Abstract
The aim of this study was to evaluate factors affecting the selection of pectoralis major flap in the era of free tissue reconstruction for post ablative head and neck defects and flap associated complications. The records of patients who underwent various reconstructive procedures between July 2009 and December 2010 were retrospectively analysed. 147 reconstructive procedures including 79 free flaps and 58 pectoralis major flaps were performed. Pectoralis major flap was selected for reconstruction in 21 patients (36%) due to resource constrains, in 12 (20%) patients for associated medical comorbidities, in 11 (19%) undergoing extended/salvage neck dissections, and in 5 patients with vessel depleted neck and free flap failure salvage surgery. None of the flaps was lost, 41% of patients had flap related complications. Most complications were self-limiting and were managed conservatively. Data from this study suggest that pectoralis major flap is a reliable option for head and neck reconstruction and has a major role even in this era of free flaps. The selection of pectoralis major flap over free flap was influenced by patient factors in most cases. Resource constraints remain a major deciding factor in a developing country setting.
Since being described by Ariyan, pectoralis major (PM) flap has been used extensively for head and neck reconstruction. PM flap has multiple advantages including: easy accessibility in the same surgical field; technically simple with a small learning curve; robust and reliable vascular anatomy; and minimal requirement for specialized instruments and training. The disadvantages include: limited manoeuvrability and contouring problems; excessive bulk; restricted superior reach; marginal necrosis; unreliability of skin paddle in female patients; and delayed neck contracture. Owing to these disadvantages, the PM flap seems to have fallen out of favour. In the last two decades, with significant advances and wider availability of microvascular techniques, free flaps are preferred for head and neck reconstruction in most units. Consistent with this trend, the authors’ unit is also biased towards selecting free flaps, but the PM flap is an important resource in head and neck reconstruction. In this study, the authors evaluated reasons for selecting the PM flap over a free flap and considered PM flap related complications.
Patients and methods
Patients who underwent regional or free flap reconstruction of head and neck defects at the authors’ centre from July 2009 to December 2010 were identified using the patient database. All patients in whom post ablative defects were reconstructed with a PM flap and who had a minimum follow up of 3 months were included in this study. Patient charts were reviewed to determine the reasons for selecting PM flap for reconstruction. Details of patients and tumour characteristics, including complications if any, were studied.
Results
Patient characteristics are detailed in Table 1 . There were 38 male and 20 female patients, their median age was 55 years (range 30–85 years). 18 patients had recurrent/residual disease at presentation, whilst the remaining 40 were previously untreated. 51 patients underwent planned PM flap reconstruction, whilst in five patients PM flap was used for salvage reconstruction after an initial free flap failure and in two patients for closure of oro-cutaneous fistula. 31 patients with oral cavity cancer underwent PM flap reconstruction. The flap was used for intraoral lining in 13 patients, whilst in 18 patients with full thickness cheek defect, the flap was bipaddled and used for both intra oral lining and external skin cover ( Fig. 1 ). Four patients had oropharyngeal primary including two with post chemo radiation recurrence. All four patients underwent total laryngopharyngectomy with PM flap reconstruction. 15 patients underwent total laryngectomy and partial/circumferential pharyngectomy for laryngeal or hypopharyngeal primary. Eight patients were previously treated with curative intent chemo radiation or radiation. PM flap was used as a patch in six patients with partial pharyngeal defect, whilst in 5 patients with circumferential defect flap it was used as a tube to repair the defect ( Fig. 2 A and B). In four patients undergoing salvage laryngectomy, the pharynx was repaired primarily and the PM myofascial flap was used to cover the pharyngeal anastomosis. Six patients underwent extended neck dissection for a variety of reasons including: N3 node with unknown primary; and post chemo radiation residual neck disease. PM myocutaneous flap was used to cover the carotid artery and provide skin cover. In two patients with post radiotherapy oro-cutaneous fistula, PM myocutaneous flap was used to repair the fistula.
| Gender ( n = 58) | |
| Male | 38 |
| Female | 20 |
| Age ( n = 58) | |
| Mean | 55 years (range 30–85 years) |
| Disease status ( n = 58) | |
| Primary | 40 |
| Recurrent | 18 |
| Flap procedure ( n = 58) | |
| Primary | 51 |
| Salvage | 7 |
| Oral cavity ( n = 31) | |
| Subsites | |
| BM | 22 |
| Alveolus | 5 |
| Tongue | 4 |
| Lining only | 13 |
| Lining and external skin cover | 18 |
| Oropharynx ( n = 4) | |
| Larynx/hypopharynx ( n = 15) | |
| Tube | 5 |
| Patch | 6 |
| Cover | 4 |
| Neck skin cover ( n = 6) | 6 |
| Oro-cutaneous fistula ( n = 2) | 2 |
The authors analysed the flap related complications in these patients ( Table 2 ). None of the flaps was lost, although one patient developed partial necrosis of the skin paddle. Marginal flap necrosis and wound dehiscence were the common complications, seen in 10 patients. In eight of these patients, the wound dehiscence was minor, requiring conservative management and/or resuturing.
| Complete flap loss | Partial skin paddle loss | Peripheral wound dehiscence | Wound infection | Salivary fistula | Mandible exposure | Reconstruction plate exposure | Peri-operative mortality | Donor site morbidity/partial loss of skin graft | |
|---|---|---|---|---|---|---|---|---|---|
| Major | Minor | ||||||||
| 0 | 1 | 2 | 8 | 8 | 4 | 4 | 1 | 1 | 1 |
Two other patients developed major oro-nasal and oro-antral fistula, requiring additional procedures. 8 patients developed local wound infection, whilst in four patients the mandible was exposed. These complications were managed conservatively with change of antibiotics and local wound care. Four patients underwent plate with PM flap reconstruction of segmental mandibular defect. One patient developed infection and plate exposure requiring removal. Fifteen patients underwent pharyngeal repair with PM flap, 2 patients with patch PM flap repair and 2 patients with circumferential defects developed salivary leak. In all patients, salivary leak settled with conservative management. There were no donor site problems, except in one patient who had partial loss of skin graft. There was one perioperative mortality due to postoperative lower respiratory infection unrelated to the PM flap.
The authors analysed the reasons for choosing PM flap for the patients included in this series ( Table 3 ). Resource constrains remain a major factor in treatment selection in developing countries. Out of pocket expenditure is significantly higher for patients undergoing free flap reconstruction. In 21 patients, the post ablative defects ideally would have required a free flap reconstruction, but PM flap was chosen over free flap reconstruction due to non-availability of required financial support from the patients. 12 patients had major comorbidities such as uncontrolled diabetes, unstable ischemic heart disease, and chronic renal failure. These patients were deemed unfit for free flap reconstruction in the opinion of the treating physician. In 11 patients undergoing extended/salvage neck dissection with sacrifice of skin over the node, PM flap provided excellent cover for the carotid artery and skin for repair of the external skin defect. PM flap was used for reconstruction in five patients following free flap failure; these patients were not considered for a second free flap due to extensive infection and internal jugular vein thrombosis ( Fig. 2 C and D). Five previously treated patients were offered PM flap reconstruction due to unavailability of suitable vessels for anastomosis. In five patients undergoing salvage laryngectomy following chemo radiotherapy/radiotherapy, PM myofascial flap was used to cover the pharyngeal anastomosis.
| Resource constrains | Medically compromised | Extended neck dissections | Free flap salvage surgery | Vessel depleted neck | Post RT/CT pharyngeal repair |
|---|---|---|---|---|---|
| 21 | 12 | 11 | 5 | 5 | 4 |
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