Pectoralis Major Flap Research Articles

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.

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.

A better way to prevent surgical complications after laryngectomy

Introduction: 1. Understanding the implications of post-operative vomiting on the rate of salivary leak amongst patients undergoing laryngectomy. 2. Developing a better way to prevent post-operative vomiting through creation of a departmental policy to minimise risk of vomiting. Methods: We carried out a retrospective study of 24 patients who underwent primary or salvage laryngectomies. A Microsoft Excel sheet data containing the age, sex, smoking status, medical comorbidities, laryngectomy type, reconstructive method and the complications were all recorded. vomiting and the antiemetics particularly in the initial 48 hour period was documented. Results: 19 were male and 5 were female . Age varied from 51-86 and 14 of these patients were smokers. 8 patients had radiotherapy and this was within the 3 year period prior to laryngectomy in all patients. 16 patients had primary and 8 underwent salvage. Reconstructive methods included pectoralis major regional flap in 10 and ALT free flap in 6 patients. 8 patients had direct closure. 4 patients who developed a salivary leak had the post-op vomiting in the first 48 hours contrasting with 7 of the 18 who didn’t have the salivary leak but had post-operative vomiting.The average length of stay amongst those receiving regular anti-emetics was 16 days compared to thenon anti emeticgroup of 23 days. Conclusions: Standardisation of the post-operative anti-emetic protocol would likely reduce the risk of post-operative vomiting with the aim to reduce the rate of salivary leak. We are developing a policy of the prescription of anti-emetics on regular side of drug chart for all laryngectomy patients. Introduction: 1. Understanding the implications of post-operative vomiting on the rate of salivary leak amongst patients undergoing laryngectomy. 2. Developing a better way to prevent post-operative vomiting through creation of a departmental policy to minimise risk of vomiting. Methods: We carried out a retrospective study of 24 patients who underwent primary or salvage laryngectomies. A Microsoft Excel sheet data containing the age, sex, smoking status, medical comorbidities, laryngectomy type, reconstructive method and the complications were all recorded. vomiting and the antiemetics particularly in the initial 48 hour period was documented. Results: 19 were male and 5 were female . Age varied from 51-86 and 14 of these patients were smokers. 8 patients had radiotherapy and this was within the 3 year period prior to laryngectomy in all patients. 16 patients had primary and 8 underwent salvage. Reconstructive methods included pectoralis major regional flap in 10 and ALT free flap in 6 patients. 8 patients had direct closure. 4 patients who developed a salivary leak had the post-op vomiting in the first 48 hours contrasting with 7 of the 18 who didn’t have the salivary leak but had post-operative vomiting.The average length of stay amongst those receiving regular anti-emetics was 16 days compared to thenon anti emeticgroup of 23 days. Conclusions: Standardisation of the post-operative anti-emetic protocol would likely reduce the risk of post-operative vomiting with the aim to reduce the rate of salivary leak. We are developing a policy of the prescription of anti-emetics on regular side of drug chart for all laryngectomy patients.

Pedicled Forehead Flap for Reconstruction of Cheek Defect: A Novel Surgical Case Report

Oral cancers are considered slow killer disease. Every year 3,00,000 cases are diagnosed worldwide. Public awareness has been a great challenge to educate people to avoid harmful oral habits to prevent oral cancer. People are not aware about life threatening complications such as death due to oral cancer. Oral cancer is the eighth most common malignancy in India and third most common malignancy in South East Asia. Buccal mucosa carcinoma spreads rapidly and invades deeply to underlying tissues and has high recurrence rate. Surgical resection is more challenging if the tumour invade adjacent anatomical structures and reconstruction should be planned according to extent of tumour resection. Regional flaps are used for oral cavity after tumour resection such as radial forearm flap, deltopectoral flap, pectoralis major flap, latissimus dorsi flap, transverse rectus abdominis myocutaneous flap, trapezius flap. In this case report folded forehead pedicle flap was used to provide both inner and outer linings of the cheek defect following buccal mucosa tumour resection.

