Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: a review of 47 cases

doi:10.1016/j.bjps.2005.07.008

Journal of Plastic, Reconstructive & Aesthetic Surgery

Volume 59, Issue 2, February 2006, Pages 166-173

https://doi.org/10.1016/j.bjps.2005.07.008 Get rights and content

Summary

We present a series of reconstruction of 47 patients with large full thickness cheek defects secondary to cancer ablative surgery. All patients were reconstructed primarily by bipaddle pectoralis major myocutaneous (PMMC) flap. The age of patients ranged from 25 to 85 years (mean 49.5 years). All patients were male. The size of the paddle used for mucosal defect repair ranged from 5×3 to 9×7 cm and the size of the paddle used for skin cover ranged from 4×4 to 9×8 cm. The total flap size ranged from 10×5 to 17×7 cm. One patient had complete loss of flap (2.12%). Sixteen patients had minor complications all of which settled with conservative management. The follow up period varied from 1 month to 4 years.

The modification adopted in bipaddling the flap was based on anatomical location of perforators to ensure good blood supply to both paddles of flap. Placing the flap horizontally with inclusion of nipple and areola increased the reach and size of available flap. We found the technique to be anatomically sound, technically easy and reliable. Precautions taken included proper assessment of reach of the paddle, placing not more than one-third of the paddle outside the muscle and securing the skin paddle to the muscle to avoid shearing of perforators during flap raising. We conclude that this technique is a useful alternative where microsurgical free tissue transfer is not possible or as a salvage procedure in selected large full thickness oral cavity lesions. However, the disadvantages of this method include loss of nipple and areola and technical difficulty in obese patients and females.

Section snippets

Anatomic details

For head and neck reconstruction, the skin between the nipple and midline based on the pectoralis major muscle is used, depending on the distance between the pivot point of the flap (the mid-clavicular point) and the recipient site. The thoracoacromial artery descends from its origin from the subclavian artery at the level of the mid-clavicular point in an inferomedial direction and anastomoses within the muscle with the direct branches of internal mammary and anterior intercostal branches of

Flap design and operative technique

On the basis of this vascular anatomy we developed the present method of bipaddling of the PMMC flap. The paddle is placed horizontally, including the nipple, extending from midline medially and crossing the lateral border of the muscle laterally (Figure 1, Figure 2(c)). Paddle for lining defect is placed around the nipple, which will be nourished by two sets of perforators (P2, P3). The paddle for the skin defect is placed on the medial edge of the muscle based on P1 perforators. As the paddle

Material and methods

This is a prospective study of 47 patients with postablative full thickness cheek defects and segmental mandibulectomy who underwent reconstruction with bipaddle PMMC flaps between May 2000 and July 2004. The age ranged from 25 years to 85 years (mean 49.5 years). All patients were male. Of these, 24 patients had lesions involving left buccal mucosa, 19 with right buccal mucosa, one involving the middle 1/3 of alveolus and floor of mouth, one with left alveolar carcinoma, one with right

Results

The size of the paddle used for mucosal defect cover ranged from 5×3 to 9×7 cm and the size of the paddle used for skin cover ranged from 4×4 to 9×8 cm. The total size of flap ranged from 10×5 to 17×7 cm (Table 1).

Of the 47 patients included in this study, all achieved satisfactory cover except one patient who had complete flap necrosis. We were unable to find the exact cause of this loss. This patient was later reconstructed with a folded forehead flap. Fifteen patients had minor complications,

Discussion

From the time of Ariyan's description⁷ in 1979, the pectoralis major myocutaneous flap has been the workhorse for head and neck reconstruction. Easy reach of the flap, reliable vascularity, technical simplicity, coverage of the exposed vessels by muscle after neck dissection and the ability to provide bulk made it a popular option amongst oncoreconstructive surgeons.

However, the availability of the skin paddle is limited for larger defects and most patients develop an unaesthetic neck

Conclusion

We conclude that this method of bipaddling the pectoralis major myocutaneous flap is a useful technique for reconstruction of complex composite cheek defects in male patients. It serves as a viable alternative to free tissue transfer or even as a salvage procedure. The method is technically easy and based on sound anatomic concepts.

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The folded, bipaddled pectoralis major composite flap in oral reconstruction
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The vascular anatomy of pectoralis major myocutaneous flap
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Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of head and neck region: an introduction to the chimeric flap principle
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There are more references available in the full text version of this article.

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2017, Oral Oncology
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These situations require composite flaps. Pedicled flaps that reliably provide significant skin and soft tissue volume are the pectoralis major myocutaneous [129] and pedicled latissimus dorsi flap [130]. These still have an important role in the unfit patient, in failed free flap reconstructions, and in combination with free flap reconstructions.
Salivary gland malignant tumors (SGMT) are of key interest for head and neck surgeons since surgery with adjuvant radiotherapy is considered the treatment of choice in most of the cases. Some factors, namely rarity, high histologic heterogeneity, and possible occurrence in all the head and neck subsites, contribute to make this topic very controversial; some unclear aspects pertain surgical treatment. When dealing with major salivary gland malignant tumors (MaSGMT), the most debated issues remain the extent of surgery and management of facial nerve. In minor salivary gland malignant tumors (MiSGMT), conversely, surgical planning is influenced by the specific pattern of growth of the different neoplasms as well as the site of origin of the lesion. Finally, two additional issues, the treatment of the neck (therapeutic or elective) and reconstructive strategy after ablative surgery, are of pivotal importance in management of both MaSGMT and MiSGMT. In this review, we discuss the most relevant and controversial issues concerning surgery of SGMT.
Paul Tessier facial reconstruction in 1970 Iran, a series of post-noma defects
2015, Journal of Cranio-Maxillofacial Surgery
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Repairing the cheek can be done with a large variety of methods either local or free flaps. Most authors agree that cheek reconstruction ideally needs double lining, although some teams use only one thick musculocutaneous flap (Adekeye et al., 1986; Adams-Ray and James, 1992; Ahmad et al., 2006; Kang et al., 2009). Tessier always used the Barron–Tessier flap to rebuild the inner lining of the cheek and mostly temporofrontal rotation flaps for the outer lining.
Paul Tessier was a pioneering plastic surgeon who founded craniofacial surgery and had an international influence in the field of reconstructive surgery. We reviewed his techniques in the reconstruction of post-noma defects in Iran in the late 1970s.
We studied a series of 23 patients operated on by Tessier from 1974 to 1978 in Iran (property of Association Française des Chirurgiens de la Face). They all suffered from noma in childhood with major facial defects.
Ten suffered from simple lip and cheek defects, nine also from nose defects and four from extensive facial defects. Abbe flaps were used in 15 patients to reconstruct the lips completed by commissuroplasty in six patients. Nose defects were reconstructed with nasofrontal flaps (ten cases). The outer cheek was reconstructed with a rotation flap (four cases), or with a frontotemporal flap (six cases). The inner cheek was reconstructed using a Barron–Tessier myocutaneous flap (ten cases). Of the 23 patients, partial flap necrosis occurred in five cases.
Tessier was a pioneering plastic surgeon who used local flaps to reconstruct these important facial defects. He had a high rate of success, although nowadays local flaps are commonly replaced by free flaps.
Double anterior (anterolateral and anteromedial) thigh flap for oral perforated defect reconstruction
2014, Journal of Cranio-Maxillofacial Surgery
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Moreover, these procedures frequently fail to provide enough tissue, especially for large, full-thickness oral perforated defects involving the mandible or maxilla. The bipaddle pectoralis major myocutaneous flap can offer an alternative method for the reconstruction of large and full-thickness cheek defects (Ahmad et al., 2006). However, the drawbacks of this method include loss of the nipple and limitation of applicability in females or in patients who do not need a radical neck dissection.
The purpose of this study was to assess the therapeutic efficacy of oral perforated defect reconstruction with a double anterior (anterolateral and anteromedial) thigh flap through the modified lateral lip-submandibular approach.
From July 2010 to August 2013, eight patients with oral perforated defects secondary to oral cancer ablation involving the superior partial mandible or the posterior partial maxilla, with immediate reconstruction by double anterior (anterolateral and anteromedial) thigh flaps, were retrospectively enrolled into this study.
All double anterior flaps were musculocutaneous flaps. Seven double flaps resulted in good functional and aesthetic outcomes with complete flap survival. One patient required operative exploration in the postoperative period due to thrombosis in the external jugular vein. After the salvage, one of the double flaps in the intraoral region resulted in partial failure of the superficial skin of the flap. No functional impairment at the donor sites occurred in any of the cases.
The double anterior (anterolateral and anteromedial) thigh flap is a feasible and acceptable technique for reconstruction of an oral perforated defect involving the mandible or the maxilla through the modified lateral lip-submandibular approach. It presents a very acceptable aesthetic and functional result with the additional advantage of low morbidity at the donor site.
Pectoralis major myocutaneous flap - Still a workhorse for maxillofacial reconstruction in developing countries
2013, Journal of Oral and Maxillofacial Surgery
To retrospectively evaluate the utility of the pectoralis major myocutaneous (PMMC) flap for head, face, and neck (HFN) reconstruction in the Indian population.
The hospital records of 496 patients in whom the PMMC flap was used (saving the deltopectoral flap) for reconstruction of HFN defects from January 1991 to December 2010 were reviewed retrospectively. All the patients were followed up for a minimum period of 6 months, and the utility of the PMMC flap was evaluated for HFN reconstruction.
Of the 496 patients, complications developed in 84 patients. The complications included complete flap failure in 12, partial skin paddle loss in 24, wound infection in 12, peripheral wound dehiscence in 16, plate exposure in 12, and donor site morbidity such as infection and a decrease in function in 8.
The PMMC flap or its modification was used in 496 cases of reconstruction after resection surgery for malignancy of the HFN region with minimal morbidity and 1 death. This technique is a useful alternative in places with a high incidence of HFN malignancies and microsurgical free tissue transfer is not possible or as a salvage procedure in selected large, full-thickness, oral cavity lesions. In our 19-year experience, the final functional and cosmetic results were satisfactory with this sturdy flap.
Reconstruction of the face and neck with different types of pre-expanded anterior chest flaps: A comprehensive strategy for multiple techniques
2013, Journal of Plastic, Reconstructive and Aesthetic Surgery
For large defects or deformities of the face and neck, the anterior chest area appears to be an excellent donor site that provides well-matched skin colour and texture. Many flap techniques based on the anterior chest area have been reported; however, there are few reports that focus on a treatment strategy for these different flap techniques.
A retrospective study was performed to propose a treatment algorithm. A total of 69 cases were reviewed from May 2005 to July 2011, in which different types of anterior chest flaps were performed for face and neck reconstruction. The reconstructive procedures, the defect characteristics and the complications were collected and analysed.
Thirty-three pedicled thoracic branch of the supraclavicular artery flaps (the pedicled TBSA flap), 11 pedicled internal mammary artery perforator flaps (the pedicled IMAP flap), 8 free internal mammary artery perforator flaps (the free IMAP flap), 4 supercharged TBSA flaps, 17 prefabricated flaps and 3 supercharged prefabricated flaps were performed. The applications of six types of pre-expanded anterior chest flaps were described in an algorithmic approach.
A treatment strategy for face and neck reconstruction using six anterior chest flap techniques is proposed. It recommended a personalised flap planning according to the characteristics of deformities/defects and the regionally dominant vessels of the anterior chest area.
Nonmelanoma Skin Cancer of the Head and Neck: Reconstruction
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Citation Excerpt :
In a retrospective study, McLean and colleagues51 reported that they successfully use this flap to reconstruct 24 patients with temporal or cheek defects; however, the aesthetic outcome was not evaluated in this study. In addition, Ahmad and colleagues52 has used pectoralis major myocutaneous flaps designed with two skin islands for the reconstruction of full-thickness cheek defects. They emphasized that although it is not the first option for these defects, this technique can be useful when free flaps are not applicable or free flap failure has occurred.

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Bipaddle pectoralis major myocutaneous flap in reconstructing full thickness defects of cheek: a review of 47 cases

Summary

Section snippets

Anatomic details

Flap design and operative technique

Material and methods

Results

Discussion

Conclusion

Br J Plast Surg

Br J Plast Surg

Br J Plast Surg

Free combined composite flaps using the lateral circumflex femoral system for repair of massive defects of head and neck region: an introduction to the chimeric flap principle

Plast Reconstr Surg