Oral Cavity Reconstruction Using Pectoralis Major Muscle and Amnion

Abstract

The pectoralis major myocutaneous flap has become the mainstay of major oral cavity reconstruction. The flap pro¬ vides excellent soft-tissue bulk and cavity or surface lining for major defects. There is a high rate of primary take. However, the flap has some deficiencies. A group of patients were identified that are likely to have less than ideal results with the pec¬ toralis major myocutaneous flap tech¬ nique. In these cases, the flap has been modified and amnion has been added. Initial results indicate enhancement of reconstruction with the modified tech¬ nique. (Arch Otolaryngol 1985;111:230-233) Si nce its advent, the pectoralis major myocutaneous flap has become the mainstay of reconstruc¬ tive techniques in major defects of the oral cavity.1 The flap is an excellent method of obtaining soft-tissue bulk and oral lining for a one-stage reconWing, Toronto Western Hospital, Toronto, Cana¬ da M5T 2S8 (Dr Lawson). structive procedure. Use of the flap in oral cavity reconstruction is generally well accepted by patients because of the low rate of associated morbidity, and the excellent functional and cos¬ metic results. The flap is particularly useful in patients who have received a prior course of radical irradiation. It has the advantage of being harvested outside the therapeutic radiation field.As with any reconstructive tech¬ niques, there are trade-offs. The trade-offs with pectoralis major myo¬ cutaneous flaps, in oral cavity recon¬ struction, range from scarring and loss of bulk of the chest wall, to mal¬ position of the female breast, to weak¬ ness of the shoulder girdle, to hair growth and excessive bulk in the oral cavity. The excessive bulk is due to adipose tissue or breast parenchyma that is interposed between the cutane¬ ous and myogenous aspects of the flap. Usually the deficiencies with the pectoralis major myocutaneous flap reconstructive techniques can be reduced with secondary procedures such as debulking of the oral cavity or augmentation and repositioning of the female breast. The natural history of the cutaneous portion of the flap is such that the epithelium changes from keratinizing to nonkeratinizing epithelium resulting in a pseudomucous membrane consistency with time. This often results in a reduction of hair growth as well.The pectoralis major myocutaneous flap design is such that there is a very low rate of total flap necrosis. Howev¬ er, the rate of partial flap necrosis involving the cutaneous portion of the flap is probably in the order of 10% to 15%. Fortunately, the oral cavity has a propensity for healing by secondary intent. Accordingly, necrosis of the cutaneous component of the pectoralis major myocutaneous flap is usually not a major disaster in terms of wound dehiscence, salivary fistulization, or secondary exposure and rup¬ ture of major vessels. However, if a Fig 1.-Liquefactive necrosis of skin (NS) of pectoralis major myocutaneous flap placed in anterior aspect of mouth floor.

Cytokine expression and ultrastructural alterations in fresh-frozen, freeze-dried and γ-irradiated human amniotic membranes

“…First employed in skin transplantation by (Davis 1910), HAM was subsequently found to be useful as a biological wound dressing for burns (Ramakrishnan and Jayaraman 1997; Branski et al 2008), acute (Tekin et al 2008) and chronic wounds (Gajiwala and Lobo 2003; Insausti et al 2010), and in the reconstruction of the dura mater (Tomita et al 2012; De Weerd et al 2013), oral cavity (Lawson 1985), vaginal vault (Ashworth et al 1986), tendons (Ozbölük et al 2010) and nerves (O’Neill et al 2009). HAM has also long been used in ophthalmic surgery, the earliest reported application being in 1940 when De Rötth used fetal membranes to correct symblepharon (De Rötth 1940).…”

Preservation, sterilization and de-epithelialization of human amniotic membrane for use in ocular surface reconstruction

“…In 1910, Davis [1] was the first to use AM in skin transplantation. Subsequently, it has been widely used in management of burns [2,3]; as a surgical dressing [4,5]; surgical reconstruction of the oral cavity [6], bladder [7], and vagina [8,9]; occlusion of pericardium [10]; and in the prevention of surgical adhesions [11,12]. Although, as discussed below the inherent biological qualities in this membrane substrate have prompted its widespread and successful use, there are some limitations.…”

The Human Amniotic Membrane: A Tissue with Multifaceted Properties and Different Potential Clinical Applications

“…Successful results have been described for the reconstruction of composite orofacial defects [Lawson, 1985]. In human otolaryngology, AM has been applied unsuccessfully as a tympanic membrane graft, while positive results have been obtained by using this membrane to cover head and neck sites after flap necrosis [Zohar et al, 1987].…”