Bipaddle Pectoralis Major Myocutaneous Flap (PMMC) for Complex Composite Oral Cavity Defects: An Experience of a Tertiary Cancer Centre

Although microvascular free flaps are considered the first choice in head and neck cancer defect reconstruction, their use is limited in developing regions by availability of resources and the expertise .The Bipaddle pectoralis major myocutaneous flap (PMMC flap) is a commonly used flap in head and neck cancer reconstruction, but in literature flap is associated with high incidence of drawbacks including donor site morbidity and added bulk of the flap reducing cosmetics and function. The purpose of the study is to evaluate the Bipaddle PMMC flap reliability, operative technique and outcome in reconstructive head and neck cancer surgery in the era of microvascular free flaps. Its a prospective study in which the records of 50 patients treated with Bippadle PMMC flap reconstruction between January 2022 to July 2022 were systematically collected and reviewed. Data of recipient site, serum albumin, history of adjuvant, recurrence, defect dimension, type of donor site closure, length of hospital stay, postoperative complications and outcomes were analysed. There were 45 males and 5 females with a mean age of 41 years (31-60). Bipaddle PMMC flap reconstruction was done in all patients of advanced squamous cell carcinoma of oral cavity. There were two males with complete necrosis of flap salvaged with latissimus dorsi flap and forehead flap. Minor infections were noted in two female and one male patient, managed conservatively and recovered well with acceptable final outcome. The Bipaddle PMMC flap is reliable for large defects in head and neck reconstructive surgery, particularly when a bulky flap is required to reconstruct composite defects where the lesion is involving the skin. Placing the flap horizontally with inclusion of nipple and areola in most of the patients increased the reach and size of available flap.

Has the Pectoralis Major flap Really Become Obsolete?

Aim

To evaluate the current role of pectoralis major (PM) flap including the reasons for selecting it over free flaps.

Materials and methods

All patients who underwent PM flap at Apollo Hospitals Ahmedabad during the 3-year period from January 2020 to December 2022 were included. Patient demographics, tumour characteristics and complications were studied and reasons for selecting pectoralis major flap were analyzed. Data was entered in Microsoft excel spreadsheet and analyzed using online statistical calculators. The p value of < 0.05 was considered statistically significant.

Results

57 patients underwent reconstruction with PM flap while 154 patients underwent free flap reconstruction. 54 were male and 3 were female. Median age was 51 years. PM flap was used for intraoral lining in 25 patients, and it was bilobed in 26 patients with full thickness cheek defect. Most common complication was wound infection seen in 10 patients. 5 patients developed marginal necrosis of the flap and 5 had donor site wound dehiscence. No complete flap loss was seen. During the same period, 15/154 (9.74%) patients with free flaps developed complete flap necrosis and this was statistically significant (p = 0.012). Reasons for choosing PM flap were also analyzed. 14 patients had major comorbidities, 18 had extensive disease, in 5 patients it was used for salvage post free flap failure, while 10 previously treated patients had unavailability of suitable vessels for anastomosis. 12 patients underwent PM flap due to financial constraints.

Conclusion

Thus, PM flap is not obsolete and continues to maintain its place in head and neck reconstruction.

Technical Considerations and Outcome Analysis of Using Extended Bipaddle Pectoralis Major Myocutaneous Flaps for Reconstructions of Large and Complex Oral Cavity Defects: Expanding the Horizons

Reconstruction of large and complex defects arising from resection of advanced oral cancers requires free flaps or multi-staged reconstructions using a combination of pedicled flaps. Bipaddle (pectoralis major myocutaneous (PMMC) flap is a good alternative for reconstruction of such defects, especially in low-middle-income countries (LMIC). However, care should be taken while expanding its limits to avoid unnecessary morbidity. We discuss technical considerations while extending the PMMC flap design beyond the usual boundaries and analyse surgical and quality of life (QOL) outcomes in our patients with large (≥ 10 cm) oral cavity defects while using extended bipaddle PMMC flaps. We retrospectively analysed the results of 72 oral cancer patients with large buccoalveolar defects with at least one dimension ≥ 10 cm who underwent single-stage reconstruction using extended bipaddle PMMC flaps between January 2018 and December 2019. Total flap loss was seen in one patient and partial loss in 10 (13.8%) patients, while 18 (25.1%) patients had major complications (Clavien-Dindo grade III). Discharge from hospital was delayed beyond a mean of 6 days in 15 (20.8%) patients and the start of adjuvant treatment was delayed in 5 patients (6.9%). On univariate analysis, age > 50 years, female gender, the largest dimension and flap area were significant factors increasing morbidity. The QOL outcomes were acceptable. The satisfactory results from our series reaffirm that extended bipaddle PMMC flaps are a viable alternate option for such reconstructive challenges in resource-limited centres. However, age, gender, the defect dimensions and flap area should be taken into consideration while using this flap.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-021-01345-1.

Nuts and bolts of PMMC flap in oral cancer and its clinical outcome in 168 indian patients: A retrospective analysis

Introduction

The gold standard for reconstruction is the microvascular free flaps, whereas pedicled flaps are generally employed as a rescue procedure. Pectoralis major myocutaneous flap (PMMC) flap being a reliable flap is associated with high rate of complication. So, the purpose of this study was to check and assess the predictability of PMMC Flap and its clinical outcome in 168 Indian patients.

Materials and method

We conducted a retrospective study of PMMC flap which was harvested in 168 Indian oral cancer patients in 3 years time span. Patients were kept on follow up for 1-3 years. Rate of complication were documented for flap necrosis and wound dehiscence; and patient related data like neck bulk acceptance and range of motion were recorded. Gender comparison of complications were also documented.

Results

The most common complication was wound dehiscence in 11 (6.5%) patients. Partial flap necrosis was observed in 3 (1.8%) female patients. There was no case of total flap necrosis. Questionare method was used for patients to record neck bulk acceptance. Range of motion was evaluated during follow up period. Follow up period of all the patients was 1-3 years.

Conclusion

PMMC flap is still a well founded 'workhorse' flap for reconstruction in head and neck cancer patients and can be used successfully with acceptable morbidity.

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.

PMMC Flap Revisited and its Clinical Outcome in 150 Patients

Introduction

Pectoralis myocutaneous flap remains the workhorse for the reconstruction of large defects in the head and neck region despite free flaps gaining popularity; because of its drawbacks such as long operating hours, high cost and special skill techniques, it is not used in most of the institutions. Even in our institution, free tissue transfers are carried out on a regular basis, but there is a definite scope and role for PMMC flap in reconstruction. We present our experience with pectoralis major myocutaneous flap in terms of postoperative complications, donor site morbidity, flap survival and long-term healing of the flap.

Materials and methods

In this study, 150 patients who underwent pectoralis myocutaneous flap reconstruction from 2008 to 2016 were analysed for postoperative complications like donor site morbidity, flap survival and long-term healing of the flap.

Results

On analysis of our data, it was found that the most common complication was wound dehiscence, which was seen in 25 patients(16%), followed by orocutaneous fistula in 15 (10%), wound infection and partial skin margin necrosis, which was seen in a maximum of 12 each(8%), hematoma in 5 (3%), and donor site wound dehiscence in 5 (3%), and there was no case of total flap failure or carotid blowout.

Discussion

We conclude that PMMC flap along with its modifications is the most cost-effective and associated with least complications.

Effectiveness of pectoralis major myocutaneous flap in the surgical management of oral cancer: A retrospective study

INTRODUCTION

Over 80,000 oral cancer cases get diagnosed each year in India, majority undergoing extensive resections owing to their late presentation. Pectoralis major myocutaneous (PMMC) flap is a pedicled axial pattern flap which is based on thoracoacromical artery. It is readily available as a viable alternative to free flap reconstruction, especially for the economically poor and malnourished patients. Its proximity to head and neck structures gives added advantage to reconstruct complex and large volume oral and maxillofacial defects. It provides a relatively good possibility of functional and aesthetic restoration providing both mucosal lining and skin cover.

MATERIALS AND METHODS

This was a prospective observational study of 29 PMMC flap reconstructions, conducted between 2013-2016. The reconstruction outcomes assessed in this study were divided into two categories namely "success" and "failure" based on certain functional parameters observed during follow-up of 1 year. The complications were broadly classified as major/minor and flap related/non-flap related. We assessed the feasibility of using a PMMC flap for reconstructing various subsites of oral cavity cancer. Further, the association of patient variables with complication rates and outcome of reconstruction were analysed.

RESULTS

Out of 29 patients overall complications were noted in 15 (51.7%) cases with a female preponderance. Flap-related complications were noted in 9 whereas non-flap-related complications were seen in 6 patients. Major and minor complications were noted in 2 (both flap related) and 13 cases respectively. Complete full thickness flap necrosis was not encountered in any patient. Patients with flap skin paddle size ≤ 36 cm² (n = 12) had significantly increased overall complication rates. Despite complications a high success rate (93.1%, n = 27) was achieved with this mode of reconstruction.

CONCLUSION

The PMMC flap reconstruction is a versatile, reliable and an affordable single staged procedure with a high success rate in terms of achieving treatment goals. Although it has moderately high complication rates, but PMMC flap proved to be a workhorse in locally advanced cases of head and neck cancer at the end of 1 year follow-up.

Reliability of the pectoralis major myocutaneous flap in reconstructive oral cancer surgery in developing countries: Our experience

BACKGROUND

Although free flaps are nowadays considered 'Gold standard' of head and neck reconstruction, pectoralis major myocutaneous (PMMC) flap is still popular among many reconstructive cancer surgeons in developing countries for its many advantages and also due to lack of resources for free flaps in most of the centers, large number of cancer patients with poor nutritional status and economic condition. However, many studies have reported high complication rate in PMMC flap. So, the purpose of our study was to evaluate the reliability of PMMC flap.

METHODS

Within a span of 2 years, 20 reconstructions were done with PMMC flaps in patients with oral cancer and they were followed for a period of 1 year. Documentation was done for patient demographics, site of lesion, duration for reconstruction, occurrence of complications, etc.

RESULT

Among 17 males and 3 female patients, complications developed in 4 males and all female patients (total 7 patients, overall 35%). Flap-related complications were - one major (5%) and six minor (30%), which were comprised of three orocutaneous fistula (15%), three partial flap loss (15%), two marginal necrosis (10%), and one donor site necrosis (5%). Total necrosis was nil in our study. All the complications were managed conservatively except the patient with major complication which required intervention. Final cosmetic and functional outcome was acceptable in majority of patients.

CONCLUSION

PMMC flap is still 'workhorse' of reconstruction in head neck cancer patients in developing countries and can be used effectively with acceptable morbidity.