Pectoralis Myocutaneous Flap Research Articles

A Perspective on Chest Wall Resection in Patients with Breast Cancer

The morbidity from locally recurrent breast cancer or osteoradionecrosis and accompanying infection is substantial. The selective use of surgical resection offers good palliation. Extended full-thickness chest wall resection is facilitated by a variety of techniques available for closure and coverage including use of latissimus dorsi myocutaneous flap, rectus abdominus myocutaneous flap, pectoralis myocutaneous flap, breast flap, and omentum with skin graft. The experience with 43 consecutive chest wall resections in patients with breast cancer affords the opportunity to define indications and contraindications for such palliative procedures. Indications include local symptoms of pain and infection, tumor recurrence refractory to radiation therapy, and infection that precludes chemotherapy. Relative contraindications are pulmonary metastases, bone metastases, hepatic metastases, and malignant pleural effusions. Absolute contraindications are brain metastases, bone marrow involvement, bulky disease in two organs, and breakthrough on multiple chemotherapy regimens. Operative revision was only required in 4 of 43 patients. Minor wound complications occurred in 12 (28%). Three patients who underwent resection for local recurrence have survived 40 months or more free from disease. This procedure provides substantial palliation by relieving pain, controlling infection, removing a weeping wound, and allowing chemotherapy for metastatic disease. In the proper setting, chest wall resection is an important part of the armamentarium for palliation of the patient with breast cancer. It can markedly improve quality of life and occasionally may result in long-term survival.

Selecting Variants in Pharyngeal Reconstruction

A dramatic change in the techniques of immediate pharyngeal reconstruction in the last 10 years is largely due to the availability of myocutaneous flaps, microvascular techniques, and the increasing popularity of the "gastric pull-up" operation. The experience of the Head and Neck Service of Memorial Sloan-Kettering Cancer Center in repair of the pharynx following pharyngeal resection between 1974 and 1983 is reviewed and the changing trends in the philosophy of pharyngeal reconstruction are highlighted. The methods of reconstruction used were deltopectoral flap, gastric pull-up, free microvascular bowel transfer, and pectoralis myocutaneous flap. The indications, morbidity, effectiveness, and complications for each of these procedures are discussed. The optimal reconstructive methods for partial and total pharyngeal reconstruction are as follows: 1) primary closure for defects not exceeding one third of the circumference of the pharynx; 2) pectoralis myocutaneous flap repair for pharyngeal defects with loss of up to 70% of the circumference of the pharynx; 3) gastric pull-up with pharyngogastrostomy for defects exceeding 70% of the circumference of the pharynx; 4) gastric pull-up for all pharyngoesophageal defects where the lower margin of resection is below the tracheostome; and 5) reversed pectoralis myocutaneous flap with split thickness skin graft on the muscle for secondary closure of the pharyngostome.

Voice Preservation in Pyriform Sinus Carcinoma by Hemicricolaryngopharyngectomy

Hemicricolaryngopharyngectomy was performed for anterior pyriform sinus carcinomas with preservation of voice and swallowing. The surgical specimen includes the homolateral half of the hypopharynx, larynx, and cricoid ring. The pharynx is reconstructed with a pectoralis myocutaneous flap, a deltopectoral flap, skin or dermal graft. A semirigid mucosa-lined speech tube is created by folding in the remaining half of the larynx. This tube, which is 4 to 5 mm in diameter, serves as a phonatory structure. Speech is produced by occluding the stoma with the finger and shunting air via this dynamic pseudolarynx. Patients maintain a permanent tracheostomy. Our experience includes 14 cases with up to 4-year follow-up.

Reconstruction after total or subtotal glossectomy

Total or subtotal resection of the tongue for malignant lesions creates difficult reconstructive problems. Though the introduction of myocutaneous flaps revolutionized the reconstruction of the oral cavity, most patients with total and subtotal (more than 75 percent) glossectomy require laryngectomy as a concommittant or subsequent procedure to prevent persistant aspiration. Two groups of patients have been compared in this study. Group I consisted of 10 patients in whom an attempt was made to preserve voice with a total (4 patients) or subtotal (6 patients) glossectomy without laryngectomy. To decrease the chance of aspiration, the tip of the epiglottis was sutured to the posterior pharyngeal wall (epiglottopexy). This additional surgical step allowed swallowing without aspiration by blocking the glottic entrance. Group II consisted of six patients who underwent total glossectomy and laryngectomy. They had reconstruction with a pectoralis myocutaneous flap in one stage. These patients were rehabilitated without any major morbidity and they resumed an oral diet within 3 weeks after surgery. The muscle bulk of the flap and the additional protection of the airway by epiglottopexy in Group I were the keys to successful reconstruction.

Skin grafts and flaps in oral cavity reconstruction.

