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Vasques LF, Kwiatkowski FV, Kwiatkowski RV, Anjos ADS, Zanatta AS, Bonow DR, Franciosi BM. Versatility of the myocutaneous pectoralis major flap in oncology reconstruction: A literature review and practical application. J Surg Oncol 2024. [PMID: 39138935 DOI: 10.1002/jso.27724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/12/2024] [Indexed: 08/15/2024]
Abstract
Pectoralis major muscle flaps are considered versatile and allow large reconstructions of anatomical defects within a single surgical procedure. Considered a "workhorse" due to these characteristics, the pectoralis major muscle is an excellent option for surgical reconstruction. Several uses of this flap are described in the literature, such as protection of the jugulocarotid system after cervical lymph node dissection, oral, cervical, breast, diaphragmatic, hypopharyngeal, pharyngeal, laryngeal, and esophageal reconstructions.
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Affiliation(s)
- Luana Ferreira Vasques
- Medicine Department of Universidade Católica de Pelotas, Pelotas, Rio Grande do Sul, Brazil
| | - Filipe Vieira Kwiatkowski
- Surgical Oncology Department, Santa Casa de Misericórdia de Pelotas, Pelotas, Rio Grande do Sul, Brazil
| | - Rafael Vieira Kwiatkowski
- Surgical Oncology Department, Santa Casa de Misericórdia de Pelotas, Pelotas, Rio Grande do Sul, Brazil
| | - Amanda da Silva Anjos
- Internal Medicine Department, Santa Casa de Misericórdia de Curitiba, Curitiba, Parana, Brazil
| | | | - Danielle Rediess Bonow
- Medicine Department of Universidade Federal de Rio Grande, Rio Grande, Rio Grande do Sul, Brazil
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Ryan JF, Tanavde VA, Gallia GL, Boahene KDO, London NR, Desai SC. Reconstruction in open anterior skull base surgery: A review and algorithmic approach. Am J Otolaryngol 2023; 44:103700. [PMID: 36473261 DOI: 10.1016/j.amjoto.2022.103700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 09/25/2022] [Accepted: 11/22/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Defects resulting from open resection of anterior skull base neoplasms are difficult to reconstruct. Our objective was to review the literature and describe an evidence-based algorithm that can guide surgeons reconstructing anterior skull base defects. METHODS A research librarian designed database search strategies. Two investigators independently reviewed the resulting abstracts and full text articles. Studies on reconstruction after open anterior skull base resection were included. Studies of lateral and posterior skull base reconstruction, endoscopic endonasal surgery, traumatic and congenital reconstruction were excluded. Based on the review, a reconstructive algorithm was proposed. RESULTS The search strategy identified 603 unique abstracts. 53 articles were included. Adjacent subsites resected, defect size, radiotherapy history, and contraindications to free tissue transfer were identified as key factors influencing decision making and were used to develop the algorithm. Discussion of the reconstructive ladder as it applies to skull base reconstruction and consideration of patient specific factors are reviewed. Patients with a prior history of radiotherapy or with simultaneous resection of multiple anatomic subsites adjacent to the anterior skull base will likely benefit from free tissue transfer. CONCLUSIONS Reconstruction of anterior skull base defects requires knowledge of the available reconstructive techniques and consideration of defect-specific and patient-specific factors.
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Affiliation(s)
- John F Ryan
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ved A Tanavde
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gary L Gallia
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kofi D O Boahene
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nyall R London
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shaun C Desai
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Vyskocil E, Janik S, Faisal M, Rath C, Weninger WJ, Hirtler L, Wormald PJ, Psaltis AJ, Callejas C, Seemann R, Erovic BM. Serratus anterior muscle free flap for endoscopic reconstruction of large and complex skull-base defects. Int Forum Allergy Rhinol 2021; 12:124-127. [PMID: 34370405 DOI: 10.1002/alr.22879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/09/2021] [Accepted: 07/14/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Erich Vyskocil
- Department of Otorhinolaryngology, Head Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Stefan Janik
- Department of Otorhinolaryngology, Head Neck Surgery, Medical University of Vienna, Vienna, Austria
| | - Muhammad Faisal
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria.,Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan
| | - Claus Rath
- Center of Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang J Weninger
- Center of Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Lena Hirtler
- Center of Anatomy and Cell Biology, Medical University of Vienna, Vienna, Austria
| | - Peter-John Wormald
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, The Queen Elizabeth Hospital, Australia and University of Adelaide, Adelaide, Australia
| | - Alkis J Psaltis
- Department of Surgery-Otorhinolaryngology, Head and Neck Surgery, The Queen Elizabeth Hospital, Australia and University of Adelaide, Adelaide, Australia
| | - Claudio Callejas
- Otolaryngology Department, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Rudolf Seemann
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
| | - Boban M Erovic
- Institute of Head and Neck Diseases, Evangelical Hospital, Vienna, Austria
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Kovacevic P, Djordjevic-Jocic J, Radojkovic M. Lateral frontal galeal-cutaneous flap for reconstruction after orbital exenteration for advanced periorbital skin cancer. Turk J Med Sci 2021; 51:359-367. [PMID: 32927925 PMCID: PMC7991890 DOI: 10.3906/sag-1809-170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Accepted: 09/08/2020] [Indexed: 12/02/2022] Open
Abstract
Background/aim Orbital exenteration (OE) is one of the most disfiguring procedures leading to significant deformity. Defect reconstruction is challenging, especially in elderly patients. Herein, experiences with orbital exenteration and primary reconstruction with lateral frontal galeal-cutaneous flap based on superficial temporal artery were reviewed. Materials and methods Data on patients treated for nonmelanoma skin cancer invading the orbit during a 10-year period were analyzed. The patient demographics, tumor features, reconstructive techniques used, complications, and survival were recorded with a median follow-up of 27.5 months. Results Included in the study were 26 patients in whom OE was performed, comprising 14 males and 12 females, with a mean age of 75.29 years (range: 61–87). The majority of the patients were treated for basal cell carcinoma with medial cantus as the primary site. All of the defects were closed using a lateral frontal galeal-cutaneous flap based on the superficial temporal artery, and in 2 patients, a temporalis muscle pedicle flap was used as an additional flap for reconstruction of the orbital roof in order to separate the brain from the empty orbit, and it was then covered with the same galeal-cutaneous flap. In 19 patients, the frontal area was closed primarily, and in 7 patients, skin graft was used for the secondary defect. There was no flap loss. Tumor-related death was registered in 3 patients (inoperable recurrent tumors) (11.5%), 7 died from complications that were unrelated to the tumors (2 were operated for recurrent orbital tumors), and 16 survived. Conclusion The preferred method for reconstruction after OE at our university affiliated center is lateral frontal galeal-cutaneous flap based on the superficial temporal artery. Flap harvesting is simple, safe, and obtains enough tissue to cover the defects, even after extended exenteration. The complication rate is low. The simultaneous use of this flap with pedicle temporalis muscle flap is suggested only for reconstruction of the scull base after anterior cranial fossa resection.