Exophytic and Fungating Papillary Thyroid Carcinoma: A Rare and Complex Presentation of a Well-differentiated Malignancy

Papillary thyroid carcinoma is the most common well-differentiated thyroid malignancy accounting for more than 80 to 90% of all thyroid tumors. It has an overall excellent prognosis owing to advances in screening via imaging and ultrasound-guided fine-needle aspiration biopsy, which have facilitated early detection, diagnosis, and surgical treatment followed by adjuvant radioactive iodine therapy. Exceptionally rare cases of papillary thyroid tumors may present with enormous growth due to delayed consultation and, thus, late diagnosis, posing a challenge to definitive management, quality of life, overall survival, and prognosis. We report a case of a 35-year-old woman who presented with a 4-year history of a bleeding exophytic and fungating anterior neck mass. Computed tomography showed a fungating mass arising from the left thyroid lobe that measured 14.1 x 14.0 x 11.1 cm with areas of necrosis and hemorrhage, left internal jugular vein thrombus formation, and compression of the left internal carotid artery. The mass causes a displacement of the trachea to the right side and multiple bilateral cervical lymphadenopathies. The patient was fully aware, and she consented to undergo wide excision, total thyroidectomy, neck dissection, and pectoralis major muscle flap reconstruction. However, she went into arrest intraoperatively attributed to massive pulmonary embolism. Papillary thyroid cancer is well known for its excellent prognosis. However, outcomes may not be favorable and can even be fatal in advanced and extensive cases. Although fungating papillary cancers are rare, they remain more common in the developing countries, where early detection and access to healthcare remains limited. They also represent a big challenge to surgeons. Even if the outcome was not good, we opted to report this case as there were many learning points. If only patients with good and excellent outcomes are reported in the literature, it will overestimate the treatment success of these complex cases.

Oncologic surgical resection with intravascular covered stent placement in patients with carotid artery encased by metastatic cancer-Our experience with 5 patients.

Importance Tumor encasement of the common carotid artery (CCA) and/or the internal carotid artery (ICA) in patients with advanced head and neck tumors represents a significant surgical challenge. At present, there are few reports on the treatment approach that can achieve the maximal oncological resection and reduce the difficulty of operation without affecting the carotid artery blood flow. Objective To examine whether the combination of oncologic complete tumor resection and intravascular covered stent placement is more advantageous in the management of advanced head and neck cancer. Design, setting, and participants Five patients with advanced head and neck squamous cell carcinoma (AHNSCC) invading one side of the carotid artery were retrospectively enrolled. The contrast-enhanced computed Tomography (CT) and angiography were performed to assess the severity of extrinsic tumor compression to the carotid artery. Covered stent was placed intra-arterially at least 1 cm proximal and distal beyond the area of tumor involvement. The tumor and the involved carotid artery were resected, and pectoralis major flap transfer was utilized for coverage of the great vessels supported with intra-arterial covered stent. Main outcomes and measures Efficacy of oncologic complete tumor resection combined with endovascular stent placement. Results The post-stenting demonstrated an improvement in the appearance and caliber of the affected carotid artery. Four patients experienced transient bradycardia and hypotension. All five patients underwent R0 resection. Postoperatively, the flap all had rich vascularity and healing. Three patients underwent adjuvant radiotherapy or chemoradiation. With median follow-up 6.5 months, one patient died of multiple organ failures at 6.5 months after surgery; one patient developed tracheal stoma recurrence and treated with salvaged surgery; the three other patients had no disease recurrence in their last follow-ups. Conclusions and relevance Surgical resection with intravascular covered stent placement could potentially achieve the maximal oncological resection without compromise carotid artery blood flow in patients with carotid artery encased head and neck cancer.

SURGICAL MANAGEMENT OF ORAL CANCER WITH PRIMARY RECONSTRUCTION

Introduction: Primary tumours of oral cavity may be derived from the mucosa, salivary glands,bone or dental tissues. Over 90% of tumours of the oral cavity are squamous cell carcinomas.1,9 Reconstructive surgery following resection for oral cancer is considered when there is functional or aesthetic loss of structures in the oral cavity. Although primary closure can be achieved within oral cavity,the larger the defect,the more is the functional compromise.The majority of soft tissue repair within the oral cavity require three – dimensional reconstruction with soft pliable skin often without significant bulk. Aims : To study the proportion of oral cancer with surgical management with primary flap reconstruction.To analyse the different surgical modalities of treatment and its outcome.Materials And Methods: This study was carried out in a tertiary care hospital in Central India, from March 2020 to August 2021. Out of 136 patients diagnosed with oral cancer, 61 (44.85%) were found to be operable. 75 (55.15%) patients were inoperable, unfit or not willing for surgery.They were assessed,evaluated and managed accordingly. Results:Oral cancer was most commonly noted in fourth decade.The most involved site was alveobuccal complex.Flap reconstruction was required in 62.3% (38 out of 61) of the patients.Out of 38 patients,Pectoralis major musculocutaneous flap only was the most common flap reconstruction accounting for 19 out of 38 patients and in combination with Deltopectoral flap in 3 patients.Conclusion: Though free flap reconstruction has emerged as a good option in primary reconstruction with increased functional repair, strict post operative monitoring was needed as complications were more frequently encountered in those cases.

