Pectoralis Major Myocutaneous Flap for Head and Neck Defects in the Era of Free Flaps: Harvesting Technique and Indications

Reconstruction of Partial Hypopharyngeal Defects following Total Laryngectomy: A Systematic Review and Meta-Analysis

BACKGROUND

Various operative techniques exist to reconstruct partial hypopharyngeal defects following total laryngectomy. The current study aimed to investigate and compare complications and functional results following commonly used reconstructive techniques.

METHODS

A systematic review and meta-analysis were performed using studies that investigated outcomes after the reconstruction of a partial hypopharyngeal defect. The outcomes of interest were fistulas, strictures, flap failure, swallowing function and postoperative speech.

RESULTS

Of the 4035 studies identified, 23 were included in this review. Four common reconstructive techniques were reported, with a total of 794 patients: (1) pectoralis major myocutaneous and (2) myofascial flap, (3) anterolateral thigh free flap and (4) radial forearm free flap. Fistulas occurred significantly more often than pectoralis major myocutaneous flaps (34%, 95% CI 23-47%) compared with other flaps (p < 0.001). No significant differences in the rates of strictures or flap failure were observed. Pectoralis major myofascial flaps were non-inferior to free-flap reconstructions. Insufficient data were available to assess speech results between flap types.

CONCLUSION

Pectoralis myocutaneous flaps should not be the preferred method of reconstruction for most patients, considering their significantly higher rate of fistulas. In contrast, pectoralis major myofascial flaps yield promising results compared to free-flap reconstructions, warranting further investigation.

Can Lateral Thoracic Artery Preservation Improve Results in Large PMMC Flaps? - Our Experience of 61 Cases from Northern India

Introduction: Pectoralis major myo-cutaneous (PMMC) flap continues to be a widely used tool to reconstruct oral cavity defects. But an unreliable and unstable vascular supply can lead to complications like flap loss, Oro-cutaneous fistula and wound dehiscence. Preservation of the lateral thoracic artery (LTA) has been suggested to improve the vascularity of the skin paddle. The present study aspires to compare the complications and flap related outcomes after preserving or sacrificing the LTA while reconstructing oral cavity defects with bi-folded PMMC flap. Materials and Methods: Retrospective analysis of the data of 61 male patients who were reconstructed with bi-folded PMMC flaps between January 2022 and September 2022 was done. 36 patients were reconstructed using a PMMC flap where the LTA was sacrificed, whereas in 25 patients the LTA was preserved. Data was analyzed in terms of patient factors and flap related complications. Results: The overall complication rate including major/minor complications was 44.26% with flap detachment at 22.95% being the commonest complication observed. 13.11% patients developed an Oro-cutaneous fistula and partial and complete flap loss were seen in 9.83% and 4.91% respectively. LTA preservation was significantly associated with only decreased flap detachment rates (p value < 0.05). No significant association was noticed between other flap related complications and LTA preservation. Conclusion: Reconstructing larger defects with a PMMC flap where the LTA is preserved can help improve the vascularity of the flap and decrease various major/minor flap related complications.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04123-3.

Reconstruction in Salvage Surgery for Head and Neck Cancers

Introduction

Salvage surgery is the treatment option in recurrences and second primary tumors. This paper aimed to study the options and outcomes of reconstruction and the predictors of poor reconstructive outcomes in salvage surgery for head and neck cancers.

Study Design

This is a retrospective study of all patients who underwent reconstructive flap surgery as part of salvage surgery for head and neck cancers between the years 2004 and 2017.

Methods

The initial treatment may be single modality radiotherapy or surgery or multimodality with combinations of surgery, radiotherapy, and chemotherapy. Any pathology that required surgical salvage was included. Any procedures done purely as reconstructive surgery were excluded. Predictor variables included demographical, clinical, and treatment factors. The outcome parameter was the occurrence of any flap-related complication or not. The complications and morbidity related to the procedures are reported.

Results

Ninety-three patients underwent loco-regional flaps (LRF group), and 100 had free flaps (FF group). Pectoralis major flap was the commonest flap used in 68 patients (73.1%). Anterolateral thigh (ALT) flap was the commonest free flap and comprised 41% of the FF group. Any skin-related complication was seen in 35 patients (37.6%) and 41 (41%), respectively, in LRF and FF subsets. Any flap-related complication was seen in 16 patients (17.2%) and 29 patients (29%), respectively, in LRF and FF subsets. A summary measure "any one of the complications" was seen in 46 (49.5%) and 57 (57%), respectively, in LRF and FF subsets. Univariate and multivariate analysis for any flap-related complication identified no statistically significant predictor.

Conclusions

Soft tissue flaps were preferred in salvage reconstruction, though the defects had a bony component. In the microvascular free flap reconstruction era, pectoralis major flap has shifted its role from a "workhorse flap" to a "salvage flap." About half of the patients develop some complications. Flap-related complications are also common. In salvage surgery, it is important that an appropriate flap is selected, suitable for the setting, according to the indications, neck, and patient conditions.

Postoperative recovery among head and neck cancer patients receiving microvascular free flap surgery with implementing nurse-protocolized targeted sedation: relationship of use of sedatives and mechanical ventilation to length of ICU stay

PURPOSE

Patients receiving microvascular free flap surgery are usually admitted to a high-dependency adult intensive care unit (ICU). Research is limited to investigate postoperative recovery among head and neck cancer patients in the ICU. This study aimed to evaluate a nursing-protocolized targeted sedation on postoperative recovery and to examine the relationship of demographic characteristics, use of sedation, mechanical ventilator to length of ICU stay in patients receiving microvascular free flap surgery for head and neck reconstruction.

METHODS

This retrospective study involves 125 ICU patients at a medical centre in Taiwan. Medical records were reviewed between 1 January 2015 and 31 December 2018 including surgery-related data, medications and sedations used, and ICU-related outcomes.

RESULTS

The mean length of ICU stay was 6.2 days (SD = 2.6), and the mean duration of mechanical ventilation was 4.7 days (SD = 2.3). The daily dosage of sedation used in patients who received microvascular free flap surgery was dramatically reduced since the postoperative day (POD) 7. Over 50% of patients switched to PS + SIMV ventilator mode on POD 4. Duration of sedation used (r = 0.331, p < 0.001), total dosage of sedation (r = 0.901, p < 0.001), clear consciousness (r =  - 0.517, p < 0.001), and duration on mechanical ventilator (r = 0.378, p < 0.001) are correlated with the length of ICU stay.

CONCLUSION

This study provides an understanding of the use of sedation, mechanical ventilator, and length of ICU stay to inform the continued education for clinicians.

Various Types of Facial-Angular Artery-Based Flaps for Reconstructing Oral and Maxillofacial Defects Following Cancer Ablation

BACKGROUND

The flap based on the facial-angular vessels (FAVs) has several names and cannot capture the hemodynamics.

AIMS

This study was performed to assess the reliability of various types of flaps based on the FAVs for reconstructing oral and maxillofacial defects following cancer ablation.

PATIENTS AND METHODS

Forty-three oral and maxillofacial defects were reconstructed with facial-angular artery island flaps (FAAIF, n=14), including V-Y advancement-type and rotation-type flaps based on FAVs and reverse-flow FAAIFs (R-FAAIF, n=29), including ipsilateral, contralateral rotation, full-thickness, and folded types, based on distal FAVs following cancer ablation. The patients (25 males and 18 females) ranged in age from 18 to 82 years. The lesions included basal cell carcinoma (n=26), squamous cell carcinoma (n=8), adenoid cystic carcinoma (n=3), mucoepidermoid carcinoma (n=3), verrucous carcinoma (n=2), and nodular melanoma (n=1). The tumors were classified as clinical stage I to III in 12, 25, and 6 cases, respectively. Lesions were observed in orbital (n=4), infraorbital (n=14), glabellar (n=2), nasal (n=4), cheek (n=10), upper lip (n=3), palate (n=4), and lower gingival (n=2) regions. The defects ranged in size from 2.0×2.5 to 5.0×12.0 cm. The skin paddle ranged in size from 1.5×3.0 to 4.0×12.0 cm.

RESULTS

There was 1 flap failure, resulting in a flap success rate of 97.7%. Complications, including hematoma, infection, wound dehiscence, and fistula, occurred in 15 (34.9%) patients. Limitations of mouth opening and ectropion occurred in 12 (28.0%) patients. The esthetic outcomes were satisfactory in 36 (83.7%) patients but were not significantly different between the FAAIF and R-FAAIF groups. The patients were followed up for 6 to 60 months. At the time of the last follow-up, 27 (62.8%) patients were alive with no disease, 9 (20.9%) were alive with disease, and 7 (16.3%) had died due to their disease. There was no significant survival difference between the 2 groups.

CONCLUSIONS

Various types of FAV-based flaps are valuable reconstructive options for the treatment of oral and maxillofacial defects following clinical stage I-III cancer ablation.

Facial-submental island flap for reconstruction of hemitongue defects in young, middle-aged and elderly patients with early and middle stage oral tongue squamous cell carcinoma

BACKGROUND

This study evaluated the outcomes of facial-submental artery island flap (FSAIF) for reconstruction of the hemitongue following cancer ablation in patients with early and middle-stage oral tongue squamous cell carcinoma (OTSCC).

METHODS

In total, 122 patients with early and middle-stage OTSCC were divided into young, middle-aged, and elderly groups. The Adult Comorbidity Evaluation-27 (ACE-27) index was used to determine the presence of comorbidities. The patients underwent surgical treatment with hemiglossectomy, neck dissection, and hemitongue reconstruction using FSAIF. In addition, stage I (n = 15) and II (n = 69) patients underwent ipsilateral selective neck dissection, whereas those with stage III (n = 38) underwent radical neck dissection. Six patients with T3N1 disease also underwent cobalt-60 adjuvant radiotherapy.

RESULTS

Young and elderly patients exhibited significant differences in comorbidities, as assessed by the ACE-27 (p < .05). The skin paddles in the young, middle-aged, and elderly patients were 3 × 9 to 4 × 12 cm, 3 × 11 to 4 × 12, and 3 ×  10 to 5 × 13 cm in size, respectively. FSAIF failure occurred in four patients (success rate: 96.7%). No significant differences were observed in the skin paddle of the flap or rate of flap failure among the age groups (p > .05). Clavien-Dindo grades I, II, IIIa, IIIb, Iva, and IVb were assigned to 7.1, 36.1, 38.5, 9.8, 4.1, and 4.1% of the patients, respectively, with significant differences seen between the young and elderly patients (p < .05). In total, 52.5% of patients could eat normally, whereas 32.8% required a soft diet. Furthermore, 53.3 and 33.6% of patients achieved normal and intelligible speech, respectively. The aesthetic results were rated as excellent and good in 32.8 and 58.2% of patients, respectively. In total, 68.0% of the patients were alive and exhibited no evidence of disease, while 19.7% were alive with active disease. In addition, 12.3% of patients with stage III OTSCC died due to local recurrence or distant metastases. No differences in swallowing, speech, aesthetic, or survival outcomes were observed among the groups.

CONCLUSIONS

FSAIF is a simple, safe, and reliable method for reconstructing hemitongue defects following cancer ablation in young, middle-aged, and elderly patients with early and middle-stage OTSCC.

Management of refractory cervical anastomotic fistula after esophagectomy using the pectoralis major myocutaneous flap

INTRODUCTION

A refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear.

OBJECTIVE

This study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review.

METHODS

Six patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed.

RESULTS

All patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th-15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25-53 months.

CONCLUSION

The satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.

Partition of Pectoralis Major Musculocutaneous Flap as a Salvage Procedure for Simultaneous Coverage of the Exposed Carotid Artery and Reconstruction of Cervical Esophagus

BACKGROUND

In advanced pharyngoesophageal cancer patients, a critical event is represented by the failure of primary reconstruction with exposure of the carotid artery and partial or total defect of the cervical esophagus. For these high-risk patients, a partitioned pectoralis major musculocutaneous (PMMC) flap can prevent carotid blowout and provide skin for simultaneous esophageal reconstruction.

METHODS

Twenty-six patients needing pharyngoesophageal reconstruction together with coverage of carotid artery exposure were included in this retrospective case series. The patients were treated with a partitioned PMMC flap, based on the branching pattern of the pectoral branch of the thoracoacromial artery and the perforators of the pectoralis major muscle, to simultaneously reconstruct the defect and provide coverage for the carotid artery.

RESULTS

In 25 patients, the partitioned PMMC flap reconstructions resulted in complete wound healing without occurrence of carotid blowout syndrome or fistula formation. Minor complications as partial flap necrosis (7.7%) and strictures formation (7.7%) were recorded but did not compromise reconstruction. Twenty-two patients were able to adopt a semisolid diet, and 4 had recurrence of cancer.

CONCLUSIONS

The partitioned PMMC flap reconstruction represents a useful salvage solution to simultaneously restore the continuity of the alimentary tract and provide reliable coverage for the exposed carotid artery.

Functional Shoulder Outcome and Quality of Life Following Modified Muscle-Sparing Pectoralis Major Flap Surgery

BACKGROUND

The pedicled pectoralis major muscle flap (PMMF) is a well established flap for fistula prophylaxis after salvage laryngectomy. To reduce donor site morbidity, we established a modified muscle-sparing harvesting technique. We herein investigate postoperative shoulder function and health-related quality of life (HRQOL).

METHODS

A chart review of patients receiving the modified muscle-sparing pectoralis major muscle flap between 2013-2020 was performed. Nineteen patients (male = 18, female = 1) were potentially eligible and six male patients were ultimately enrolled. Postoperative shoulder function was assessed on both sides (flap side versus non-flap side) using the Constant Murley Score and the Bak criteria. Health-related quality of life was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire in cancer patients (EORTC QLQ-C30) and head and neck cancer patients (EORTC H&N35).

RESULTS

No Constant Murley Score subscale was statistically significant (p ≥ 0.180). Bak criteria was overall rated "Good". Solely upper extremity adduction force was significantly altered on the flap side (p = 0.039). Median EORTC QLQ-C30 score was 82.2 (IQR 11.1) on the functional scale and 10.3 (IQR 2.6) on the symptomatic scale. Median quality of life score was 75.0 (IQR 33.3) and median EORTC QLQ-H&N35 was 20.6 (IQR 9.8).

CONCLUSIONS

Postoperative shoulder function after modified muscle-sparing pectoralis major muscle flap surgery is comparable to function of the healthy side with a significant deficiency in adduction force not compromising daily life in this small study cohort.

Postoperative Complications Associated with the Choice of Reconstruction in Head and Neck Cancer: An Outcome Analysis of 4,712 Patients from the ACS-NSQIP Database

BACKGROUND

 Microsurgical free flaps have largely supplanted pedicled flaps as the gold standard for head and neck cancer reconstruction. However, incidence of postoperative complications after accounting for patient comorbidities based on choice of reconstruction has not been well-defined in the literature in recent years.

METHODS

 Patients undergoing head and neck reconstruction were identified in the 2011-2016 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database and stratified into groups by free flap, myocutaneous pedicled flap, and other reconstruction. Demographics were analyzed and covariates balanced using overlap propensity score-based weighting. Logistic regression was used for binary outcomes and Gamma generalized linear model was used for length of stay.

RESULTS

 A total of 4,712 patients met inclusion criteria out of which 1,297 patients (28%) underwent free flap, 208 patients (4%) pedicled flap, and 3,207 patients (68%) had other, or no reconstruction performed. After adjusting for patient and disease-specific factors, pedicled flap reconstruction was associated with a higher risk of deep vein thrombosis (odds ratio [OR] = 2.64, confidence interval [CI] 1.02-6.85, p = 0.045), sepsis (OR = 2.95, CI 1.52-5.71, p = 0.001), and infection (OR = 2.03, CI 1.39-2.96, p <0.001) compared with free flap reconstruction. Free flaps had the longest mean operative time compared with the other two groups (unadjusted 578 vs. 440 vs. 326, p <0.001). Pedicled flaps had a lower incidence of bleeding requiring transfusion (adjusted OR = 0.65, CI 0.50-0.85, p = 0.002), and lower incidence of prolonged mechanical ventilation (adjusted OR = 0.33, CI 0.12-0.92, p = 0.034) compared with free flaps. There was no difference in rates of reoperation, hospital readmission, or hospital length-of-stay between pedicled and free flaps.

CONCLUSION

 Myocutaneous pedicled flaps are associated with higher overall short-term postoperative complications compared with free flaps in head and neck reconstruction, which demonstrate a more favorable morbidity profile without significantly impacting hospital readmission, reoperation, or length-of-stay.

Use of Supraclavicular Flap by End to Side Technique in Pharyngeal SCC: A Case Report and Review of Literature

Objectives

In recent years, conservation laryngeal surgeries, including partial pharyngectomy, have been introduced as an alternative procedure for selected cases of hypopharyngeal squamous cell carcinoma (HSCC). Reconstruction of these defects presents a considerable challenge for the surgeon after partial pharyngectomy due to its circumferential nature. In this case report, we represent the innovative "End to side" technique to reconstruct hypopharyngeal defect using the rolled supraclavicular flap after laryngeal-preserving partial pharyngectomy.

Methods and Results

A 70-year-old female presented with a history of progressive dysphagia and odynophagia. The evaluations revealed a T3N0M0 SCC of pyriform sinus. The mass was successfully resected through partial pharyngectomy, and the hypopharyngeal defect reconstruction was achieved using the rolled supraclavicular flap via the "End to side" technique. The patient was discharged after decannulation on day 10. The 3-week barium swallow was performed with no evidence of anastomotic leakage, and the oral feeding was started after NG tube removal. At week 5, complete movement of the true vocal cord on the one side and good phonation and deglutition was observed. There was no evidence of recurrence after 1 year.

Conclusions

Laryngeal-preserving partial pharyngectomy and hypopharyngeal reconstruction with the rolled supraclavicular flap via the "End to side" technique could lead to good oncological and functional outcomes in selected cases of pyriform sinus.

Facial Gunshot Wound: Mandibular Fracture With Internal Fixation and a Pectoralis Myocutaneous Flap Coverage

Facial penetrating gunshot wounds (GSWs) are seen in an assault, suicide, and accidental injury. They often carry high mortality given the important anatomical structures located within the neck. The foundations of maxillofacial GSWs are rooted in data from military combat, specifically the last world war. This type of injury is complex for reconstructive surgery due to significant soft tissue and bone loss. Management of maxillofacial GSWs is often challenging and has trended from serial debridement, immediate reconstruction, local tissue flaps, and distant free flap transfers depending on bullet trajectory and wound intricacy.

