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

Versatility of the myocutaneous pectoralis major flap in oncology reconstruction: A literature review and practical application

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.

Silicone Pectoral Implant to Solve Aesthetic Chest Deformity After Pectoralis Flap Harvesting for Laryngotracheal Reconstruction

BACKGROUND

 The pectoralis major musculocutaneous flap has been considered for decades the workhorse in head and neck reconstruction. However, the disadvantages of the pectoralis flap include the morbidity of the donor site in terms of cosmetic and functional results. A silicone pectoral implant  can be used to solve such aesthetic chest deformity in male patients.

METHODS

A 33-years-old man with a history of cervical tracheoesophageal fistula after a blunt trauma due to a motorcycle accident, previously reconstructed with a pectoralis major flap, consulted our Plastic Surgery Department for an aesthetic defect of the donor site . The use of an anatomical pectoral implant was planned with the aim of aesthetic reshaping of the male chest. A pocket was created following the preoperative design to position a 190 cc pectoral implant. Dissection was performed in a subcutaneous plane that included the underneath adipose tissue layer and then over the pectoralis minor and the serratus muscle. Three months later, in a second stage, lipofilling of the depressed areas was performed with 100 ml of adipose tissue obtained from the abdomen.

RESULTS

After two years of follow-up, the patient obtained a satisfactory aesthetic result, with an improvement in the projection of the thorax and the symmetry of the body contour. As the implant was placed into the subcutaneous pocket, no functional compromise in shoulder flexion or adduction was detected during follow-up.

CONCLUSIONS

 The pectoral implant technique seems safe and provides reshaping of the male chest wall, significantly improving the cosmetic appearance of the patient. In addition, its use with associated procedures such as lipofilling allows optimal results to be obtained. To the best of our knowledge, this is the first case to describe the use of a pectoral implant to solve donor site morbidity after pectoralis flap harvesting for any reconstructive purpose. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Meta-analysis of Complication Rates Among Various Surgical Modifications of Pectoralis Major Myocutaneous Flap

The purpose of this study is to aggregate and summarize the complication rates among various modified techniques of pectoralis major myocutaneous flap harvesting. Various databases were searched from its inception to September 2020. Studies describing surgical management of head and neck oncologic reconstruction using pectoralis major myocutaneous flap and its surgical modifications were included in study. All included studies: (1) described a pectoralis major flap harvesting technique categorized by author as conventional technique, bipaddle or bilobed flap, segmental flap, flap transfer using subclavicular route, skin paddle over Pectoralis Major, Flap with Multiple vascular supply, U shaped skin paddle, modified short incision technique; and (2) reported the number of postoperative complications in participants. Meta-analysis was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total 183 studies were included. Segmental flap (0.20%), flap with multiple vascular supply (5.18%) and parasternal skin flap (6.38%) had the highest rates of total complications and were the only techniques to show a statistically significant increase in odds ratio compared with conventional technique (odds ratio 1.89, 9.05 and 7.26, respectively, P < 0.05). Bipaddle flap (57.48%) and u shaped skin flap (78.05%) show statistically significant decrease in odds ratio as compared to conventional technique. Among all the modifications in surgical technique of pectoralis major myocutaneous flap harvesting bipaddle flap and u shaped skin flap show least total complication rates. But on the contrary rates of partial flap necrosis and fistula are significantly higher in bipaddle flap as compared to conventional technique. As such, the choice of surgical technique should primarily be made based on the defect size, patient selection and surgeons' discretion rather than the presumed complication rate.

Hypopharyngeal reconstruction using prelaminated autologous bio-engineered pectoralis major flaps

After removal of metastatic malignant tumors of the hypopharynx and larynx, hypopharyngeal defects are formed. To restore the hypopharynx, a mucosa and a muscular component are needed.

The objective of this study is to develop a hypopharyngeal reconstruction technique using prelaminated pectoralis major flap with mucosal epithelium analogue from autologous epithelial layers.

Materials and methods. Nine patients underwent reconstruction of the hypopharynx using bioengineered prelaminated pectoralis major flaps. The mucosa was restored by tissue-engineered autologous epithelial cell layers that were obtained by culturing in vitro cells isolated from skin biopsies that were previously obtained from patients.

Results. Oral nutrition was restored in all cases. Pharyngeal stenosis was detected in one (11%) patient. A stratified squamous epithelium on the pectoral fascia was revealed in 67% of cases at week 2 after prelamination, in 89% of cases at week 4 after reconstruction and in 100% of cases at month 3, 6, 12 and 24 after reconstruction.

Conclusion. Reconstruction using prelaminated bioengineered flaps allows recreating the anatomical integrity and function of the hypopharynx.

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.

Efficacy of A Novel Smart Polymeric Nanodrug in the Treatment of Experimental Wounds in Rats

High-quality and aesthetic wound healing, as well as effective medical support of this process, continue to be relevant. This study aims to evaluate the medical efficacy of a novel smart polymeric nanodrug (SPN) on the rate and mechanism of wound healing in experimental animals. The study was carried out in male Wistar rats (aged 8-9 months). In these animals, identical square wounds down to the fascia were made in non-sterile conditions on the back on both sides of the vertebra. SPN was used for the treatment of one wound, and the other wound was left without treatment (control group). Biocompatible citrate-stabilized cerium oxide nanoparticles integrated into a polysaccharide hydrogel matrix containing natural and synthetic polysaccharide polymers (pectin, alginate, chitosan, agar-agar, water-soluble cellulose derivatives) were used as the therapeutic agent. Changes in the wound sizes (area, volume) over time and wound temperature were assessed on Days 0, 1, 3, 5, 7, and 14. Histological examination of the wounds was performed on Days 3, 7, and 14. The study showed that the use of SPN accelerated wound healing in comparison with control wounds by inhibiting the inflammatory response, which was measured by a decreased number of white blood cells in SPN-treated wounds. It also accelerated the development of fibroblasts, with an early onset of new collagen synthesis, which eventually led to the formation of more tender postoperative scars. Thus, the study demonstrated that the use of SPN for the treatment of wounds was effective and promising.