The folded, bipaddled pectoralis major myocutaneous flap for complex oral cavity defects: Undiminished relevance in the era of free flaps

ABSTRACT Introduction Oral cavity cancers account for 30% of head and neck cancers and represent a significant challenge to clinicians. Treatment requires multi disciplinary expertise and is complicated by. the complex role that the oral cavity plays in speech, mastication, and swallowing. Surgery remains the cornerstone of most treatment regimens; the primary objective is cure, not withstanding preservation of form and function to retain a good quality of life that can be further improved by reconstructive techniques using various local flaps, distant flaps or microvascular reconstruction. The pectoralis major [PM] flap has many advantages in that it is very reliable, and allows a single-stage reconstruction of most head and neckdefects to the level of the maxilla with well-vascularized tissue capable of carrying a large skin paddle. The donor site morbidity is surprisingly low, and few patients complain of difficulties with arm movement. Aims & Objectives This paper revisits the surgical anatomy and technique of harvesting the Pectoralis Major myocutaneous flap used to reconstruct complex defects of the lower face following composite therapeutic resection. In addition, we describe our experience using this flap and discuss associated merits and demerits and complications. Conclusion Despite contemporary micro vascular techniques, the Pectoralis Major myocutaneous flap continues to be a versatile option in the reconstruction of complex head and neck defects following ablative surgery. However, regardless of the site, stage and degree of tumor differentiation, such cases will always pose as a therapeutic challenge to the reconstructive surgeon.

<p class="abstract"><strong>Background:</strong> Reconstruction following advanced oral cancer is a formidable task in developing country, with poor infrastructure and heavy chunk of advanced stage (T3-T4) oral malignancy. Options available for reconstructions are regional pedicle flaps and microvascular free flaps. Pedicle flaps particularly the pectoralis major myocutaneous (PMMC) flap have an easy learning curve for most of surgeons. Pectoralis major myocutaneous flap is regarded as the workhorse for reconstruction in many head and neck surgeries.</p><p class="abstract"><strong>Methods:</strong> A study was undertaken on patients of soft tissue defects of head and neck region after resection of tumor of oral cavity (squamous cell carcinoma). Total 60 patients, who were managed in ENT department, Sir T hospital, Bhavnagar from 2016-19 were included in this study.  </p><p class="abstract"><strong>Results:</strong> Gingivo-buccal complex was the most common site observed for oral malignancy and majority of patients were in TNM stage-I, II, III in this study. Apart from total flap necrosis observed in 1 patient, in rest all the patients PMMC flap very well survived with some major/minor, flap related and unrelated complications.</p><p class="abstract"><strong>Conclusions:</strong> The PMMC flap is effective in reconstruction of defect after excision of oral cavity cancers in developing country with heavy chunk of oral cavity cancer patients. In spite of several minor flap related and flap unrelated complications, PMMC flap survival rate is high and total flap necrosis rate is very low.</p>

Since the introduction of microvascular free flaps, the pectoralis major myocutaneous flap (PMMF) has been relegated to background for most reconstructive surgeons. The objective of this article is to show the advantages of cervicofacial defects reconstruction with PMMF using the subclavicular plane route in a challenging clinical case. An 83-year-old man presented with cutaneous temporomalar lesion with orbital spread. Tumor resection was performed, including 12 × 11 cm skin and subcutaneous tissue, overlying zygomatic and malar bone, and orbital exenteration. Radical parotidectomy and functional neck dissection were performed. PMMF was chosen as reconstructive option routing the pedicle to the subclavicular plane. The length of the pedicle was 31 cm. The subclavicular route for PMMF increases the flap's length and arc of rotation compared with the conventional supraclavicular one. This procedure decreases the bulk of the PMMF pedicle which makes it functionally and cosmetically favorable. By using this modification, we may widen the “safe” reconstructive possibilities.

In the last six years, anterior mandibulotomy was used to approach tumours of the oropharynx and oral cavity in 39 cases. Twenty-six of these had primary lesions in the anterior two-thirds of the tongue. Eight cases had lesions in the base tongue, three in the cheek, and two in the tonsil. Twenty-six cases had T3 tumours, nine had T2 lesions, and four had T4 tumours. Twenty-five patients received post-operative radiotherapy. In 16 cases the mandibulotomy was combined with a marginal mandibulectomy. In 23 cases reconstruction was carried out using a pectoralis major myocutaneous flap. Adequate margins on histopathology obtained in all but eight patients. Bone-related complications occurred in only three patients, all of whom were previously irradiated. Thus the anterior mandibulotomy provides excellent exposure for oral and oropharyngeal tumours, with low complication rate, and avoidance of segmental mandibulectomy.