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ORIGINAL ARTICLE
Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 1291-1294  

The effectiveness of the bilobed pectoralis major myocutaneous flap at a tertiary care hospital: A retrospective analytical study


1 Department of Surgical Oncology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
2 Oral and Maxillofacial Surgery, Redmond, Washington, US
3 Department of OMFS, Narsinhbhai Patel Dental College and Hospital, Sankalchand Patel University, Visnagar, Gujarat, India
4 Department of Oral and Maxillofacial Surgery, College of Dental Sciences and Hospital, Bhavnagar, Gujarat, India
5 Malabar Dental College and Research Centre, Malappuram, Kerala, India
6 Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha, Saudi Arabia
7 Ministry of Health, Riyadh, Saudi Arabia

Date of Submission26-Feb-2021
Date of Decision12-Mar-2021
Date of Acceptance26-Mar-2021
Date of Web Publication10-Nov-2021

Correspondence Address:
Rohit Kumar Jha
Department of Surgical Oncology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpbs.jpbs_111_21

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   Abstract 


Background: Cosmetic defects after the major orofacial disease corrections may have an effect on the overall well-being of the patient. Head-and-neck cosmetic surgeries after a major episode of oral cancer impact the functional ability of the individual in several ways. In general, two types of flap are used in reconstructive surgery: microvascular free flaps and regional pedicle flaps. In socioeconomically poor countries like India, bilobed pectoralis major myocutaneous (PMMC) flap has been seen as a mainstay in facial reconstructive surgeries. Materials and Methods: The present study was conducted on 100 individuals with oral neoplasm who underwent resective surgery had a soft-tissue defect. All the complications that arose after reconstructive surgery were noted. Simple proportions were recorded. Results: Majority of the individuals had the buccal mucosa as the common site of oral neoplasm, and the tumor nodes and metastases staging was I + II. One individual sustained total flap necrosis. Wound infection and dehiscence were the most common complications. Conclusions: PMMC is best proven for flap reconstruction in oral neoplasm cases. It is established to be effective with good acceptability and very few complications. Due to these reasons, in spite of the known advances in facial reconstructive surgeries, this technique is widely followed in developing countries.

Keywords: Bilobed pectoralis major myocutaneous, complications, flap necrosis


How to cite this article:
Jha RK, Jami S, Tiwari RV, Purohit J, Vipindas A P, Ibrahim M, Binyahya FA. The effectiveness of the bilobed pectoralis major myocutaneous flap at a tertiary care hospital: A retrospective analytical study. J Pharm Bioall Sci 2021;13, Suppl S2:1291-4

How to cite this URL:
Jha RK, Jami S, Tiwari RV, Purohit J, Vipindas A P, Ibrahim M, Binyahya FA. The effectiveness of the bilobed pectoralis major myocutaneous flap at a tertiary care hospital: A retrospective analytical study. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Oct 2];13, Suppl S2:1291-4. Available from: https://www.jpbsonline.org/text.asp?2021/13/6/1291/329938




   Introduction Top


Oral cancer is a known burden worldwide, and in particular, due to late recognition in developing countries like India, reconstruction of the deficit in facial region is a challenge.[1] Cosmetic defects after the major orofacial disease corrections may have an effect on the overall well-being of the patient. Head-and-neck cosmetic surgeries after a major episode of oral cancer impact the functional ability of the individual in several ways.[2] In general, two types of flap are used in reconstructive surgery: microvascular free flaps and regional pedicle flaps. It is possible now with the global access to knowledge, improved clinical accessibility, and abilities of the maxillofacial surgeons in developing countries; the free flap has emerged as a preferred mode of operation and has remained a gold slandered. In these conditions, bilobed pectoralis major myocutaneous (PMMC) flap may be employed. These flap designs can be used in various procedures such as compromised patient status, failure of free flaps, or in combination with free flaps as soft-tissue filler.[3],[4] Reconstruction with free flaps in nonindustrial nation is troublesome because of significant expense, much time, infrastructure lapses, and trained manpower deficit. Flaps can be of two types myocutaneous flap (latissimus dorsi, pectoralis major, trapezius flaps) or fasciocutaneous flap (deltopectoral flap). Myocutaneous flaps have an advantage over the other designs as it is easy to learn. For this reason, it is employed in most of the reconstruction surgeries. In the study of Arlyan and Cuono, myocutaneous flaps, mainly pectoralis major, and its application were described.[1],[5] PMMC has the following advantages. Has adequate blood supply, preserves, and protects the major structures even when they have been compromised due to the irradiation or other medical conditions, viability is good,[1],[6],[7] There has been a vast range of the success and associated complications of the PMMC reported from the various studies.[8] The complications commonly seen in the other reconstruction techniques are also reported with this design, however, the rate is not uniform.[9],[10] Hence, in the present study, we aim to evaluate the reliability of PMMC flap in head-and-neck reconstruction. The technique, complications, and the functional as well as esthetic outcome of the flap utilization were evaluated.