Ultra Sound Guided Erector Spinae Plane Block for Perioperative Analgesia in Post Coronary Artery Bypass Grafting Sternal Dehiscence (Type 2b) Patient Posted for Pectoralis Major Flap

Sternal dehiscence is a grave complication after cardiac surgery. Deep sternal dehiscence usually requires debridement and flap coverage as the mainstay of management. The perioperative period is considered very challenging and the anesthetic technique has a direct impact on the risk of perioperative complications. Perioperative pain management is usually carried out with the help of regional anesthetic techniques as they offer various benefits for this patient population, including the provision of high-quality analgesia, reduced requirements for opioids and nonsteroidal anti-inflammatory drugs, and reduced autonomic system activation. Conventionally, regional anesthesia techniques such as epidural and paravertebral blocks have been shown to provide effective analgesia and enhance postoperative recovery. However, these techniques were associated with minimal but unacceptable complications. Ultrasound-guided erector spinae plane (ESP) block is a recently described technique providing thoracic analgesia. This is the first case report to our knowledge, which describes the use of ESP block as perioperative analgesic technique for pectoralis flap in a high-risk cardiovascular patient.

Reconstruction of Complex Lateral Skull Base Defects After Oral Cancer Resection With Individualized Anterolateral Thigh Flap.

ObjectivesComplex lateral skull base defects resulting from advanced or recurrent oral cancer resection are continuously challenging reconstructive surgeons. This study aimed to use reconstructive methods for lateral skull base defects, explore their feasibility, and evaluate the efficacy of defect reconstruction using anterolateral thigh (ALT) flaps.Patients and MethodsWe performed a retrospective case series of 37 patients who underwent lateral skull base defect reconstruction using the ALT/anteromedial thigh (AMT) flap between March 2016 and May 2021 at the Second Xiangya Hospital. The design and harvest of the flaps, methods for defect reconstruction, and reconstructive efficacy are described.ResultsOf the 37 patients, 3 were women and 34 were men, with a mean age of 51.7 years. Among the defects, 26 were through-and-through defects and were reconstructed using ALT chimeric flaps, double ALT flaps, folded ALT flap, combined ALT chimeric flaps and AMT flaps, or combined ALT chimeric flaps and pectoralis major flaps; the large lateral skull base dead spaces were filled with muscle tissues or fatty tissues. Postoperatively, 38 of the 39 ALT/AMT flaps survived completely, and the remaining flap experienced partial necrosis. Venous compromise occurred in one patient who was salvaged after operative exploration. Oral and maxillofacial wound infections occurred in two patients, salivary fistula in three patients, and thigh wound effusion in three patients. The wounds healed gradually in all patients after repeated dressing changes. Thirty-three patients were followed up for approximately 3–60 months; their oral functions and appearance were acceptable, and thigh motor dysfunction was not observed.ConclusionsWith the convenient flap design and muscle flap harvest, large and individualized tissue supply, feasible combination with other flaps, effective reduction or avoidance of wound complications, and acceptable donor site morbidity, the ALT flap is an appropriate choice for complex lateral skull base defect reconstruction.

