Head and Neck Reconstruction by Using Extended Pectoralis Major Myocutaneous Flap

Abstract

Background Pectoralis major flaps have been the workhorse in head and neck region reconstructions till date. However, pectoralis major flaps have disadvantages, including limitations regarding flap range and less stable blood flow than that in free flaps. Here, we report on the safe reconstruction to the oral cavity and neck area by using extended pectoralis major flaps. These flaps include both the normal vessels that feed pectoralis major flaps (the thoracoacromial artery and vein) and the lateral thoracic artery and vein to stabilize blood flow and expand flap survival area caudally.

Methods Eight patients who had undergone reconstruction with extended pectoralis major flaps after the resection of head and neck cancers from June 2009 to March 2013. In all cases, the pectoralis major flap was elevated with a vascular pedicle comprising the thoracoacromial artery and vein and the lateral thoracic artery and vein.

Results No blood circulation disorders, such as ischemia or congestion, were observed after the flaps were elevated and moved to the resected areas. All flaps were sutured on without difficulty. The area the flaps were harvested from was closed in a single stage. No postoperative complications such as hematoma, abscess, or fistula were observed.

Conclusion Extended pectoralis major flaps have a wide range and more stable blood flow, so they are thought to be useful in situations in which free flaps cannot be used for a variety of reasons.

Keywords

pectoralis major myocutaneous flap - thoracoacromial vessels - lateral thoracic vessels

• References

• 1 Hueston JT, McConchie IH. A compound pectoral flap. Aust N Z J Surg 1968; 38 (1) 61-63
• 2 Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979; 63 (1) 73-81
• 3 Ariyan S. Further experiences with the pectoralis major myocutaneous flap for the immediate repair of defects from excisions of head and neck cancers. Plast Reconstr Surg 1979; 64 (5) 605-612
• 4 Aycock JK, Stenson KM, Gottlieb LJ. The thoracoacromial trunk: alternative recipient vessels in reoperative head and neck reconstructive microsurgery. Plast Reconstr Surg 2008; 121 (1) 88-94
• 5 Onoda S, Sakuraba M, Asano T , et al. Thoracoacromial vessels as recipients for head and neck reconstruction and cause of vascular complications. Microsurgery 2011; 31 (8) 628-631
• 6 Harris JR, Lueg E, Genden E, Urken ML. The thoracoacromial/cephalic vascular system for microvascular anastomoses in the vessel-depleted neck. Arch Otolaryngol Head Neck Surg 2002; 128 (3) 319-323
• 7 Dolan R, Gooey J, Cho YJ, Fuleihan N. Microvascular access in the multiply operated neck: thoracodorsal transposition. Laryngoscope 1996; 106 (11) 1436-1437
• 8 Kompatscher P, Manestar M, Schuster A, Lang A, Beer GM. The thoracoacromial vessels as recipient vessels in microsurgery and supermicrosurgery: an anatomical and sonographic study. Plast Reconstr Surg 2005; 115 (1) 77-83
• 9 Hallock GG. The total pectoralis major muscle myocutaneous free flap. J Reconstr Microsurg 2013; 29 (7) 461-464
• 10 Teo KG, Rozen WM, Acosta R. The pectoralis major myocutaneous flap. J Reconstr Microsurg 2013; 29 (7) 449-456
• 11 Li Z, Cui J, Zhang YX , et al. Versatility of the thoracoacromial artery perforator flap in head and neck reconstruction. J Reconstr Microsurg 2014; 30 (7) 497-503
• 12 Rikimaru H, Kiyokawa K, Inoue Y, Tai Y. Three-dimensional anatomical vascular distribution in the pectoralis major myocutaneous flap. Plast Reconstr Surg 2005; 115 (5) 1342-1352 , discussion 1353–1354
• 13 Kiyokawa K, Tai Y, Tanabe HY , et al. A method that preserves circulation during preparation of the pectoralis major myocutaneous flap in head and neck reconstruction. Plast Reconstr Surg 1998; 102 (7) 2336-2345
• 14 Rikimaru H, Kiyokawa K, Watanabe K, Koga N, Nishi Y, Sakamoto A. New method of preparing a pectoralis major myocutaneous flap with a skin paddle that includes the third intercostal perforating branch of the internal thoracic artery. Plast Reconstr Surg 2009; 123 (4) 1220-1228
• 15 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40 (2) 113-141
• 16 Taylor GI, Minabe T. The angiosomes of the mammals and other vertebrates. Plast Reconstr Surg 1992; 89 (2) 181-215
• 17 Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998; 102 (3) 599-616 , discussion 617–618
• 18 Taylor GI. The angiosomes of the body and their supply to perforator flaps. Clin Plast Surg 2003; 30 (3) 331-342 , v
• 19 Suami H, Taylor GI, Pan WR. Angiosome territories of the nerves of the lower limbs. Plast Reconstr Surg 2003; 112 (7) 1790-1798
• 20 Nakajima H, Maruyama Y, Koda E. The definition of vascular skin territories with prostaglandin E1—the anterior chest, abdomen and thigh-inguinal region. Br J Plast Surg 1981; 34 (3) 258-263
• 21 Maruyama Y, Nakajima H, Fujino T, Koda E. The definition of cutaneous vascular territories over the back using selective angiography and the intra-arterial injection of prostaglandin E1: some observations on the use of the lower trapezius myocutaneous flap. Br J Plast Surg 1981; 34 (2) 157-161
• 22 Kiyokawa K, Tai Y, Inoue Y , et al. Reliable, minimally invasive oromandibular reconstruction using metal plate rolled with pectoralis major myocutaneous flap. J Craniofac Surg 2001; 12 (4) 326-336
• 23 Kadlub N, Shin JH, Ross DA , et al. Use of the external pectoralis myocutaneous major flap in anterior skull base reconstruction. Int J Oral Maxillofac Surg 2013; 42 (4) 453-457
• 24 Espitalier F, Ferron C, Leux C , et al. Results after U-shaped pectoralis major myocutaneous flapreconstruction of circumferential pharyngeal defects. Laryngoscope 2012; 122 (12) 2677-2682
• 25 Burke MS, Kaplan SE, Kaplowitz LJ , et al. Pectoralis major myocutaneous flap for reconstruction of circumferential pharyngeal defects. Ann Plast Surg 2013; 71 (6) 649-651
• 26 Chang SH, Tung KY, Hsiao HT, Chen CH, Liu HK. Combined free vascularized iliac osteocutaneous flap and pedicled pectoralis major myocutaneous flap for reconstruction of anterior chest wall full-thickness defect. Ann Thorac Surg 2011; 91 (2) 586-588
• 27 He J, Xu X, Chen M , et al. Novel method to repair tracheal defect by pectoralis major myocutaneous flap. Ann Thorac Surg 2009; 88 (1) 288-291
• 28 Kerawala CJ, Sun J, Zhang ZY, Guoyu Z. The pectoralis major myocutaneous flap: Is the subclavicular route safe?. Head Neck 2001; 23 (10) 879-884
• 29 Vanni CM, Pinto FR, de Matos LL, de Matos MG, Kanda JL. The subclavicular versus the supraclavicular route for pectoralis major myocutaneous flap: a cadaveric anatomic study. Eur Arch Otorhinolaryngol 2010; 267 (7) 1141-1146