No
complication complication
patients, the surface area of the muscle contracted by 41 % and 45%. The degree of contraction in the remaining patients was estimated to be one third to one half by gross inspection. The appearance of the flap postoperatively fol¬ lowed a consistent pattern for all patients.
Fig 1.—Skin incisions for pectoralis major myofascial flap in male (left)
(right) patient. Skin flaps are initially elevated laterally and superiorly (shaded area), and then inferomedially (dashed area) after ensuring that the length of the muscle is adequate for reconstruction. and female
Postoperative Evaluation The flaps were inspected daily during the first 7 to 10 postop¬ erative days, then weekly for 2 months, and monthly for 1 year. If a complication developed, the wounds were checked more fre¬ quently. The size of the muscle paddle and the gross appearance on the surface of the muscle were noted. Biopsy specimens from the center of the flap were taken at 2 weeks, 1 month, 2 months, 3 months, 6 months, and 9 months. Barium swallow videofluoroscopy was performed by the speech and swallowing team in 15 of the 26 patients between 7 days and 1 month postoperatively to assess the patient's swallowing function.
RESULTS Flap necrosis was not seen in any of the patients. Three of the 12 patients who underwent mandibular reconstruc¬ tion with the myofascial flap and mandibular reconstruc¬ tion plate developed wound dehiscence with exposure of the plate. Those three patients had large defects, 5 to 7 cm, resulting from resection of the anterior mandibular arch and floor of the mouth. One of those three patients died with recurrent disease at the primary site. The second pa¬ tient developed distant metastasis, and no further recon¬ structive attempts were made. The third patient required removal of the plate. The flaps healed without any complications in the remaining 23 patients. The flap remained viable during and after radiation therapy. The degree of flap contracture was measured with tat¬ too marks in two patients. Such measurements were not possible in all of the patients because the flaps were not in readily accessible locations for measurement. In those two
The surface of the myofascial flap was covered with a fibrinous exúdate at 1 week postoperatively. At 2 weeks, granulation tissue was seen on the surface of the flap. Af¬ ter 1 month, the surface of the flap appeared to be covered with mucosa (Fig 2). A biopsy specimen taken from the central portion of the flap at this time showed that the flap was covered with a thin layer of squamous mucosa. With time, this layer progressively increased in thickness (Fig 3). These changes were the same regardless of whether the patients underwent postoperative radiation. All of the patients were able to resume the swallowing function postoperatively. In the 15 patients who under¬ went barium swallow videofluoroscopy, the grade of their initial swallowing attempt was categorized as normal, fair, or good; the majority of the patients were graded good. Those with a fair grade improved with therapy over time. All donor sites healed without complication. There was no significant distortion of the chest wall (Fig 4). COMMENT The fact that various muscles in the head and neck re¬ gion, such as the temporalis and omohyoid muscles, have been successfully used without overlying skin to recon¬ struct mucosal defects demonstrates the effectiveness of myogenous or myofascial flaps. The pectoralis major muscle flap without the overlying skin paddle has been used to reconstruct head and neck defects since the early 1980s. Its early uses were for reconstruction of pharyngeal and/or esophageal defects. Since then, several authors have described the use of the PMF flap for reconstruction of various defects in the head and neck region. Some au¬ thors reported 100% success rate with this technique, the number of cases in each series ranging from three to 12 cases. However, in one5 of the larger series consisting of 24 cases, the minor complication rate was 46%, and the inci¬ dence of major flap loss was 4%. In another large series,12 consisting of 23 patients, the complication rate was not specified. The only type of complication in our series was wound dehiscence with resultant exposure of the mandib¬ ular reconstruction plate, which occurred in three (12%) of the patients. All three cases involved large anterior floor of mouth and mandibular arch defects. The results suggest
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Fig 2.—Smooth, mucosa-covered appearance of the pectoralis myofas¬ flap at 3 months postoperatively. The flap right mandible and floor of mouth defect.
cial a
was
used
to reconstruct
Fig 4.—Appearance of the donor site at 6 weeks postoperatively. healed, cosmetically acceptable incisions (bottom) patient.
