Salvage for pectoralis major myocutaneous flap failure in head and neck reconstruction by microvascular flap

Abstract

The pectoralis major myocutaneous pedicled flap (PMMPF) - the "workhorse" for head and neck reconstruction - is associated with a high incidence of complications in certain cases. This study presents free tissue transfer as an alternative salvage technique after PMMPF failure in head and neck reconstruction. It includes seven consecutive patients who underwent free tissue salvage after PMMPF failure in head and neck reconstruction from January 2008 to September 2010 at Kaohsiung Medical University Hospital, Taiwan. Four vertical rectus abdominis myocutaneous (VRAM) flaps were applied for tongue and mouth floor defects, while three anterolateral thigh (ALT) flaps were used for mouth floor, buccal, and cheek defects. All flaps survived uneventfully, and normal oral feeding was achieved without major complications. Free tissue transfer has several advantages and can be successfully employed in head and neck reconstruction, and it is also a reliable salvage procedure after PMMPF failure in such cases.

A perspective on the role of the pectoralis major flap in oral and maxillofacial oncology surgery

“…Complications are greatest following salvage surgery, at oral cavity and pharyngeal sites 30,33,54,64,71,72 , and are variably described as either associated with 30,34,52,73 or unrelated to 16,29,32,54,72,74 radiotherapy. Many other factors have been inconsistently linked including: smoking, age, diabetes mellitus, low albumin, obesity, male or female gender, prolonged operation, and an inexperienced surgeon 32,52,60,69,75 . In recent retrospective comparisons with free tissue transfer wound dehiscence 15,16 and blood loss 25 were greater with the PPM flap, but there were often no other substantive differences 16,25,44,48 .…”

“…Major (4-10%) or minor (8-15% or higher) partial skin flap loss and orocutaneous fistulae (3-29%) are frequent 3,4,28,29,32,34,35,69,76 but lower in recent reports and only occasionally delay adjuvant treatment. Conservative wound care procedures are common (10-50%) 16,33,34,38,60 but major secondary surgery infrequent (2-5%) 4,28,34,35,38,69 . In the Leicester study, a reduction in complications coincided with a reduced incidence of methicillin-resistant Staphylococcus aureus 38,51 and possibly increasing surgical experience 48,60 .…”

“…Conservative wound care procedures are common (10-50%) 16,33,34,38,60 but major secondary surgery infrequent (2-5%) 4,28,34,35,38,69 . In the Leicester study, a reduction in complications coincided with a reduced incidence of methicillin-resistant Staphylococcus aureus 38,51 and possibly increasing surgical experience 48,60 . Donor site complications are usually minor and occur in 4-6% 28,35,76 .…”

“…Shortcomings include: restricted arc of rotation and pedicle length with a watershed at the zygomatic arch and superior tonsillar pole. The cosmetic result is compromised by the supraclavicular bulge, skin colour match, unwanted hair and gravity. Radiotherapy may cause epilation but reduction of excessive bulk is difficult because of delayed healing following radiotherapy.…”

Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction

“…However, naturally, some complications such as partial or total necrosis of the skin island or wound healing problems may occur (Shah et al, 1990) and the final defects may require free flaps for the best reconstructive results. While there are many studies about the use, advantages, complication rates and modifications of PMF, the number of detailed studies focusing on what should be done against failure of this life‐boat flap is insufficient (Lyu et al, 2021; Makiguchi et al, 2013; Ossoff et al, 1983; Shah et al, 1990; Squaquara et al, 2010; Tang et al, 2012). In this scenario, instead of discarding or totally sacrificing the complicated PMF, they may still be used as a beneficial server for free flaps.…”