Indications and Outcomes for Pedicled Pectoralis Major Myocutaneous Flaps at a Primary Microvascular Head and Neck Reconstructive Center

doi:10.4236/mps.2012.24025

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Modern Plastic Surgery, 2012, 2, 103-107

http://dx.doi.org/10.4236/mps.2012.24025 Published Online October 2012 (http://www.SciRP.org/journal/mps) 103

Indications and Outcomes for Pedicled Pectoralis Major

Myocutaneous Flaps at a Primary Microvascular

Head and Neck Reconstructive Center

Akira Saito1, Hidehiko Minakawa1, Noriko Saito2, Tatsumi Nagahashi3

1Division of Plastic and Reconstructive Surgery, Hokkaido Cancer Center, Sapporo, Japan; 2Department of Plastic and Reconstruc-

tive Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan; 3Division of Head and Neck Surgery, Hokkaido

Cancer Center, Sapporo, Japan.

Email: [email protected]

Received July 14th, 2012; revised August 16th, 2012; accepted September 17th, 2012

ABSTRACT

The pectoralis major musculocutaneous (PMMC) flap has been a useful technique for head and neck reconstruction

since its first description by Ariyan in 1979. How ever, techniques in microvascular surgery have since evolved and re-

cently free tissue transfer has played an important role in head and neck reconstruction. Although we use free flaps as

the first choice for head and neck reconstruction, similar to many other institutions, some patients at our hospital have

undergone reconstruction with PMMC flaps. We retrospectively analyzed the indications and outcomes of this recon-

structive technique from our experience with 12 patients. The medical records of all patients who underwent PMMC

flaps at Hokkaido Cancer Center from 2001 to 2010 were reviewed. Data concerning diagnosis, main indication, site of

reconstruction, previous treatment, and postoperative complications were analyzed. Of the 12 PMMC flap surgeries

performed, 3 were carried out as primary reconstructive procedures, whereas 9 were done as “salvage” procedures.

Flap-related complications were observed in 6 cases. Partial flap loss developed in 4 patients, although there were no

cases of total flap loss. There were 3 recurrent fistulae following reconstruction with PMMC flaps. The preoperative

goals of performing PMMC flap surgery were met in 83% of our cases. The authors conclude that while free flap trans-

fer is usually the first choice for head and neck reconstruction, PMMC flaps can produce acceptable results in certain

situations.

Keywords: Pectoralis Major Myocutaneous Flap; Head and Neck Reconstruction; Pedicled Flap; Pedicled Pectoralis

Major Myocutaneous Flap; Reconstruction, Microsurgery

1. Introduction

Since its first description by Ariyan in 1979 [1], pector-

alis major musculocutaneous (PMMC) flap surgery has

been a useful technique for head and neck reconstruction

[2-5], the advantages of which include robust size, versa-

tility, and determinate blood supply [6]. However, since

the early 1980s, techniques of microvascular surgery

have evolved and free tissue transfer has played an im-

portant role in reconstructive surgery for advanced head

and neck cancers [7].

There have been studies comparing the differences

between free flaps and pedicled myocutaneous flaps for

head and neck reconstruction which suggest that free

flaps are superior with regard to postoperative results and

cost effectiveness [8,9]. Currently, free tissue transfer is

the first choice for head and neck reconstruction at many

institutes [10].

However, free flap transfer cannot be used for all pa-

tients at every institute since it requires special tech-

niques and equipment for microsurgery, and it takes a

longer time to perform than does the pedicled myocuta-

neous flap. Although we usually use free flaps as the first

choice for head and neck reconstruction, some patients at

our institution have undergone reconstruction using

PMMC flaps. We retrospectively analyzed the indica-

tions and outcomes for this technique from our experi-

ence with 12 patients.

2. Methods

The medical records of all patients who underwent

PMMC flap surgery at Hokkaido Cancer Center from

2001 to 2010 were reviewed. Thirteen patients were

identified as having undergone a PMMC flap for head

and neck reconstruction, but 1 patient was excluded due

Indications and Outcomes for Pedicled Pectoralis Major Myocutaneous Flaps at a

Primary Microvascular Head and Neck Reconstructive Center

104

to a lack of adequate information. The medical charts of

the 12 participating patients were retrospectively re-

viewed for data regarding diagnosis, main indication, site

of reconstruction, previous treatment, and postoperative

complications. Major complications were defined as

those requiring revision surg eries, while minor complica-

tions required conservative wound care alone. Statistical

analyses were performed by Fisher’s exact probability

tests. A value of p < 0.05 was considered statistically

significant.