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Affiliation(s)
- Predrag Kovacevic
- Clinic for Plastic and Reconstructive Surgery, Faculty of Medicine, University Nis, Nis, Serbia
| | | | - Milan Radojkovic
- Clinic for Surgery, Faculty of Medicine, University Nis, Nis, Serbia
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Huge Anterior Skull Base Defect Reconstruction on Communicating Between Cranium and Nasal Cavity: Combination Flap of Galeal Flap and Reverse Temporalis Flap. J Craniofac Surg 2020; 31:436-439. [PMID: 32049922 DOI: 10.1097/scs.0000000000006221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Traditionally, galeal flap or cranialization was often used to reconstruct the skull base defect caused by trauma or tumor removal. However, in the case of huge skull base defect, galeal flap is not enough to block the communication between nasal cavity and intracranial space. In this study, authors suggest combination flap of galea and reverse temporalis muscle as a method for reconstruction of huge skull base defect. MATERIALS AND METHODS From 2016 to 2019, retrospective review was conducted, assessing 7 patients with bone defect which is not just opening of frontal sinus but extends to frontal sinus and cribriform plate. Reconstructions were done by combination of galeal flap and reverse temporalis muscle flap transposition. RESULTS Defects were caused by nasal cavity tumor with intracranial extension or brain tumor with nasal cavity extension. There was no major complication in every case. During the follow up period, no patient had signs of complication such as ascending infection, herniation and CSF rhinorrhea. Postoperative radiologic images of all patients that were taken at least 6 months after the surgery showed that flaps maintained the lining and the volume well. DISCUSSION Conventional reconstruction of skull base defect with galeal flap is not effective enough to cover the large sized defect. In conclusion, galeal flap in combination with reverse temporalis muscle flap can effectively block the communication of nasal cavity and intracranium.
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Lim X, Rajagopal R, Silva P, Jeyaretna DS, Mykula R, Potter M. A Systematic Review on Outcomes of Anterior Skull Base Reconstruction. J Plast Reconstr Aesthet Surg 2020; 73:1940-1950. [PMID: 32546425 DOI: 10.1016/j.bjps.2020.05.044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Revised: 04/21/2020] [Accepted: 05/09/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Anterior skull base resection often results in large defects that need to be reconstructed. This can be done using loco-regional, free flaps or both. OBJECTIVE The aim of this systematic review is to evaluate the surgical outcomes (mortality, complication rates and functional outcomes) for patients undergoing anterior skull base reconstruction. METHODS Electronic databases (MEDLINE, EMBASE and Scopus) were systematically searched for relevant articles from 1974 to March 2018. A total of 41 studies were included in this systematic review. No randomized controlled trials were identified; therefore, a meta-analysis was not performed. RESULTS Mortality from anterior skull base reconstruction were about 0-4% for loco-regional flaps while free flaps were around 0-7%. Overall complications ranged from 0% to 43% in loco-regional flaps, while rate of complications for free flaps ranged from 25% to 66.7%. Flap complications ranged from 0% to 14% for free flaps and 0% to 35% for local flaps. Quality-of-life measures did not differ significantly depending on surgical approach but were worse for patients with malignancies. CONCLUSION Due to varying standards of reporting of outcomes, lack of a standardized classification system for anterior skull base defects and absence of clinical trials, we were unable to perform a meta-analysis in this systematic review. Recommendations to guide future studies are proposed.
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Affiliation(s)
- Xuxin Lim
- Institute of Biomedical Engineering, The University of Oxford, Oxfordshire, UK.
| | - Rajini Rajagopal
- Department of Ear, Nose and Throat, John Radcliffe Hospital, Headington, Oxford, UK
| | - Priyamal Silva
- Blenheim Head and Neck Unit, Department of Plastics and Reconstructive Surgery, Churchill Hospital, Headington, Oxford, UK
| | - Deva Sanjeeva Jeyaretna
- Blenheim Head and Neck Unit, Department of Plastics and Reconstructive Surgery, Churchill Hospital, Headington, Oxford, UK
| | - Roman Mykula
- Blenheim Head and Neck Unit, Department of Plastics and Reconstructive Surgery, Churchill Hospital, Headington, Oxford, UK
| | - Matthew Potter
- Blenheim Head and Neck Unit, Department of Plastics and Reconstructive Surgery, Churchill Hospital, Headington, Oxford, UK
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Chen WL, Zhang DM, Huang ZQ, Wang Y, Zhou B, Wang YY. Comparison of outcomes with extensive segmental pectoralis major myocutaneous flap via the anterior axillary line and the conventional technique in oral and oropharyngeal cancer. Head Neck 2017; 40:349-354. [PMID: 28963817 DOI: 10.1002/hed.24959] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 08/16/2017] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND This study compared the outcomes of an extensive segmental pectoralis major myocutaneous flap (esPMMF) and a conventional pectoralis major myocutaneous flap (PMMF). METHODS The study enrolled 91 patients with primary oral and oropharyngeal squamous cell carcinoma (SCC) who underwent radical resection followed by reconstruction of the defect using either an esPMMF via the anterior axillary line or a PMMF. The pedicle lengths of the esPMMF and PMMF were 22-28 and 18-22 cm, respectively. The esPMMF and PMMF had skin paddle dimensions of 5 × 8 to 7 × 14 cm and 6 × 7 to 8 × 17 cm, respectively. RESULTS The esPMMF pedicle was longer than that of the PMMF. The range of shoulder abduction was significantly greater in the esPMMF group and the donor-site aesthetic results were better. CONCLUSION The esPMMF has a longer pedicle flap, enables a greater range of shoulder abduction, and has a better aesthetic result than the conventional technique.