746 EXPERIENCE IN RECONSTRUCTION OF LARYNGOPHARYNGOESOPHAGECTOMIES IN A THIRD LEVEL CENTER

Abstract Pharyngoesophageal reconstruction after laryngo-pharyngo-esophagectomy, due to malignant or benign causes, is challenging due to its high morbidity and mortality. There are different reconstructive flaps: visceral flaps (pedicle stomach and colon flaps and free jejunum or colon grafts) and myocutaneous flaps (pedicle local flaps, such as the pectoralis major flap, or free grafts, such as the anterolateral thigh-ALT). The objective is to evaluate the morbidity and mortality and functional results of the reconstruction after laryngo-pharyngo-esophagectomy. Methods This is a retrospective study of patients who underwent laryngo-pharyngo-esophagectomy in our center, due to a benign cause (ingestion of caustic) or malignant (cancer of the larynx, pharynx, parathyroid and cervical esophagus) with circumferential pharyngeal reconstruction with flap, from 2008 to November 2020. Demographic variables, neoadjuvant treatment, procedure performed and flap used for reconstruction, complications related to reconstruction (fistula, stenosis, necrosis), postoperative complications, days until adequate swallowing, functional result of the flap, hospital stay, recurrence and mortality were collected. Results Twelve patients, with a median age of 59 years (45–78), underwent surgery, 1 case due to benign cause and 11 cases with an oncological diagnosis. There were complications related to the reconstruction in 42% of the patients (see table 1). Postoperative morbidity was 67% (75% Clavien-Dindo ≥ III). The median hospital stay was 21 days (16–94). The median time to swallowing was 13 days (3–73). An optimal functional result (oral intake) was achieved in 75% (only 3 patients with poor results). The median follow-up was 18 months (4–56), with a survival rate of 50%. 30-days mortality was 8% (1 case). Conclusion Our study shows a high morbidity and mortality after circumferential pharyngeal reconstruction, similar to literature published. We have observed a higher rate of reconstruction related complications (fistulas and stenosis) and worse functional results in reconstructions performed with gastroplasty and coloplasty after total laryngo-pharyngo-esophagectomy, compared to less aggressive local resections (laryngopharyngeal) with ALT free flap reconstruction.

Decreasing complications of pectoralis major muscle flap reconstruction with two modalities of negative pressure wound therapy.

Deep sternal wound infection is a feared complication of open-heart surgery. Negative pressure wound therapy has gained an important role in the treatment of deep sternal wound infection. Incisional negative pressure wound therapy has been introduced as a method to prevent wound complications after sternotomy, and lately, after flap reconstructions in the treatment of deep sternal wound infection. We aimed to study if incisional negative pressure wound therapy with PICO™ had similar beneficial effect described earlier with competing commercial devices. This study included 82 patients treated with pectoralis major muscle flap for deep sternal wound infection during the years 2006-2020. PICO group consisted of 24 patients treated with preoperative negative pressure wound therapy and postoperative incisional negative pressure wound therapy (PICO™). Two control groups included 48 patients with conventional treatment and 10 patients with preoperative negative pressure wound therapy only. In the PICO group, the complication rate declined from 50.0% to 33.30%, major complication rate from 29.2% to 12.5%, and need for an additional flap from 14.6.% to 4.2% when compared to conventional treatment. The length of hospital stay decreased as well. Preoperative negative pressure wound therapy alone was associated with moderate decline in the complication rates. In addition, we described the use of split pectoralis major muscle flap reconstruction in 57 patients. To our knowledge, this is the largest published patient series describing this method in the treatment of deep sternal wound infection. Incisional negative pressure wound therapy with PICO™ seems beneficial after flap reconstruction. Split pectoralis major muscle flap is a versatile reconstruction option suitable to be used as a workhorse in the treatment of deep sternal wound infection.

Functional Shoulder Outcome and Quality of Life Following Modified Muscle-Sparing Pectoralis Major Flap Surgery.

Background: The pedicled pectoralis major muscle flap (PMMF) is a well established flap for fistula prophylaxis after salvage laryngectomy. To reduce donor site morbidity, we established a modified muscle-sparing harvesting technique. We herein investigate postoperative shoulder function and health-related quality of life (HRQOL). Methods: A chart review of patients receiving the modified muscle-sparing pectoralis major muscle flap between 2013–2020 was performed. Nineteen patients (male = 18, female = 1) were potentially eligible and six male patients were ultimately enrolled. Postoperative shoulder function was assessed on both sides (flap side versus non-flap side) using the Constant Murley Score and the Bak criteria. Health-related quality of life was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire in cancer patients (EORTC QLQ-C30) and head and neck cancer patients (EORTC H&N35). Results: No Constant Murley Score subscale was statistically significant (p ≥ 0.180). Bak criteria was overall rated “Good“. Solely upper extremity adduction force was significantly altered on the flap side (p = 0.039). Median EORTC QLQ-C30 score was 82.2 (IQR 11.1) on the functional scale and 10.3 (IQR 2.6) on the symptomatic scale. Median quality of life score was 75.0 (IQR 33.3) and median EORTC QLQ-H&N35 was 20.6 (IQR 9.8). Conclusions: Postoperative shoulder function after modified muscle-sparing pectoralis major muscle flap surgery is comparable to function of the healthy side with a significant deficiency in adduction force not compromising daily life in this small study cohort.

