Pectoralis major myocutaneous flap in females: Report of the technique and literature review

Shreya Bhattacharya; Achyuth Panuganti; Krishnakumar Thankappan; Deepak Balasubramanian; Subramania Iyer

doi:10.4103/jhnps.jhnps_63_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 9 | Issue : 2 | Page : 159-162

Pectoralis major myocutaneous flap in females: Report of the technique and literature review

Shreya Bhattacharya¹, Achyuth Panuganti², Krishnakumar Thankappan³, Deepak Balasubramanian³, Subramania Iyer³
¹ Department of Surgical Oncology, Cancer Institute Adyar, Chennai, Tamil Nadu, India
² Department of Head and Neck Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
³ Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, Amrita Vishwa Vidyapeetham, Kochi, Kerala, India

Date of Submission	20-Oct-2021
Date of Acceptance	31-Oct-2021
Date of Web Publication	17-Dec-2021

Correspondence Address:
Dr. Subramania Iyer
Department of Head and Neck Surgery and Oncology, Amrita Institute of Medical Sciences, AIMS Ponekkara PO, Kochi, Kerala
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/jhnps.jhnps_63_21

Abstract

Background: Pectoralis major myocutaneous (PMMC) flap still finds a place in oral cancer reconstruction in certain settings such as salvage, free flap failure, and medically unfit patients. In females, raising a PMMC is considered challenging owing to its unreliability and donor site morbidity. We hereby report a literature review of the female PMMC and present our technique of the harvest to overcome these caveats. Patients and Methods: We followed our method of flap harvest in eight women. The lower neck flap and the upper chest flap are dissected and elevated in continuity. The skin paddle is placed completely in the infra-mammary crease, the dissection superior to the flap is done to raise the breast tissue off the PMMC, thus maintaining the integrity of breast tissue and incorporating the least amount of fat between the muscle and skin paddle. Results: The indications for the female PMMC were locally advanced primary in 2, surgical salvage in 2, free flap failure in 3, and medical comorbidity in 1 patient. Two patients had partial flap loss, one patient contracted a surgical site infection and another developed a seroma; all were managed conservatively. None had a complete flap loss. The mean duration of the hospital stay was 6 days. Conclusion: PMMC is still a viable reconstructive option in selected female patients. Our technique of flap harvest gives acceptable outcomes and retains the breast aesthetics.

Keywords: Flap reconstruction, head and neck cancer, microsurgery, oral cancer, pectoralis major flap

How to cite this article:
Bhattacharya S, Panuganti A, Thankappan K, Balasubramanian D, Iyer S. Pectoralis major myocutaneous flap in females: Report of the technique and literature review. J Head Neck Physicians Surg 2021;9:159-62

How to cite this URL:
Bhattacharya S, