The folded, bipaddled pectoralis major myocutaneous flap for complex oral cavity defects: Undiminished relevance in the era of free flaps

Abstract

Oral cancer often presents at an advanced stage, requiring extensive resection and complex reconstruction, such as free tissue transfers, which may not be available in a remote or resource-constrained facility. The common alternative in these cases is the use of the workhorse flap, the pectoralis major myocutaneous (PMMC) flap for lining and a second regional flap for cover. The results are variable, increase operative time and cost, and may cause additional donor site morbidity. We present a series of patients who underwent reconstruction for complex oral cavity and neck defects with a single PMMC flap with a unique design, folded or bipaddled to serve as both lining and cover. Pre- and post-operative data pertaining to patients with oral cancer who were selected to undergo bipaddled PMMC flap reconstruction in our unit between January 2017 and July 2019 were collected and analysed. Of the 41 patients, 28 were males and 13 were females. The surgical resection involved full-thickness excision of primary tumour and involved skin (face or neck) for oral cancers. The size of skin paddle harvested ranged from 8 to 15 cm horizontally to 6 to 22 cm vertically. Usually, the distal part of the skin paddle formed the mucosal lining and the proximal formed the skin cover. Complication rates in the immediate postoperative period and on initial follow-up visits were comparable to a conventional PMMC flap. Reconstruction of complex head and neck defects requiring mucosal lining and skin cover can be achieved with a single stage, bipaddled PMMC flap, a reliable and easily learnt alternative to technically demanding free tissue transfers. The complication rate observed in our series is remarkably low, even in females. With a proper design of the flap and appropriate orientation of the skin paddle, excellent results can be achieved with a bipaddled PMMC flap.

Keywords: Bipaddled pectoralis major myocutaneous flap; Folded pectoralis major myocutaneous flap; Head and neck cancer; Head and neck reconstruction; Pedicled flaps.

Fig. 1

Pre-operative photograph of the lesion in a patient with recurrent carcinoma left buccal mucosa planned for salvage surgery (A). Intraoperative photograph post-resection (B), demonstrating the challenges of reconstructing an extensive and composite defect.

Fig. 2

Skin paddle designed like a “boomerang” or “banana” within a laterally facing “C” marked on the pectoral region.

Fig. 3

Illustration showing the flap design (A) and orientation of flap for inset (B and C). Distal skin paddle (D) coloured in green and proximal skin paddle (P) in blue; areas de-epithelialized before inset coloured grey with cross-hatching.

Fig. 4

Immediate post-operative photograph of the same patient shown in Fig. 2. Closure of large defects at the donor site is possible without the need for skin grafts, with the “boomerang”-shaped skin paddle design.

Fig. 5

Sacrifice of the nipple-areolar complex is avoided during flap harvest and the “C”-shaped donor-site closure allows for the symmetry of the chest, as seen in this patient 6 months after surgery.

Fig. 6

Bipaddled osteomyocutaneous flap used for reconstruction of an anterior segmental mandibulectomy defect.

Fig. 7

Long-term outcome, the same patient shown in Fig. 5, at one year of follow-up after completion of adjuvant radiation, showing good oral competence and jaw contour.

Fig. 8

Inset of upper and lower lips onto de-epithelialized portions of the flap, to recreate the oral commissure. Overcorrection of the neocommissure ensures symmetry of lips post-operatively, despite sagging of the flap.

Fig. 9

Tension-free inset of a large bipaddled flap in a female patient minimizes the risk of congestion and flap loss. Bulk of the folded flap can counteract the mandibular deviation following hemimandibulectomy.

Fig. 10

Immediate post-operative result (A) and long-term result after 11 months of completion of adjuvant therapy (B).