Pedicled pectoralis major flap in head and neck reconstruction - our experience

INTRODUCTION

The pedicled pectoralis major flap (PPM) is usually considered as a second choice flap after free flaps and the reasons for their primary use varies. The most common indications for primary use of PPM are associated comorbities, extended radical neck dissection, neck vessel depletion for microvascular anastomosis and previous various malignancies ^(1–5). Another preferred choice is the use of PPM in combination with a free flap ^(6–8). Other indications for use of PPM are a salvage reconstruction following complications ⁽⁸⁾, a salvage reconstruction following free flap failure ⁽⁹⁾ and a salvage reconstruction in prevailing or recurrent primary disease ⁽¹⁰⁾. The PPM used for our cases includes all these indications.

MATERIALS AND METHODS

This was a retrospective study of 18 patients operated at the Department of Oral and Maxillofacial Surgery between 1^st January 2014 and 1^st December 2016. 18 patients underwent reconstruction using 18 PPM flaps. All procedures were performed by two surgeons in one stage reconstruction. Patient demographic data, indications for the procedure, site and extent of primary tumor, defect itself, clinical stage of malignant disease, postoperative complications and management of these postoperative complications related to the flap were recorded and analysed.

Complications were divided into major and minor complications according to the Chepeha classification ⁽¹¹⁾. Flap failures that required surgical intervention were classified as major complications. Failures, which did not require surgical intervention and were resolved conservatively by regular bandaging, incisions, excochleations, drainages, changes of compression and antibiotic therapy, were classified as minor complications. These included: partial flap necrosis, salivary gland fistula, partial flap dehiscence, wound infection, plate exposure, hematoma, seroma and other similar complications at the donor sites.

The pathological stage of the disease was based on preoperative evaluation of USG, CT and MRI results, according to current TMN classification.

Elevation of the flap was done using complete dissection of clavicular portion of pectoralis muscle from the flap and with denervation of the muscle. Photo documentation of patients (before, during and after the procedure) was taken.

RESULTS

All patients were males, average age 58.5 years (minimum 29 years, maximum 71 years and median 60.5 years). In terms of tumor type, all patients suffered from spinocellular carcinoma. In the case of patient no. 2, it was combined with chronic lymphacytic leukemia (Table 1). In terms of disease stage, there were 6 patients in stage II, 3 in stage III and 6 patients in stage IV of cancer. 15 reconstructions of oropharyngeal defects and 1 reconstruction of submandibular defect of the neck were performed using PPM. Indications for the procedure were:

• 10 cases of primary resection of polymorbid patient (all these patients were long-term smokers with a history of alcohol abuse and hepatic dysfunction).
• 5 cases in which the indication was disease recurrence after previous neck dissection and radiotherapy.
• 3 cases of secondary reconstruction due to osteonecrosis or absence of the mandible in irradiated area

Denervated PPM in all cases, 14 PPM with skin island, 3 PPM without skin island and 1 PPM with skin island and rib bone (osteomyocutaneous flap).

Surgeries were used for the reconstruction of the floor of the oral cavity, oropharynx, lateral side of the neck and in one case was PPM used for the treatment of osteomyelitis after complete radionecrosis of the mandible (see Table 1).

Complications occurred in 9 out of 18 patients (50.0 %). There were 5 major (27.8 %) and 4 minor complications (22.2 %).

Major complications included:

• 1 case of total flap failure (necrosis) due to technical error (5.5 %). This submandibular defect was successfully treated afterwards using the LDM flap transfer - free tissue transfer of latissimus dorsi myocutaneous flap).
• 2 cases of large dehiscence with plate exposure. These two cases were treated by secondary surgery with plate coverage using an ipsilateral supraclavicular flap (11.1 %).
• 1 case of large dehiscence was treated with secondary surgery (5.5 %).
• 1 case of large hemorrhage mainly to donor area in the thorax, accompanied by blood loss of about 600 ml with drop of hemoglobin level to 60 g/l. This case was a polymorbid patient with systemic morbidities and impaired coagulation cascade due to previous toxonutritive hepatopathy. During the successful surgical revision was diffuse bleeding stopped with QuikClot® devices impregnated with kaolin that were removed the next day after compensation of the blood loss.

Minor complications were only small dehiscences. These occurred in 4 cases (22,2 %), one of them was associated with fluidothorax after the rib harvesting (5,5 %). Repeated needle aspiration of pleural effusion was used to resolve this complication.

No case of muscle abundance on the neck or supraclavicular bulge was observed; the overall morbidity of donor site was very low and no orocutaneous fistula occurred.

The median duration of hospitalization was 15 days (minimum 6 days, maximum 28 days).

The rate of complications on the sample of 5 patients, who underwent radiotherapy before the surgery, was 80 %. There were 2 cases of small dehiscences and 2 cases of large dehiscence that required secondary surgical intervention as a transposition of a supraclavicular flap.