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Affiliation(s)
- Wei-Liang Chen
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Da-Ming Zhang
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhi-Quan Huang
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yan Wang
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bin Zhou
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - You-Yuan Wang
- Department of Oral and Maxillofacial Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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Pingarron L, Ruiz J, Rey J, Maniegas L, Roson S, Martinez D. Subclavicular pectoralis major myocutaneous flap for optimal reconstruction of large orbitozygomatic defects: a case report. Craniomaxillofac Trauma Reconstr 2014; 7:245-8. [PMID: 25136415 DOI: 10.1055/s-0034-1371975] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 07/29/2013] [Indexed: 10/25/2022] Open
Abstract
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.
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Affiliation(s)
- Lorena Pingarron
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Julian Ruiz
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Juan Rey
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Lourdes Maniegas
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Silvia Roson
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - Dolores Martinez
- Department of Oral and Maxillofacial Surgery, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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A plea for the systematic preservation of the deltopectoralis (Bakamjian) flap in pectoralis major flap harvesting. Int J Oral Maxillofac Surg 2014; 43:1169. [PMID: 24951177 DOI: 10.1016/j.ijom.2014.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 05/19/2014] [Indexed: 11/21/2022]
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Use of the clavicular part of the pectoralis major in treatment of failed revision osteosynthesis of the clavicle. J Shoulder Elbow Surg 2014; 23:729-36. [PMID: 24129056 DOI: 10.1016/j.jse.2013.07.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 07/17/2013] [Accepted: 07/28/2013] [Indexed: 02/01/2023]
Abstract
BACKGROUND Symptomatic atrophic nonunion after multiple clavicle osteosynthesis can be difficult to treat. The aim of this study was to evaluate the results of a transfer of the clavicular part of the pectoralis major muscle as augmentation of osteosynthesis of these nonunions. MATERIALS AND METHODS A retrospective study included all patients who were treated between 2001 and 2010 (minimum 2-year follow-up). The indications for primary surgery, the number of operations, and the indication for a pectoralis major transfer were evaluated. Time of radiologic consolidation and postoperative complications were assessed. Clinical evaluation was performed with preoperative and postoperative satisfaction ratings and Constant-Murley scores. RESULTS The study included 11 patients. The indications for a primary osteosynthesis were acute displaced fractures (7), delayed union (2), nonunion (1), and malunion (1). On average, 3.7 procedures were performed (range, 2-6) before the tendon transfer. At revision, there were 2 patients with infection and 9 without infection. Of the 11 clavicles, 10 showed radiologic consolidation after a mean time of 10 weeks (6-20 weeks). The mean follow-up was 62 months (24-132 months). The mean Constant-Murley score increased from 37 (24-55) preoperatively to 59 (43-98), and the satisfaction rating increased from 2 (1-3) to 7 (2-10). Complications included nonunion (1), hardware removal (2), hardware irritation (4), and donor site pain (1). CONCLUSION The use of the clavicular part of the pectoralis major transfer as an augmentation in revision for symptomatic atrophic nonunion after multiple clavicle osteosynthesis showed good radiologic and acceptable clinical results.
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