We present a case of a 51-year-old male with a 22-caliber GSW to the left side of his face. Hemodynamics were stable on arrival and history included alcohol use. A left mandibular wound measured approximately 8 cm in diameter with exposed bone. A small 0.5-1 cm wound was also present inferiorly. A maxillofacial CT scan was utilized, showing a left mandibular body fracture.

The patient underwent exploration and debridement on the same day of injury. Open reduction with internal fixation of the left mandible fracture and Synthes 2.5 mm locking plate was done. Additionally, a left pectoralis major myocutaneous muscle flap was performed two days later.

Regional pectoralis flap reconstruction of facial firearm injury is scarcely acknowledged in the literature. Due to the location of the wound, the functionality of the jaw can be maintained in addition to ample blood supply by performing mandibular fixation and pectoralis major myocutaneous flap.

Taking a step down on the reconstruction ladder for head and neck reconstruction during the COVID-19 pandemic

Background

Most of the head and neck cancers are time-critical and need urgent surgical treatment. Our unit is one of the departments in the region, at the forefront in treating head and neck cancers in Pakistan. We have continued treating these patients in the COVID-19 pandemic with certain modified protocols. The objective of this study is to share our experience and approach towards head and neck reconstruction during the COVID-19 pandemic.

Results

There were a total of 31 patients, 20 (64.5%) were males and 11 (35.4%) patients were females. The mean age of patients was 52 years. Patients presented with different pathologies, i.e. Squamous cell carcinoma n = 26 (83.8%), mucoepidermoid carcinoma n = 2 (6.4%), adenoid cystic carcinoma n = 2 (6.4%) and mucormycosis n = 1 (3%). The reconstruction was done with loco-regional flaps like temporalis muscle flap n = 12 (38.7%), Pectoralis major myocutaneous flap n = 8 (25.8%), supraclavicular artery flap n = 10 (32.2%) and combination of fore-head, temporalis major and cheek rotation flaps n = 1 (3%). Defects involved different regions like maxilla n = 11 (35.4%), buccal mucosa n = 6 (19.3%), tongue with floor of mouth n = 6 (19.3%), mandible n = 4 (12.9%), parotid gland, mastoid n = 3 (9.6%) and combination of defects n = 1 (3%). Metal reconstruction plate was used in 3 (9.6%) patients with mandibular defects. All flaps survived, with the maximum follow-up of 8 months and minimum follow-up of 6 months.

Conclusion

Pedicled flaps are proving as the workhorse for head and neck reconstruction in unique global health crisis. Vigilant use of proper PPE and adherence to the ethical principles proves to be the only shield that will benefit patients, HCW and health system.

Renovating the Old Fashion: The "Functional Technique" for Harvesting Pectoralis Major Muscle Flap in Head and Neck Reconstruction

Although free flaps are widely recognized as a gold standard, pectoralis major muscle flap (PMMF) still remains a valuable workhorse in head and neck reconstruction. The technique we describe in the present paper allows to harvesting the PMMF with an accurate and complete isolation of the pedicle, sparing the superior sternum-acromion muscular fibers.

Analysis of the efficacy of the pectoralis major myocutaneous flap in reconstructive head and neck surgery

INTRODUCTION

Although free flaps have been used predominantly in past decades for the soft tissue reconstruction of head and neck malignancies, Pectoralis major myocutaneous flap (PMMF) is still a reliable workhorse for patients with co-existing co-morbidities or low economic status where free flaps are not feasible.

PATIENTS AND METHODS

It was a retrospective study done on 36 patients of head and neck malignancies over the period of 5 years in which PMMF was used as a method of reconstruction in our hospital. Patients were followed up for a period of one year and outcome of PMMF was evaluated.

RESULTS

Out of 36 patients 31 were of oral cancer and 5 were of carcinoma hypopharynx. Incidence of total flap necrosis was nil and partial flap necrosis was 16.6%. Orocutaneous fistula was found in 16.6%, wound dehiscence was in 19.4% and infection was found in 13.5% of patients. Non-flap related complications were found in 13.8% of patients. 35 out of 36 patients (97.2%) eventually achieved satisfactory surgical outcome of PMMF reconstruction.

CONCLUSION

PMMF is a reliable method of reconstruction for head and neck malignancies especially in basic healthcare settings. With minimal expertise and groundwork, it is still a cost-effective workhorse flap for head and neck reconstruction.

Postoperative outcomes of free myocutaneous flap and pedicled myocutaneous flap for reconstruction in locally invasive thyroid carcinoma

Locally invasive thyroid carcinoma (TC) often involves trachea. In such patients, the trachea needs to be reconstructed after surgery. We discuss the postoperative outcome and complications after trachea reconstruction by free myocutaneous flap (FMF) and pedicled myocutaneous flap (PMF).From January 2009 to September 2019, the clinical data of 38 patients with TC were retrospectively analyzed. Demographics, pathologic results, neoplasm staging, surgical protocol, decannulation, subjective speech function, and complications were documented.A total of 38 patients were analyzed (22 FMFs and 16 PMFs). Of the 38 patients, there is a similar rate of decannulation (81.8% in FMF and 75% in PMF), subjective speech function and complications.The FMF reconstruction and the PMF reconstruction have a similar result in terms of postoperative outcome and complications.