Split-thickness skin grafts and regional flaps have been used to reconstruct deficits produced by oral cavity and oropharyngeal cancer resection in 191 patients. The rate of complication, delay in oral alimentation, and the postoperative length of hospitalization was greater for pectoralis myocutaneous and deltopectoral flap reconstructions than for skin grafts, even when comparably sized defects are considered. The adverse effect of weight loss is greater on flap reconstructions than skin grafts and is influenced little by preoperative nutritional therapy. Skin graft reconstruction is recommended for moderate and large defects. The pectoralis myocutaneous flap may be reserved for massive defects or when the anterior part of the mandible has been resected.

Pectoralis myocutaneous flap in head and neck cancer reconstruction.

This review of 50 consecutive myocutaneous flaps provided an opportunity to assess the value of this particular reconstructive technique in head and neck cancer surgery. There is no question that the flap has certain disadvantages. In this series, it was not found to be a reliable means of one-stage pharyngoesophageal reconstruction. However, its technical ease, versatility, and reliability as a one-stage reconstructive technique strongly outweigh any disadvantages and prove it to be a valuable recent addition to head and neck cancer surgery reconstruction.

Complications in surgery for stomal recurrences.

Stomal recurrences are diffuse epidermoid carcinomas of the tracheostoma. There is a 8.3% incidence associated with patients having a total laryngectomy. Most can be prevented by several prophylactic measures; however, surgery may be required. The procedure advocated is mediastinal dissection and its surgical technique is outlined. Recently the use of the pectoralis myocutaneous flap has greatly diminished morbidity and mortality associated with this procedure. The complications that may be encountered with mediastinal dissection have been categorized and analyzed. The dynamic interplay of these complications is stressed. Separately, each complication is formidible, but collectively, they may be overwhelming. This entire web of complications is synergistic and at times fatal. In essence, the motto of the surgeon when operating on a patient with a stomal recurrence should be eternal vigilance.

Delayed failure of myocutaneous flaps in head and neck reconstruction.

Since the concept of myocutaneous flap reconstruction of the head and neck region was introduced it has opened a new approach to surgical management in this area. This flap not only reduced the number of operations as compared to "staged procedure", but also reduced the costs of medical care. We are, however, experiencing significant failures as the applications of this flap are extended. This paper reviews our experience with myocutaneous flaps in 15 partial and total failures. An evaluation of these failures reveals that most occurred 1 1/2 to 3 weeks after reconstruction. The factors predisposing to failure seem related more to technical errors rather than to general factors. Diabetes, peripheral vascular disease, malnutrition and low hemoglobin, and low blood pressure were not major contributors to the failures in our series. Local factors predisposing to failure of myocutaneous flaps can be divided into two large categories--arterial failure and venous failure. In our series of unsuccessful myocutaneous flaps, the major factors appeared to be venous stasis leading to arterial insufficiency. All failures had developed after the initial critical period of flap survival (7-10 days). The following techniques showed an especially high rate of failure: 1. SCM--myocutaneous flap to resurface floor of mouth. 2. Tubed pectoralis myocutaneous flap to reconstruct pharynx and esophagus. 3. Flaps developed with very narrow vascular pedicles. Individual cases representing delayed failure are presented.

Skull base surgery in composite resection.

We extended the limits of standard jaw and neck dissection in large tumors of the oropharynx with extension to the soft and hard palate. Resection of the primary tumor with adequate margins and the lymphatics of the infratemporal fossa is required for tumor control in these extensive lesions. Splitting the lip in the midline and developing a large cervicofacial flap gives an excellent exposure to the region. The resection includes the hemimandible and the soft tissues of the intratemporal fossa. The internal carotid artery is followed to the skull base and all structures medial to this vessel, including the cartilaginous portion of the eustachian tube and the external carotid, are included in the en bloc specimen. The resection of the posterior maxilla, pterygoid plate, and palate may vary according to tumor size. The surgical defect is usually reconstructed with a pectoralis myocutaneous flap.

Pectoralis myocutaneous flap for chin augmentation.

Radical resection of the anterior portion of the oral cavity, including a portion of the tongue, floor of the mouth, mandible, and neck, has always been, and remains, a perplexing problem in immediate rehabilitation of the area of the oral cavity and mentum. In the past, these deformities were classified as "Andy Gump." Attempts at correction of this deformity are protracted and complex. The use of the pectoralis myocutaneous flap offers an improvement in the concept of mamagement in that it supplies a skin lining for the oral cavity and augments the chin and neck in a single-stage procedure that may be combined with the primary operation.

Pectoralis major myocutaneous island flap in head and neck surgery: Analysis of complications in 42 cases.

The pectoralis myocutaneous island flap was used for head and neck reconstruction in 42 patients. Major necrosis did not occur in any case, and minor necrosis was present in three of the cases (7%). The advantages of this flap over other myocutaneous flaps and cutaneous pedicle flaps are delineated.