   Materials and Methods Top


A retrospective analytic study was conducted among 100 individuals with cosmetic defects post tumor resection in the head-and-neck region. The individuals were selected only after the histopathological and radiographic confirmation of oral squamous cell carcinoma (SCC) was done and the stage was established. All the routine diagnostic tests were done. In the established participants, the wide local excision of the tumor (with 2 cm safety margin) with or without hemimandibulectomy with modified radical neck dissection was done and the bilobed PMMC flap was done for the reconstruction. Finally, the parameters such as the success and viability of the flap, functional restoration, and all the complications were noted. The patients who underwent chemoradiation were excluded from our study. Only the simple proportions for the site, stage, and complications were calculated.

Procedure

Demarcations

A line was drawn from the same side acromion to the xiphisternum for the vascular pedicle and alternative line vertically from the median of the clavicle to interconnect the first line.

Skin paddle design

The skin paddle was planned and set apart over the chest caudally-medially to the nipple with saving of the areola. The shape of the skin paddle coordinated the defect, principally elliptical, and it is situated over the pectoralis major muscle along the course of pectoral part of thoracoacromial artery. The distance between the highest point of the skin pedicle and inferior edge of the clavicle should equal to or surpass the distance between the receiving site for the flap and the inferior edge of the clavicle.

Skin paddle elevation

The skin is chiseled around the skin paddle, and the dissection is expanded onto the surface of pectoralis significant muscle. During flap rise, care was taken not to undermine the skin paddle, but instead to bevel it, in order to incorporate myocutaneous perforators.

The skin paddle was stitched to the hidden pectoralis muscle with a couple of stitches to limit the danger of shearing injury to myocutaneous perforators. The dissection plane between the pectoralis minor and pectoralis significant muscles with its vascular pedicle was found by line by dissecting the lateral border of pectoralis major muscle. Once in the plane, we could undoubtedly free the pectoralis major with its vascular pedicle from pectoralis minor muscle. The pectoralis major muscle was separated laterally to the pedicle while keeping the pedicle in view, along these lines liberating it from the humerus.

Skin tunnel over clavicle

A segment of the clavicular strands of the muscle was divided to accommodate just the neurovascular pedicle and its adventitia, disposing of the supraclavicular hump. The flap was presently passed into the neck through a subcutaneous passage made shallow to the clavicle. The passage was made wide enough to allow simple conveyance of the fold into the neck with no pressure.

Donor site defect closure

Stitching of the fold was made with 3-0 vicryl intruded on stitches. Drains were put in the neck and chest, and the injuries were shut in layers. The contributor site was constantly shut basically, which required extensive mobilization fasciocutaneous flaps.[11],[12]


   Results Top


Majority in our study were men followed by women. The mean age was observed 35 ± 12 years. With region of the presence of the lesion, the most common site observed was buccal mucosa (59%) followed by sulcus. The least common site was lower lip [Table 1]. With regard to the TNM stage of oral SCC, the stage that was seen in most of the participants was at the time of the reconstruction was Stages I + II (52%), nearly similar percentage of participants were seen at Stage III (42%), the least percentage was seen in Stage IV (6%) [Table 2]. The complications were noted in 69% of the participants. Overall good survival of the flap was observed in the present study. In only a single participant, total necrosis was seen (1%). Partial skin necrosis, orocutaneous fistula, and wound hematoma were the next least distributed complications (<10%). Wound infections and wound dehiscence were the major complications seen in the participants in our study. Spontaneous healing was observed in the minor dehiscence. Resuturing was done in the participants with larger dehiscence. No fatality was reported in the present study. Appropriate treatments were done for all the complications [Table 3]. Furthermore, in few participants, hair growing intraorally was observed. This was observed in male participants particularly. Other complications that are not related to the PMMC were also observed. They were pleural empyema, neck seroma, chyle leak, parotid leaks and fistula, and neck skin dehiscence. However, they were seen in very few patients (<10%). All these complications were thoroughly managed later.
Table 1: The site of oral squamous cell carcinoma distribution

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Table 2: Staging among the participants

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Table 3: Complications related to permanent magnet moving coil observed in the participants