Giant Borderline Phyllodes Tumor With Malignant Presentation: A Case Report

Phyllodes tumor (PT) is a rare benign tumor with malignant potential. There have been few case reports that have described this condition. We report the case of a 61-year-old woman with a “giant” borderline PT who underwent a modified radical left breast mastectomy with left axillary lymph node dissection, followed by chest wall reconstruction using serratus anterior and pectoralis major muscle flap coverage. A breast tissue measuring 22.5 × 18.5 × 12.5 cm and weighing a total of 5.2 lbs was resected. A case report like this can provide further information on surgical management of the tumor and the importance of an early diagnosis. In addition, PTs are rare to find in patients and this case will further contribute to the literature regarding PT. J Curr Surg. 2021;11(3):69-72 doi: https://doi.org/10.14740/jcs445

Intra- and Extrathoracic Malignant Tracheoesophageal Fistula-A Differentiated Reconstructive Algorithm.

Simple SummaryTracheoesophageal fistulae (TEF) after oncologic resections represent a therapeutic challenge. Reconstructive options vary from the upper to the lower airways and include the complete therapeutic armamentarium from pedicled flaps to chimeric free flaps. Derived from the experience of 18 oncologic patients with TEF, we present a therapeutic algorithm that may guide future treatment strategies and shows that an interdisciplinary approach leads to satisfying success rates. However, disease-specific morbidity has to be anticipated.Background: Tracheoesophageal fistulae (TEF) after oncologic resections and multimodal treatment are life-threatening and surgically challenging. Radiation and prior procedures hamper wound healing and lead to high complication rates. We present an interdisciplinary algorithm for the treatment of TEF derived from the therapy of consecutive patients. Patients and methods: 18 patients (3 females, 15 males) treated for TEF from January 2015 to July 2017 were included. Two patients were treated palliatively, whereas reconstructions were attempted in 16 cases undergoing 24 procedures. Discontinuity resection and secondary gastric pull-up were performed in two patients. Pedicled reconstructions were pectoralis major (n = 2), sternocleidomastoid muscle (n = 2), latissimus dorsi (n = 1) or intercostal muscle (ICM, n = 7) flaps. Free flaps were anterolateral thigh (ALT, n = 4), combined anterolateral thigh/anteromedial thigh (ALT/AMT, n = 1), jejunum (n = 3) or combined ALT–jejunum flaps (n = 2). Results: Regarding all 18 patients, 11 of 16 reconstructive attempts were primarily successful (61%), whereas long-term success after multiple procedures was possible in 83% (n = 15). The 30-day survival was 89%. Derived from the experience, patients were divided into three subgroups (extrathoracic, cervicothoracic, intrathroracic TEF) and a treatment algorithm was developed. Primary reconstructions for extra- and cervicothoracic TEF were pedicled flaps, whereas free flaps were used in recurrent or persistent cases. Pedicled ICM flaps were mostly used for intrathoracic TEF. Conclusion: TEF after multimodal tumor treatment require concerted interdisciplinary efforts for successful reconstruction. We describe a differentiated reconstructive approach including multiple reconstructive techniques from pedicled to chimeric ALT/jejunum flaps. Hereby, successful reconstructions are mostly possible. However, disease and patient-specific morbidity has to be anticipated and requires further interdisciplinary management.

Partition of Pectoralis Major Musculocutaneous Flap as a Salvage Procedure for Simultaneous Coverage of the Exposed Carotid Artery and Reconstruction of Cervical Esophagus.