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

Oral cancer often presents at an advanced stage, requiring extensive resection and complex reconstruction, such as free tissue transfers, which may not be available in a remote or resource-constrained facility. The common alternative in these cases is the use of the workhorse flap, the pectoralis major myocutaneous (PMMC) flap for lining and a second regional flap for cover. The results are variable, increase operative time and cost, and may cause additional donor site morbidity.

We present a series of patients who underwent reconstruction for complex oral cavity and neck defects with a single PMMC flap with a unique design, folded or bipaddled to serve as both lining and cover. Pre- and post-operative data pertaining to patients with oral cancer who were selected to undergo bipaddled PMMC flap reconstruction in our unit between January 2017 and July 2019 were collected and analysed.

Of the 41 patients, 28 were males and 13 were females. The surgical resection involved full-thickness excision of primary tumour and involved skin (face or neck) for oral cancers. The size of skin paddle harvested ranged from 8 to 15 cm horizontally to 6 to 22 cm vertically. Usually, the distal part of the skin paddle formed the mucosal lining and the proximal formed the skin cover. Complication rates in the immediate postoperative period and on initial follow-up visits were comparable to a conventional PMMC flap.

Reconstruction of complex head and neck defects requiring mucosal lining and skin cover can be achieved with a single stage, bipaddled PMMC flap, a reliable and easily learnt alternative to technically demanding free tissue transfers. The complication rate observed in our series is remarkably low, even in females. With a proper design of the flap and appropriate orientation of the skin paddle, excellent results can be achieved with a bipaddled PMMC flap.

Colgajo de pectoral mayor para reconstrucción de defectos faríngeos. Descripción de un caso

Introducción: La fístula faringocutánea post-laringectomía total (LT) continúa siendo una complicación frecuente luego de esta intervención especialmente tras tratamiento radioterápico. Cuando fracasan las medidas conservadoras, es necesario recurrir a cirugía reconstructiva. En nuestro centro se utiliza el colgajo miocutáneo de pectoral mayor (CMPM), que asegura un flujo sanguíneo adecuado para el tratamiento fístulas post-irradiación. Descripción: Presentamos un paciente con una fístula faringocutánea tras LT que requirió una amplia reconstrucción mediante CMPM asimismo discutiremos el importante papel que juega el tratamiento con oxígeno hiperbárico en el manejo de las consecuencias post-radioterapia. Conclusión: En la era de la reconstrucción microvascular, el PMMC puede ser utilizado para la reconstrucción de grandes defectos de cabeza y cuello, consiguiendo una adecuada cobertura tras protocolos de preservación de órgano o pacientes con historia de enfermedad vascular.

Submental flap: Game changer in oral cancer reconstruction-A study of 1169 cases

BACKGROUND

Free-flap reconstructions (FFRs) are the standard-of-care following resections for oral cancer. This study assessed an alternative, the pedicled submental flap (SF) for its versatility, oncological outcomes, and comparative operative time and cost.

METHODS

This was a longitudinal prospective study of 1169 patients of oral cancer reconstructed with the SF. Oncological outcomes in terms of recurrence rate and disease-free survival (DFS), were analyzed in 730 cases with a minimum of 18 months follow-up. Surgical time and cost were compared between 20 SFs and 14 FFRs performed consecutively.

RESULTS

SF was used to reconstruct defects in the cheek (29.2%), mandible (41.6%), tongue (26.3%) and palate (2.7%) with a 94% flap survival. N+ at level 1 did not adversely affect the recurrence rate as compared with N+ at levels other than level 1 (27.52% vs 29.81%). SFs took a shorter time (186 minutes vs 474 minutes) and cost significantly less than FFRs (P < .0001).

CONCLUSIONS

SF can reconstruct various oral defects, is sturdy, and esthetically and functionally satisfactory. The procedure time is much shorter than for FFR and costs considerably less. With careful case selection and meticulous clearance, SF reconstruction is oncologically safe even in N+ neck.

The use of negative pressure wound therapy in the primary setting for high-risk head and neck surgery

BACKGROUND

In head and neck surgery, dead space is typically managed by transferring a secondary pedicled flap or harvesting a larger composite flap with a muscular component. We demonstrate the novel use of prophylactic negative pressure wound therapy (NPWT) to obliterate dead space and reduce possible communication between the upper aerodigestive tract and the contents of the neck.

METHODS

We present a single-institutional case series of five patients with high-risk head and neck cancer treated with NPWT after ablative and reconstructive surgery to eliminate dead space following surgical resection.

RESULTS

All patients achieved successful wound closure following NPWT, which was applied in the secondary setting to combat infection in one patient and the primary setting to prophylactically eliminate dead space in four patients.

CONCLUSION

NPWT can be used to treat unfilled dead space in the primary setting of head and neck ablative and reconstructive surgery and help to avoid wound healing problems as well as the need for secondary flap transfers.

A decade of reconstructive surgery: outcome and perspectives of free tissue transfer in the head and neck. Experience of a single center institution

PURPOSE

Free flaps have become the standard option in reconstructive surgery of the head and neck. Even though many authors have outlined the reliability of free transplants, there is an ongoing discussion about treatment options for patients bearing particular risks as previous irradiation treatment. In this analysis, we aim to address these patients with particular risk profiles by comparing different flap entity outcome parameters.

METHODS

We retrospectively analyzed a cohort of 494 patients who underwent flap surgery between 2009 and 2018 in our department. Focusing on free microvascular transplants, we additionally analyzed the pectoralis major myocutaneous flap as the most frequently used vascular pedicled flap. Data analysis was performed by uni- and multivariate statistics.

RESULTS

Overall flap success rate was 90%, with the radial forearm flap occurring to be most reliable (93%) in head and neck reconstruction. Previous radiation therapy (RT) and intraoperative revision of vascular anastomosis during primary surgery significantly resulted in impaired transplant outcome with a success rate of 91.8% (no RT) vs. 83.7% (RT), respectively. There was a negative linear correlation between incision to suture time and number of flaps per year (R² = 0.67).

CONCLUSIONS

Preoperative radiation therapy and intraoperative revision of anastomosis significantly impair outcome of microvascular flaps in the head and neck and oral cavity, whereas patient's age is not a predictor of flap failure. Increasing case number and experience reduces time of flap surgery as well as rate of complications and flap failure.

Choice of Regional Flaps for Oral Cancer Defects: Relevance in Current Era

Introduction

Microvascular free flaps (MVFF) are the current standard of care for reconstruction of oral ablative defects; however, pedicled myocutaneous flaps (PMCF) are still used widely in India. The rationale behind the preference for selecting PMCF in the present era is not well understood. The associated complications and swallowing outcomes are variable.

Methods

We retrospectively analysed the records of patients who underwent reconstructive surgery for oral cancer ablative defects over a 3-year period.

Results

Ninety-seven pedicled myocutaneous flaps [89 pectoralis major myocutaneous (PMMC) flaps, eight lower trapezius island myocutaneous (TMC) flaps] and 113 MVFFs were performed. The reasons for selecting PMCF were financial constraints 38.7%, MVFF salvage 22.5%, medically compromised 10.7%, vessel-depleted neck 6.4%, old age with PS2 + 5.3%, early recurrence 5.3%, borderline resectable 4.3%, palliative resection 2.1%. Overall complication rate was 20.4%. Of patients, 50.7% and 34.7% were on regular and semisolid diet, respectively; 66.6% had acceptable swallowing-related social well-being.

Conclusion

PMCFs have an important role in developing countries with patients having financial constraints. The other potential reasons driven by patient factors were discussed. The swallowing outcomes are good, with majority of the people having socially acceptable swallowing function.

The Pectoralis Major Island Flap: Short Scar Modified Muscle-Sparing Harvesting Technique Improves Aesthetic Outcome in Reconstructive Head and Neck Surgery

BACKGROUND

Pectoralis major flap reconstruction is often associated with large unappealing scars in head-neck surgery. We recently established an alternative harvesting technique that improves aesthetic outcome.

OBJECTIVES

The objective of this study was to demonstrate a modified surgical technique that harvests the pectoralis major muscle as an island flap and focuses on minimizing incision lines and applying a muscle-sparing approach.

METHODS

A retrospective analysis covering the period 2008-2018 was conducted. Patients who underwent pectoralis major island flap reconstruction for fistula prophylaxis after salvage laryngectomy at the Medical University of Innsbruck were included. Flap harvesting was performed subcutaneously using two small incision lines, thereby sparing the clavicular and upper sternocostal aspects of the pectoralis muscle.

RESULTS

Twenty-three patients with squamous cell carcinoma of the larynx (n = 19) or pharynx (n = 4) underwent salvage laryngectomy and consecutive reconstruction using a pectoralis major island flap and our muscle-sparing technique. Mean overall operation time was 147 ± 48.6 min. The majority (70%) of patients had an uneventful course of recovery and showed satisfying aesthetic results and low donor site morbidity as compared to traditional harvesting techniques. Six (26%) patients had major complications that required surgical revision. Three (13%) cases were complicated with fistulas.