3. Results

Patient demographics and prior treatments are presented

in Table 1. There were 11 males and 1 female patient,

with a mean age of 66.3 years (range: 27 - 83 years).

The distribution of cases regarding site of reconstruc-

tion, indication for PMMC flaps, type of reconstruction,

and the requirement for skin grafts is shown in Table 2.

Of the 12 PMMC flaps, 3 were carried out as primary

reconstructive procedures, whereas 9 were done as “sal-

vage” procedures (5 for fistula, 2 for free flap failure, 1

for ablation of recurrent tumor after a free flap recon-

struction, and 1 for ablation of recurrent tumor after ra-

diation therapy). A titanium reconstruction plate was

used to restore mandibular con tinuity in conj unction with

Table 1. Patient and characteristics.

Characteristics n

Patients 12

Male 11

Female 1

Age, mean (range), years 66.3 (27 - 83)

Disease

Laryngeal cancer 4

Floor of mouth c a n ce r 3

Tongue cancer 2

Hypopharyngeal cancer 1

Esophageal cancer 1

Skin cancer 1

Prior treatment

Surgery only 3

Surgery + RT 4

Surgery + CCRT 2

CCRT 1

None 2

Table 2. Case distribution in relation to reconstructive sur-

gery.

Site of reconstruction n

Neck 6

Oral cavity 5

Cheek 1

Indication for PMMC flap

Repair of fistula 5

Pharyngocutaneous fistula 4

Gastric tube—skin fistula 1

Repair of defect following tumor ablation 5

Primary tumor 3

Recurrent tumor 2

Repair of total flap loss 2

Type of recon struction

PMMC flap 11

PMMC flap + reconstruction plate 1

Skin graft

Yes 4

Donor site 1

On the muscle 3

No 8

the PMMC flap.

Flap-related complications were observed in 6 cases

(50%) and are shown in Table 3. Major complications

were observed in 3 patients (25%) and minor complica-

tions were seen in 3 patients (25%). Partial flap loss de-

veloped in 4 patients, although there were no cases of

total flap loss. There were 3 recurrent fistulae following

reconstruction with PMMC flaps.

Data regarding comparisons between the occurrence of

complications and indications or previous treatments are

presented in Ta ble 4 . Among the 7 patients who received

prior radiotherapy, 5 (71%) developed complications,

whereas only 1 patient (20%) developed complications

among the 5 who did not receive pr i or radiot h erapy.

4. Discussion

Free flap transfers have become the first choice for head

and neck reconstruction surgeries at many institutions.

This procedure provides a one-stage restoration with sig-

nificantly lower morbidity and complication rate at donor

and recipient sites, and usually has better outcomes than

Indications and Outcomes for Pedicled Pectoralis Major Myocutaneous Flaps at a

Primary Microvascular Head and Neck Reconstructive Center 105

Table 3. Complications following reconstructive surgery

with PMMC flaps.

Complications n

Yes 6

Major complications 3

Minor complications 3

No 6

Detail of complications

Partial flap necrosis 4

Fistula 4

Wound dehiscence 1

Table 4. Comparisons between the presence of complication

and variables of interest.

Complication

Variables Yes No

Indication

Fistula 4 1

Others 2 5

Previous RT therapy

Yes 5 2

No 1 4

Previous surgery

Yes 5 4

No 1 2

alternative approaches [5,11]. At out institute, we also

use free flaps as the fi rst choice for head and ne ck recon-

struction, including free anterolateral thigh flaps, free

radial forearm flaps, free rectus abdominis flaps, and free

jejunum transfer. Nowadays, free flaps are more common

due to improved microsurgical techniques, while PMMC

flaps have lost much of their reputation for reconstruct-

tion of the head and neck region [12].