In advanced pharyngoesophageal cancer patients, a critical event is represented by the failure of primary reconstruction with exposure of the carotid artery and partial or total defect of the cervical esophagus. For these high-risk patients, a partitioned pectoralis major musculocutaneous (PMMC) flap can prevent carotid blowout and provide skin for simultaneous esophageal reconstruction. Twenty-six patients needing pharyngoesophageal reconstruction together with coverage of carotid artery exposure were included in this retrospective case series. The patients were treated with a partitioned PMMC flap, based on the branching pattern of the pectoral branch of the thoracoacromial artery and the perforators of the pectoralis major muscle, to simultaneously reconstruct the defect and provide coverage for the carotid artery. In 25 patients, the partitioned PMMC flap reconstructions resulted in complete wound healing without occurrence of carotid blowout syndrome or fistula formation. Minor complications as partial flap necrosis (7.7%) and strictures formation (7.7%) were recorded but did not compromise reconstruction. Twenty-two patients were able to adopt a semisolid diet, and 4 had recurrence of cancer. The partitioned PMMC flap reconstruction represents a useful salvage solution to simultaneously restore the continuity of the alimentary tract and provide reliable coverage for the exposed carotid artery.

Techniques for island design of pectoralis major muscle flap and risk control

The pectoralis major muscle flap has been clinically used for more than 40 years. When harvesting the traditional pectoralis major muscle flaps, it is necessary to cut the upper half of the pectoralis major muscle, and use the thoracoacromial vessels and its surrounding pectoralis major muscle as the pedicle, resulting in the loss of the function of the pectoralis major muscle. Hypertrophic pedicle also squeezes the responsible vessels and prevents the flap from being transferred to recipient area, often leading to the partial necrosis of the flap end. The author proposes an improved method to harvesting pectoralis major muscle island flap, and summarizes it as a "ten-step procedures". The key point is to identify the "lowest penetrating muscle point"（LPMP） during the operation, and points out that it is safe to cut off the muscle pedicle 2cm above LPMP. The pectoralis major muscle island flaps not only preserves the function of the donor site's pectoralis major muscle to the utmost extent, better restores the swallowing and vocal function of the recipient site, but also improves the safety of flap harvesting, which will be benefit to patients.

ZOR DURUMLARDA ALICI DAMAR OLARAK SERBEST FLEP KİMERİZASYONUNU İÇEREN FARKLI MODALİTELERLE BİRLİKTE TORAKOAKROMİAL ARTERYEL GÖVDE VE SEFALİK VEN SİSTEMİNİN KULLANIMI

Objective
 We aimed to remind surgeons of the presence of the
 thoracoacromial arterial trunk and cephalic vein (TATCV)
 for a comfortable and reliable free flap transfer
 to the head, arm, and trunk, in case the mainstream recipient vessels of these regions pose some inconveniences
 due to previous surgery, radiotherapy, or
 trauma.
 Material and Methods
 Eight cases of trauma or tumor involving the head and
 neck or upper extremity, treated with free tissue transfer
 in which this vascular system was used with different
 modalities, were reviewed retrospectively.
 Results
 This vascular system proved to be reliable in all cases.
 It enabled chimerization with the pectoral flap. It was
 used in six patients for head and neck reconstructions
 and in two upper extremity restrorations. Switching
 the anastomoses to TAT-CV site and cephalic vein
 transposition were found to be rapid and reliable methods
 to rescue a flap with compromised circulation.
 Discussion
 Although anatomically well known by many reconstructive
 surgeons, its ease of dissection, consistency,
 supply of branches of differing caliber, and strategic
 location is not adequately appreciated. Moreover, in
 cases of pectoralis major flap transfer in which additional
 tissue is required, this vascular system is already
 there to receive it.

Novel modification of infrahyoid myocutaneous flap for the reconstruction of oral cavity defects

This study was intended to describe the technique used and the results obtained with the modification of the infrahyoid flap (IHF) for the reconstruction of oral tongue defects following resection for advanced squamous cell carcinoma (SCC). Patients with oral tongue defects following ablation for T2 to T4a SCC had reconstructions using a modified infrahyoid flap. Demographic data, tumour characteristics, and the complications were evaluated for each patient. We observed no complications regarding the healing process of the donor site or success of the flap in 49 (of 55) patients. None of the flaps had massive oedema or venous congestion in the postoperative period. Six patients experienced flap-related complications of which five had partial skin paddle necrosis, but eventually their flaps recovered and re-epithelialised without any further intervention. However, total flap necrosis was seen in one patient in whom a pectoralis major flap was used for the defect reconstruction following revision surgery. History of previous radiotherapy to the neck (p = 0.003), tumour stage (p = 0.017), and metastasis to cervical lymph nodes (p = 0.004) were associated with higher prevalence of partial or total flap necrosis. The modified infrahyoid flap is a reliable, quick, and simple procedure with a reasonable cost that makes it a valuable option for the reconstruction of the oropharynx and oral cavity with minimal donor site morbidity and good outcomes. It seems the modified IHF is a valid surgical procedure that may be considered in selected patients undergoing reconstruction of oncological oral tongue defects with fewer complications.