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   Discussion Top


In developing countries like the USA, there has been a paradigm shift in reconstructive surgeries. However, in developing countries like India, PMMC flap designs are still practiced due to the less economic, time for the procedure, ease of learning, safe to the major structures passing near the surgical site, viability, and good functional and cosmetic results. PMMC flap design has been appreciated for the reliability in many studies as it is most commonly used to treat the cosmetic defects that arose from the tumor respective surgeries. This was also supported in the study done by Brusati et al., where they observed a lower complication and a greater survival rate.[13] There have been several variations suggested in the flap design. In the study of Ahmad et al., bipedicle PMMC flap was performed with a good success rate.[14] In our study similar to the above study, all the participants were treated with the bipedicle PMMC flap for the reconstruction of the defect. In our study, 69% of the participants had complications related to the flap. In the study conducted by Pinto, the complications after a PMMC flap were identified to be due to external compression to flap, injudicious use of the electrocautery, the general condition of the patient improper infection control, flap extended past the seventh rib, and longer pedicle.[15] Total necrosis was seen in 1% of the participants. Similar observations were seen in Mehrhof et al., where 4% flap necrosis was noticed.[16] In the study of Brusati et al., 2% were seen to have necrosis.[13] Our study was in unison with the above study. Along with the total flap necrosis, other complications such as partial necrosis, dehiscence, fistula, and infections were observed. Flap unrelated complications were noted in few. The noted complications were 69% which is in concurrence with the literature. Satisfactory outcome was observed in the present study, with the greater acceptability of the flap.


   Conclusions Top


PMMC is best proven for flap reconstruction in oral neoplasm cases. It is established to be effective with good acceptability and very few complications. Due to these reasons in spite of the known advances in facial reconstructive surgeries, this technique is widely followed in developing countries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Chaudhary R, Akhtar S, Bariar M. Use of pectoralis major myocutaneous flap for resurfacing the soft tissue defects of head and neck. J Orofac Sci 2014;68:93.  Back to cited text no. 1
    
2.
Vos JD, Burkey BB. Functional outcomes after free flap reconstruction of the upper aerodigestive tract. Curr Opin Otolaryngol Head Neck Surg 2004;12:305-10.  Back to cited text no. 2
    
3.
Saito A, Minakawa H, Saito N, Nagahashi T. Indications and outcomes for pedicled pectoralis major myocutaneous flaps at a primary microvascular head and neck reconstructive center. Mod Plast Surg 2012;2:103-7.  Back to cited text no. 3
    
4.
Vartanian JG, Carvalho AL, Carvalho SM, Mizobe L, Magrin J, Kowalski LP. Pectoralis major and other myofascial / myocutaneous flaps in head and neck cancer reconstruction: Experience with 437 cases at a single institution. Head Neck 2004;26:1018-23.  Back to cited text no. 4
    
5.
Arlyan S, Cuono B. Use of pectoralis major myocutaneous flap for reconstruction of large cervical, facial or cranial defects. Am J Surg 1980;140:503-6.  Back to cited text no. 5
    
6.
Schuller E. Pectoralis myocutaneous flap in head and neck cancer reconstruction. Arch Otolaryngol 1983;109:18-9.  Back to cited text no. 6
    
7.
Shank EC, Patow CA. The pectoralis major flap. Ear Nose Throat J 1992;71:161-5.  Back to cited text no. 7
    
8.
Castelli ML, Pecorari G, Succo G, Bena A, Andreis M, Sartoris A. Pectoralis major myocutaneous flap: Analysis of complications in difficult patients. Eur Arch Otorhinolaryngol 2001;258:542-5.  Back to cited text no. 8
    
9.
Wadwongtham W, Isipradit P, Supanakorn S. The pectoralis major myocutaneous flap: Applications and complications in head and neck reconstruction. J Med Assoc Thai 2004;87 Suppl 2:S95-9.  Back to cited text no. 9
    
10.
Koh KS, Eom JS, Kirk I, Kim SY, Nam S. Pectoralis major musculocutaneous flap in oropharyngeal reconstruction: Revisited. Plast Reconstr Surg 2006;118:1145-9.  Back to cited text no. 10
    
11.
Freeman JL, Walker EP, Wilson JS, Shaw HJ. The vascular anatomy of the pectoralis major myocutaneous flap. Br J Plast Surg 1981;34:3-10.  Back to cited text no. 11
    
12.
Tripathi M, Parshad S, Karwasra RK, Singh V. Pectoralis major myocutaneous flap in head and neck reconstruction: An experience in 100 consecutive cases. Natl J Maxillofac Surg 2015;6:37-41.  Back to cited text no. 12
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13.
Brusati R, Collini M, Bozzetti A, Chiapasco M, Galioto S. The pectoralis major myocutaneous flap. Experience in 100 consecutive cases. J Craniomaxillofac Surg 1988;16:35-9.  Back to cited text no. 13
    
14.
Ahmad QG, Navadgi S, Agarwal R, Kanhere H, Shetty KP, Prasad R. Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: A review of 47 cases. J Plast Reconstr Aesthet Surg 2006;59:166-73.  Back to cited text no. 14
    
15.
Pinto R. Pectoralis major myocutaneous flaps for head and neck reconstruction. Factors influencing occurences of complications and final outcomes. Sao Paulo Med J 2010;128:336-41.  Back to cited text no. 15
    
16.
Mehrhof AI Jr., Rosenstock A, Neifeld JP, Merritt WH, Theogaraj SD, Cohen IK. The pectoralis major myocutaneous flap in head and neck reconstruction. Analysis of complications. Am J Surg 1983;146:478-82.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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