However, PMMC flaps still have a place in head and

neck reconstruction. This technique can be used as a sal-

vage procedure after necrosis of free flaps and in cases

where there are contraindications to free flaps, such as

medical conditions that make the patient unable to toler-

ate long surgical procedures or inadequate recipient ves-

sels for microanastomosis in the necks of patients who

previously underwent high-dose radiotherapy [5]. PMMC

flaps can also be performed in combination with free

flaps, usually for covering large defects, to protect neck

vessels in patients that are at risk for rupture, and to pre-

vent possible complications of wounds that have a high

risk of breakdown [13].

Schneider et al. have previously described the indica-

tions for PMMC flap surgery at a primary microvascular

head and neck reconstructive center. In their series o f 53

patients, PMMC flaps were used: 1) to salvage free flap

complications (38%), 2) with simultaneous free flap re-

construction for additional soft tissue filler in extensive

resections, or for cervical skin reconstruction (33%), and

3) for primary reconstructions, most frequently involving

compromised host status with a need for cervical skin

reconstruction and great vessel coverage after radical

neck dissection (29%) [14]. In our series, primary recon-

struction with PMMC flaps was performed on 3 patients

(25%), while the other 9 patients (75%) underwent “sal-

vage” reconstructions (i.e., reconstruction after free flap

failure, fistulas, and recurrent tumor ablation). Since 2 of

them were elderly and another suffered from malnutrition,

the 3 patients who underwent primary reconstruction

with PMMC flaps were considered unable to tolerate

long, invasive surgeries.

Flap-related complications developed in 6 (50%) of

the patients, with 3 experiencing major complications.

Thus, the results of our series were comparable to previ-

ous reports, since overall complication rates of PMMC

flaps have been reported to be quite high, ranging from

16% to 63% [5].

One of the main advantages of PMMC flaps is survival.

Even if performed by an experienced microsurgeon, total

flap loss can occur in free flap reconstructions. On the

other hand, total loss of PMMC flaps is rare, although

partial flap loss can occur [13]. In the cu rrent series, par-

tial flap necrosis occurred in 4 patients (33%), although

all flaps survived. We suppose that it might occur since

the skin paddle was designed more inferiorly beyond

vascular territories for the flap in some cases. Two pa-

tients required revision surgery with other flaps because

they developed fistulas following reconstruction with

PMMC flaps. In all other patients, reconstructions with

primary PMMC flaps were successful, with the recon-

struction success rate being 83%. These results are

slightly lower than success rates of other studies, which

ranged from 87.5% to 100% [13,15-17].

Previous reports have described the risk factors asso-

ciated with the development of flap complications, such

as age, sex, tumor location, site of reconstruction, prior

radiotherapy, and comorbidities, large tumor resections,

cigarette packs smoked, and salvage procedures [3,15,18,

19]. However, results were not similar in all series with

some reports describing that complication rates were not

associated with age, sex, smoking, preoperative radio-

therapy, diabetes, o r obesity [2,4,5,12].

Indications and Outcomes for Pedicled Pectoralis Major Myocutaneous Flaps at a

Primary Microvascular Head and Neck Reconstructive Center

106

In our series, 5 out of the 6 patients (83%) who devel-

oped complications had a history of preoperative radio-

therapy, while only 1 of 6 patients (17%) who did not

develop complications had undergone preoperative ra-

diotherapy. However, this difference was not statistically

significant.

Three out of 5 patients with fistula had recurrences af-

ter the reconstructive procedures, with 2 of them devel-

oping fistula recurrence following partial flap loss. Since

many cases with fistula have a prior history of radiation,

which delays healing, when the primary indication of the

procedure is to repair a fistula, special care should be

taken to safely elevate the flap in order to minimize ne-

crosis.

In conclusion, of 12 PMMC flap surgeries performed

at our institution, 3 were carried out as primary recon-

structive procedures, whereas 9 were done as “salvage”

procedures. Major complications were observed in 3 pa-

tients (25%), and minor complications were seen in 3

patients (25%). Partial flap loss developed in 4 patients

(33%), although there were no cases of total flap loss.

The preoperative goals of the flaps were met in 83% of

our cases.

5. Conclusion

The authors conclude that although free flap transfer is

most often the first choice for head and neck reconstruct-

tion, PMMC flaps can produce acceptable results in cer-

tain situations.

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