Autonomization of pectoralis major flap in head and neck surgery

The pectoralis major flap (PMF) is one of the most used pedicled flaps for reconstructive surgery in head and neck. Basing on previous studies observing that a vascular accident or pedicle ligation not always resulted in necrosis of free flaps, sometimes after a short critical period, we describe the possibility to perform the division of the PMF pedicle. The autonomization of PMF is based on the hypothesis that the flap, after a critical period, develops a neoangiogenesis at the free portion in the recipient site. It represents a possible choice in selected patients with relapse or second tumour of the oral floor and/or mobile tongue, who have been already treated with PMF reconstruction. We provide a step-by-step description of the autonomization and use of the modified PMF. Moreover, we reported advantages and pitfalls. The modified PMF represents a safe reconstructive choice for patients advised against a free flap or a second pedicled flap, with good surgical outcomes.

Role of pectoralis major flap in resource limited settings (developing world): A case report of huge neck cancer done in Tanzania

Skin cancers are common in head and neck region particularly Basal cell carcinoma and Squamous cell carcinoma. Treatment options includes wide local excision with neck dissection followed by adjuvant radiation/chemo/chemoradiation. We report a case of a huge skin cancer of the neck about 8.5 cm in its greatest dimensions and reconstructive techniques of the defect using pectoralis major flap in a 61-years old Albino patient, what’s important is good understanding of anatomy and surgical land marks to identify the thoracoacromial artery which is the main feeder to the flap. Reconstruction was successful with acceptable morbidity and the patient was sent for chemoradiation with no reported recurrence. Presentation from this case demonstrates that the pectoralis major flap still remains the ‘workhorse’ of reconstruction in Tanzania. It is advocated to be used in resource limited countries, effectively with acceptable morbidity and results.

Surgical Outcome of Pharyngocutaneous Fistula After Total Laryngectomy: A Retrospective Study.

The management of pharyngocutaneous fistula is challenging. We typically treat postlaryngectomy pharyngocutaneous fistulas with a pedicled pectoralis major flap transfer. This study analyzed the outcomes of our surgical treatments for pharyngocutaneous fistula to propose considerations for surgical strategies. This retrospective review included all patients who underwent surgical repair of a postlaryngectomy pharyngocutaneous fistula at the National Cancer Center Hospital East in Kashiwa, Japan, from January 2005 to December 2019. The final analysis included 33 cases (median age, 71 years). Twenty-two cases had a history of radiotherapy to the head and neck region. Wound closures were performed with a pedicled pectoralis major musculocutaneous flap (n = 26) or pedicled pectoralis major muscle flap (n = 7). In 1 case, a deltopectoral flap was combined with the pectoralis major musculocutaneous flap. The median total operation time was 236 minutes, the median blood loss during surgery was 144 mL, and the median hospital stay after the reconstructive surgery was 39 days. Minor leakage occurred in 19 cases, and major leakage occurred in 2 cases. The fistula was finally cured successfully in 31 cases. We compared the outcomes in patients with leakage after surgical repair to those in patients without leakage after surgical repair to determine the risk factors for leakage after surgical repair of a pharyngocutaneous fistula. Five patients in the nonleakage group and 17 in the leakage group had a history of preoperative radiation (P = 0.052). The median preoperative blood values in the nonleakage and leakage groups were as follows: albumin, 3.6 and 3.2 g/dL (P = 0.061), and C-reactive protein, 2.36 and 6.77 mg/dL (P = 0.031), respectively. The time between the occurrence of the fistula and reconstructive surgery was 32 and 9 days in the nonleakage and leakage groups, respectively (P = 0.009). Our surgical treatment for postlaryngectomy pharyngocutaneous fistula succeeded in 31 of 33 cases (94%). This study demonstrated that pedicled pectoralis major flap transfer is useful for the treatment of postlaryngectomy pharyngocutaneous fistula.