Postoperative folow up was 5 to 36 months. There were 6 deaths observed during the postoperative period (38%), none of them related to the surgery. Five were caused by recurrence and overall progression of the cancer and one pacient died due to heart failure.

In one case, metastasis was found after a period from the surgery, which was resolved by excision and coverage of the defect using a supraclavicular flap.

DISCUSSION

The overall incidence of complications in our small sample of patients was 50%, which can be considered as the mid-range of values referred from other groups of patients - Wilson et al. 16% ⁽¹²⁾, Milenovic et al. 33% ⁽¹³⁾, Liu et al. 35% ⁽⁶⁾, Vartanian 36.1% ⁽¹⁴⁾, Pinto et al 43.1% ⁽¹⁵⁾, Ijsselstein et al. 53% ⁽¹⁶⁾, Rudes et al. 59.3% ⁽¹⁷⁾, Kroll et al. 63% ⁽¹⁸⁾, and Shah et al. 63% ⁽¹⁹⁾. Total flap necrosis occurred in 6% of cases although the literature reports a flap failure from 2% to 3% ^(13,18,19). This fact may be due to the small sample. The microvascular free tissue transfer (free flap reconstruction) was used as a salvage operation as Tang et al. 2012 ⁽²⁰⁾.

The rate of minor and major complications contrasts with the literature ^{(5,6,9,13,19,21,22)} but like Vanni Salles Ribeiro et al., ⁽²³⁾ and Pinto et al. ⁽¹⁵⁾ probably due to the small sample size. Previous radiotherapy increased the incidence of postoperative complications as observed in other studies ^(24,25) and also deterioration in perception of quality of life ^(26).

All patients were males. The supraclavicular flap is the preferred option for women patients due to a higher risk of skin paddlefailure and subsequent deformity of the breast ⁽²⁷⁾. The mean duration of hospitalisation time was 14.7 as in other authors ^(4,21,28). During the elevation of the flap, we did not use surgical sparing of the field of elevation of deltopectoral flap. However, this can be used after harvesting of pedicled pectoral major flap ^(13,17,29). We used the supraclavicular flap instead, to achieve a better aesthetic result for the contours of the soft tissues on the head and neck ^(30–32).

Our team has always performed nerve transection ⁽¹³⁾ and we have never observed development of bulges or contracting folds in place of the vascular pedicle as it is often reported in the literature. Another factor that is fundamentally involved in any supraclavicular bulge is strict disconnection of the transferred muscle flap and rotation around the clavicle only on the vascular bundle ^(33,34). There was no neck deformity in our patients probably owing to the above.

In our sample, we did not use the dominance of the lateral thoracic artery. Kanno et al. reported ⁽³⁵⁾ that preservation of the lateral thoracic artery and use of the subclavian route are alternatives to ensure sufficient blood supply and an increased rotation arc of PPM. In our sample, we did not use the subclavian route.

There was no complaint of ipsilateral shoulder movement restriction or reduced functional capability. PPM flap reconstruction has a small but significant negative effect on upper extremity dysfunction and also neck ROM limitations ^(36–38). In general, we can say that patients who undergo primary reconstruction using PPM, often have significantly reduced working capacity, mainly due to preoperative polymorbidity.

Due to poor quality of rib bone, we refrain from mandible reconstruction using osteomyocutaneous PPM flap ⁽³⁹⁾. Another aspect that needs to be considered is the necessity of donor site closure using mesh, need for chest tube drainage due to distortion of pleural cavity and long term patient recovery ⁽⁴⁰⁾. Given these facts, we refrain from bone reconstruction and rarely use a reconstructive plate in the case of severely polymorbid patients ⁽³⁾. If possible, we prefer the reconstruction using fibular free flap even for “borderline” indicated patients whenever the condition of blood vessels that supply lower limb permits ⁽²⁾.

CONCLUSION

Even today, usage the PPM in head and neck reconstruction surgery cannot be considered as a historical reconstructive procedure that has been completely replaced by a free microvascular flap. Innovations of flap harvesting techniques and high rate of flap survival are the main reasons why PPM can still be primarily indicated for high-risk patients, non-cooperative patients and also for patients with extensive neck dissection. A combination of PPM and free flap can be advantageous for reconstruction of large complex defects. PPM has been the first choice in salvage surgery, in cases of a complication or free flap failure or a recurrence of a primary disease. In these cases, PPM morbidity remains comparable to morbidity in patients undergoing reconstruction using a free flap.

Acknowledgements: This research received no funding from public agencies, commercial, or not-for-profit sectors.

Conflict of interest statement: The authors state that there are no conflicts of interest regarding the publication of this article.

Corresponding author:

Richard Pink M.D., Ph.D.

Department of Oral and Maxillofacial Surgery, University Hospital

I. P. Pavlova 6, 779 00, Olomouc, Czech Republic

E-mail: richard.pink@seznam.cz