CONCLUSION

The pectoralis major island flap is shown to be reliable in otolaryngeal surgery. This surgical technique minimizes scarring and preserves thoracic wall architecture by taking a less invasive approach, thereby improving aesthetic outcome and reducing overall patient morbidity.

Novel Technique to Increase the PMMC Flap Pedicle Length by Coplanar Rotation Along the Pedicle Axis

Pectoralis major myocutaneous flap (PMMC) continues to be a prime tool in the armamentarium for the reconstruction of head and neck malignancies even though free flaps have proved their versatility in functional and cosmetic outcomes. It still holds significance in both primary reconstruction and salvage procedures in head and neck malignancies. Inadequate infrastructure and resources make PMMC a preferred choice in many high-volume centres of developing countries. However, the length of the PMMC flap becomes a limiting factor for the distance that flap can be transferred when extensive reconstructions are being planned (Kudva et al. in J Maxillofac Oral Surg 14:481-483, 2015). We propose a modification in the conventional technique that maximises the length of the pedicle in orofacial reconstruction. Our technique allows the rotation of skin paddle along the longitudinal axis of the pedicle at the distal end along the same plane. This technique provides an easily reproducible and reliable technique that enables the surgeon to enhance the reach of the skin paddle and flexibility considerably.

Successful management of the supraclavicular artery island flap combined with a sternohyoid muscle flap for hypopharyngeal and laryngeal reconstruction

This retrospective study evaluated operative outcomes when using a supraclavicular artery island flap (SAIF) combined with a sternohyoid muscle flap (SHMF) to reconstruct defects after hypopharyngeal carcinoma resection. Reconstructive surgery for hypopharyngeal and laryngeal defects was performed with the SAIF + SHME combination in 6 patients during 2016 to 2018. Within 14 to 16 days after the surgery, all 6 patients could ingest food and block the tube (avoiding aspiration), with no pharyngeal fistulas. They then underwent irradiation up to a total of 60.5 Gy during the 4 weeks postoperatively. All 6 flaps survived, and there were no donor-site complications except minor dehiscence in 1 patient. Thus, the SAIF + SHMF combination can be used to reconstruct hypopharyngeal and laryngeal defects after hemi-laryngectomy in patients with hypopharyngeal carcinoma involving the unilateral larynx. This technique effectively preserved the swallowing function and phonation of the patients, thereby improving their quality of life.

Pectoralis major myocutaneous flap in salvage reconstruction following free flap failure in head and neck cancer surgery

Objective

This study aimed to compare the results of the pectoralis major myocutaneous (PMM) flap in primary and salvage head and neck cancer surgery.

Methods

A total of 160 patients were enrolled in this study. The salvage group consisted of 30 patients who received immediate PMM flap surgery following free flap failure. In the primary group, the PMM flap was primarily chosen for 130 patients. Related information was collected and analysed. The University of Washington (UW)-Quality of Life questionnaire, version 4, was mailed to every patient.

Results

Partial necrosis was significantly lower in the primary group (n = 13, 10.0%) than in the salvage group (n = 7, 23.3%). Surgical site infection was found in 10 (7.8%) patients in the primary group and in six (20.0%) patients in the salvage group. The mean composite quality of life scores were 66.8 ± 20.5 and 66.2 ± 22.1 in the two groups, respectively. Differences in scores for domains of activity, mood, and anxiety were significant. Disease-specific survival and recurrence-free survival rates were not different between the two groups.

Conclusion

PMM flap salvage reconstruction has a higher complication rate and poorer functional results, but similar survival prognosis, compared with primary surgery.

[Research progress of pedicled flaps for defect repair and reconstruction after head and neck tumor resection]

Objective

To summarize the current status of pedicled flaps for defect repair and reconstruction after head and neck tumor resection, and to present its application prospects.

Methods

Related literature was reviewed, and the role evolution of pedicled flaps in the reconstruction of head and neck defects were discussed. The advance, anatomical basis, indications, advantages, disadvantages, and modification of several frequently used pedicled flaps were summarized.

Results

The evolution of pedicled flaps application showed a resurgence trend in recent years. Some new pedicled flaps, e.g., submental artery island flap, supraclavicular artery island flap, submandibular gland flap, and facial artery musculomucosal flap, can acquire equivalent or even superior outcome to free flaps in certain cases. Technological modification of some traditional pedicled flaps, e.g., nasolabial flap, pectoralis major myocutaneous flap, latissimus dorsi musculocutaneous flap, temporalis myofascial flap, and temporoparietal fascial flap, can further broaden their indications. These traditional flaps still occupy an irreplaceable role, especially in patients with poor condition and institution with immature microsurgical techniques.

Conclusion

The pedicled flaps still plays an important role in head and neck reconstruction after tumor resection. In certain cases, they demonstrate some advantages over free flaps, e.g., more convenient harvest, more rapid recovery, less expenditure, and better functional and aesthetic effect.