Mango-shaped Bi-paddled pectoralis major myocutaneous flap reconstruction for large full-thickness defects post resection of squamous cell carcinoma of oral cavity: An analysis of 232 cases

Abstract

Objectives: The objective of the study was to examine the feasibility of bi-paddled pectoralis major myocutaneous (PMMC) flap reconstruction in patient undergoing full thickness composite resection.

Materials and methods: Inclusion criteria: The subjects chosen were patients with clinically T4A squamous cell carcinoma of buccal mucosa, lower alveolus, and maxilla in with skin involvement. Patients required a full-thickness composite resection of intraoral lesion, bone (mandibular segment and/or maxilla), and overlying involved skin and had modified radical neck dissection. Exclusion criteria: Patients not requiring full thickness composite resection including skin. Patients were observed postoperatively for early and late postoperative complications, starting of oral feeding, post-operative trismus, and dysphagia during subsequent follow-up and cosmetic outcome.

Results: Overall, the complication rate was 33.8% out of which only 7.8% required major re-surgery with second flap reconstruction. This is comparable with other large series of PMMC flap. Clavien-Dindo Grade I complications were seen in 9.5%, Grade II in 69.7%, Grade IIIA in 13.4%, and Grade IIIB in 7.45% of patients. Full-thickness partial flap necrosis included necrosis of either the external or the internal skin paddle. There were 15 cases - 6.5% of full thickness external paddle necrosis. These were mostly in patients with bite composite resections and having a larger random fasciocutaneous distal component of the flap without underlying muscle. Furthermore, 40% of these patients were females. In females, the flap necrosis comprised 4 of the 12 patients (33.33%).

Conclusion: Pectoralis major mycocutaneous flap has been a boon to reconstruction of the oral cavity post its inception. In case of locally advanced squamous cell carcinomas of the oral cavity, in many instances, there is a clinically significant cervical lymph nodal spread vessels post mandating a comprehensive lymph node dissection. PMMC flap provides a robust well vascularized muscular cover to the cervical vessels poststernocleidomastoid excision.

Keywords: Bi-paddled pectoralis major myocutaneous flap; oral cavity; squamous cell carcinoma.

Figure 1

Pre operative photos of a patient having Squamous cell carcinoma of Right Gingivo-Buccal Sulcus from angle of mouth to Retromolar trigone region with overlying skin involvement (Post NACT 3 cycles). Note that patient is having trismus due to involvement of masticator spaces

Figure 2

Pre operative marking for Wide excision with Bite Composite Resection for the same patient shown in figure 1, Post resection defect following MRND and measurement of the defect size

Figure 3

Marking for Bi-paddled PMMC flap based on the perforators of pectoral branch of Thoracoacromial artery with preservation of nipple; the random pattern of the flap is marked with asterisk

Figure 4

PMMC flap marking preserving the blood supply for delto-pectoral flap, which can be utilized for secondary surgery if needed

Figure 5

Marking showing Bi –paddled PMMC flap to be harvested with marked central area that has to be de-epithelised before inset

Figure 6

Post operative photograph of patient showing Closure of Bi-paddled PMMC flap sutured to the defect with minimal tension

Figure 7

Primary closure of the donor site following harvest of Bi-paddled PMMC flap, Closure resembling the shape of tongue