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Subclavicular pectoralis major myocutaneous flap for optimal reconstruction of large orbitozygomatic defects: a case report.

ABSTRACT: Since the introduction of microvascular free flaps, the pectoralis major myocutaneous flap (PMMF) has been relegated to background for most reconstructive surgeons. The objective of this article is to show the advantages of cervicofacial defects reconstruction with PMMF using the subclavicular plane route in a challenging clinical case. An 83-year-old man presented with cutaneous temporomalar lesion with orbital spread. Tumor resection was performed, including 12 × 11 cm skin and subcutaneous tissue, overlying zygomatic and malar bone, and orbital exenteration. Radical parotidectomy and functional neck dissection were performed. PMMF was chosen as reconstructive option routing the pedicle to the subclavicular plane. The length of the pedicle was 31 cm. The subclavicular route for PMMF increases the flap's length and arc of rotation compared with the conventional supraclavicular one. This procedure decreases the bulk of the PMMF pedicle which makes it functionally and cosmetically favorable. By using this modification, we may widen the "safe" reconstructive possibilities.

SUBMITTER: Pingarron L

PROVIDER: S-EPMC4130757 | biostudies-other | 2014 Sep

REPOSITORIES: biostudies-other

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Project description:BackgroundExtensive through-and-through oromandibular defects after advanced oral carcinoma excision pose a reconstructive challenge for the head and neck surgeon. These complex oromandibular wounds often involve the mandible, oral and/or aerodigestive mucosa, and the external skin. As a result, these defects are often not amenable to reconstruction with a single flap due to the volume of soft tissue needed and the three-dimensional reconstructive requirement. The use of two free flaps has often been suggested to overcome this reconstructive challenge. A simpler and less technically demanding way to deal with this may involve the use of a free flap in combination with a pedicled regional flap. We present our experience of the use of a simultaneous microvascular fibula free flap (FFF) with a pectoralis major myocutaneous flap (PMMC) for addressing these defects.MethodsA retrospective chart review was performed of patients treated with a FFF and PMMC combination for the reconstruction of oromandibular defects at the University of Mississippi Medical Center (Jackson, MS) between October 2013 and February 2016. A minimum follow-up of 12 months was required. Data collected included the extent and location of tumor involvement, size of the postablative defect, tumor histology, clinical and pathological staging, length of follow-up, functional outcomes, and associated complications.ResultsA total of three patients were identified to have been treated with the above technique. Defects repaired involved through-and-through mandibular defects with associated oral mucosa and external skin defects. In all cases, the FFF was used for restoring bony continuity with the skin paddle used to reconstruct the intraoral lining. The PMMC was used for reconstruction of the external skin defect and for providing soft tissue bulk. The average size of the fibula skin paddle used for intraoral reconstruction was 7.7 cm × 11.7 cm. The average size of the PMMC paddle was 7.3 × 9 cm. The mean follow-up was 21.7 months. Both the FFF and PMMC survived in all cases, although postoperative wound healing complications occurred in two of the three patients. There was one partial flap loss. Two patients regained good oral intake while one patient tolerated oral intake but was PEG tube-dependent.ConclusionsThe combination of pectoralis major myocutaneous flap and a vascularized free fibular flap is a viable option for the reconstruction of complex through-and-through oromandibular defects. This technique may be useful when a single microvascular free flap is not sufficient for reconstruction of such defects.

Project description:IntroductionA refractory cervical anastomotic fistula which postoperatively remains unhealed for more than 2 months under conservative care severely impacts the quality of life of the patient and potentially leads to anastomotic stricture after the fistula heals. It is widely accepted that, to avoid this complication, refractory cervical anastomotic fistulas should undergo more aggressive treatments. However, when and which surgical intervention should be considered is unclear.ObjectiveThis study was designed to evaluate the role of the pectoralis major myocutaneous flap in the management of refractory cervical anastomotic fistulas based on our experience of 6 cases and a literature review.MethodsSix patients diagnosed with refractory cervical anastomotic fistula after esophagectomy treated using pectoralis major myocutaneous flap transfer were included in the study. The clinical data, surgical details, and treatment outcome were retrospectively analyzed.ResultsAll patients survived the operations. One patient who had a circumferential anastomotic defect resulting from surgical exploration developed a mild fistula in the neo-anastomotic site in the 5th postoperative day, which healed after 7 days of conservative care. This patient developed an anastomotic stricture which was partially alleviated by an endoscopic anastomotic dilatation. All the other 5 patients had uneventful recoveries after operations and restored oral intake on the 10th-15th days after operation, and they tolerated normal diets without subsequent sequelae on follow-up. One patient developed both local and lung recurrence and died in 15 months after operation, while the other 5 patients survived with good tumor control during the follow-up of 25-53 months.ConclusionThe satisfactory treatment outcome in our study demonstrates that pectoralis major myocutaneous flap reconstruction is a reliable management modality for refractory cervical anastomotic fistulas after esophagectomy, particularly for those patients who experienced persistent fistulas after conservative wound care and repeated wound closures.

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Subclavicular pectoralis major myocutaneous flap for optimal reconstruction of large orbitozygomatic defects: a case report.

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