Fig 3.—Biopsy specimen from central portion of pectoralis major myo¬ fascial flap at 6 weeks postoperatively, showing squamous epithelium on the surface (hematoxylin-eosin, X400). that patients with large, combined anterior floor of mouth and mandibular arch defects are not ideal candidates for reconstruction with the PMF flap and mandible plates. However, the technique appears to be feasible for recon¬ struction of small defects in this location, ie, less than 5 cm in diameter. The contraction rate of the muscle paddle of the PMF flap has been reported to be 60% to 75% of the original surface area.14 The degree of contracture in our series was
in the male
Well-
(top) and female
estimated to be approximately one third to one half. To ac¬ count for this contraction, it is extremely important to use a muscle paddle that is at least twice the size of the defect. Meticulous dissection and preservation of the fascia over¬ lying the muscle cannot be overemphasized, as we believe that it minimizes contraction. Furthermore, placing su¬ tures through both muscle and fascia rather than through only muscle results in a more "secure" closure, minimiz¬ ing the chance of suture line separation. We do not believe that there is any added advantage to placement of some form of graft, such as split-thickness skin or amnion, as advocated in several articles.11"13 A previous article14 on the PMF flap indicated that the flap is most useful for intermediate-size defects of approx¬ imately 6X6 cm. The fact that defects as large as 9X4 cm were successfully reconstructed in our series suggests that the size of the defect is not necessarily a limiting factor. We found it useful for defects of various sizes. Smaller defects in the oral cavity or oropharynx can potentially be closed primarily. However, this can ultimately result in tethering of the tongue and limitation of its motion. Reconstruction of such defects with the PMF flap can avoid some of these problems with wound contracture in the oral cavity and oropharynx. Large defects can also be reconstructed with judicious selection of the cases. An important determina¬ tion is the "relative" length of the pectoralis muscle; when rotated, the length must be sufficient to reach well beyond the most distal portion of the defect so that the muscle paddle that is laid into the defect is approximately twice the size of the defect. Thus, in individuals with a long pec-
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toralis major muscle and a short neck, large defects can be easily reconstructed. Due to individual variations in the length of the upper torso, no specific rule can be made re¬ garding the limits of the defect size that can be recon¬ structed. The feasibility of using a PMF flap can be deter¬ mined prior to elevation of the skin flap over the entire anterior part of the chest, as described in the "Surgical Technique" section. In the event that the pectoralis muscle is too short, the flap can be readily converted to a PMC flap, and greater length can be obtained from the skin paddle. In summary, the PMF flap is an excellent alternative to the PMC flap for soft-tissue coverage of oral cavity and pharyngeal defects. The success rate is comparable to that of the myocutaneous flap, with advantages of decreased bulk and improved cosmesis. The authors thank Jerilyn A. Logemann, PhD, for her assistance in the evaluation and analysis of the patients' swallowing function. References 1. Biller
HF, Baek S, Lawson W, Krespi YP, Blaugrund SM. Pectoralis major myocutaneous island flap in head and neck surgery: analysis of complications in 42 cases. Arch Otolaryngol. 1981;107:23-26. 2. Baek S, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast Reconstr Surg. 1982;69:460-467. 3. Maisel RH, Lisyon SL, Adams L. Complications of pectoralis myocutaneous flaps. Laryngoscope. 1983;93:928-930.
4. de Azevedo JF. Modified pectoralis major myocutaneous flap with partial preservation of the muscle: a study of 55 cases. Head Neck Surg. 1986;
8:327-331. 5. Kroll SS,
Goepfert H, Jones M, Guillamondegui O, Schusterman M. Analysis of complications in 168 pectoralis major myocutaneous flaps used
for head and neck reconstruction. Ann Plast Surg. 1990;25:93-97. 6. Bradley P, Brockbank J. The temporalis muscle flap in oral reconstruction. J Maxillofac Surg. 1981;9:139-145. 7. Birt BD, Antonyshyn O, Gruss JS. The temporalis muscle flap for head and neck reconstruction. J Otolaryngol. 1987;16:179-194. 8. Koranda FC, McMahon MF, Jernstrom VR. The temporalis muscle flap for intraoral reconstruction. Arch Otolaryngol Head Neck Surg. 1987;113:
740-743. 9. Calcaterra TC: Bilateral omohyoid muscle flap reconstruction for anterior commissure cancer. Laryngoscope. 1987;97:810-813. 10. Robertson MS, Robinson JM. Immediate pharyngoesophageal reconstruction: use of a 'quilted' skin-grafted pectoralis major muscle flap. Arch
Otolaryngol Head Neck Surg. 1984;110:386-387.
11. Robertson MS, Robinson JM. Pectoralis major muscle flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 1986;112:297-301. 12. Robertson MS, Allison RS. The pectoralis major muscle in head and neck reconstruction. Aust N Z J Surg. 1986:56:753-757. 13. Lawson VG. Oral cavity reconstruction using pectoralis major muscle and amnion. Arch Otolaryngol Head Neck Surg. 1985;111:230-233. 14. Moloy PJ. Reconstruction of intermediate sized mucosal defects with the pectoralis major myofascial flap. J Otolaryngol. 1989;18:32-35. 15. Phillips JG, Postlethwaite K, Peckitt N. The pectoralis major muscle flap without skin in intra-oral reconstruction. Br J Oral Maxillofac Surg.
1988;26:479-485. 16. Johnson MA, Langdon JD. Is skin necessary for intraoral reconstruction with myocutaneous flaps? Br J Oral Maxillofac Surg. 1990;28:299-301.
NEWS AND COMMENT Fourth Annual
Meeting of the North American Skull Base Soci¬
ety. —The fourth annual meeting of the North American Skull Base Society will be held at the Camelback Inn, Scottsdale, Ariz, from February 12 through 14,1993. For further information, contact Pe¬ ter G. Smith, MD, PhD, Midwest Otologie Group, 621 S New Ballas Rd, St Louis, MO 63141; (314) 569-6873; fax: (314) 432-8795.
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