Enhanced Morbidity of Pectoralis Major Myocutaneous Flap Used for Salvage after Previously Failed Oncological Treatment and Unsuccessful Reconstructive Head and Neck Surgery

Abstract

Introduction. The reconstruction of complex cervicofacial defects arising from surgical treatment for cancer is a real challenge for head and neck surgeons, especially in salvage reconstruction surgery and/or failed previous reconstruction. The pectoralis major myocutaneous flap (PMMF) has been widely used in these specific situations due to its reliability and low rate of failure or complications. Objectives. Identify factors that determine complications and influence the final outcome of the reconstructions with PMMF in salvage cancer surgery or in salvage reconstruction. Methods. A cross-sectional study design was used to evaluate a sample including 17 surgical patients treated over a period of ten years that met the inclusion criteria. Results. Reconstruction was successful in 13 cases (76.5%), with two cases of partial flap loss and no case of total loss. Complications occurred in 13 cases (76.5%) and were specifically related to the flap in nine instances (52.9%). An association was identified between the development of major complications and reconstruction of the hypopharynx (P = 0.013) as well as in patients submitted to surgery in association with radiation therapy as a previous cancer treatment (P = 0.002). The former condition is also associated with major reconstruction failure (P = 0.018). An even lower incidence of major complications was noted in patients under the age of 53 (P = 0.044). Conclusion. Older patients, with hypopharyngeal defects and submitted to previous surgery plus radiation therapy, presented a higher risk of complications and reconstruction failure with PMMF.

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

“…Several studies on PMMC flap have also correlated higher complication with age, sex, site of reconstruction, previous therapy, etc. Liu et al, 16 El-Marakby et al, 6 Pinto et al, 4 and Ribeiro Salles Vanni et al 14 have described the risk factors for flap-related complications as, advanced age, female patients, reconstruction of oral or hypo-pharyngeal defects, history of previous irradiation, salvage procedure, lower margin of skin island over chest, presence of co-morbidities, reconstruction in heavy tobacco users, etc. Leite et al 5 correlated risk of fistula formation to be associated with Hb level <13 g/dl, serum albumin <3.4 g/dl, and hypopharynx reconstruction.…”

“…6 In addition, there may be resultant malocclusion due to the weight of the flap. A review of relevant literature 4,6,[8][9][10][11][12][13][14][15] (Table 3) shows that the overall complication rates vary from low (4.7%) to very high (60%); however, total necrosis of PMMC flap is low in most of the studies. Several studies on PMMC flap have also correlated higher complication with age, sex, site of reconstruction, previous therapy, etc.…”

A perspective on the role of the pectoralis major flap in oral and maxillofacial oncology surgery

“…Unfortunately, the prognosis for recurrent disease is poor so free tissue transfer may not be appropriate. However, the PPM flap remains a versatile option, although complications are frequent at all sites (53–63%) or following surgery with radiotherapy. The rate of ‘successful reconstruction’ is variable (50–93%), but these studies have small sample sizes, multiple clinical variables, differing reconstruction and radiotherapy regimens, and variable outcome definitions.…”

Resection and reconstruction of giant cervical metastatic cancer using a pectoralis major muscular flap transfer: A prospective study of 16 patients

“…After completing a radical neck dissection, a suitable flap must be obtained for the reconstruction of the affected region. The pectoralis major myocutaneous flap includes a large quantity of tissue; thus, this flap can adequately repair defects in cervical tissue caused by radical neck dissection, and this flap may therefore be utilized for a complete reconstruction that addresses these defects (8)(9)(10). In addition, this flap has a rich blood supply, exhibits strong resistance to infection and necrosis, and heals rapidly.…”

“…Thus, the use of this flap does not delay post-operative chemoradiotherapy or raise concerns regarding the exposure of the carotid artery due to post-operative flap necrosis. Therefore, the flap meets the clinical requirements for the treatment of patients with cervical metastatic cancer involving an unknown primary tumor (8)(9)(10). The present study examined the feasibility and efficacy of radical neck dissection combined with reconstruction using the pectoralis major myocutaneous flap for the treatment of giant cervical metastatic cancers that have developed from unknown primary tumors and have invaded the skin.…”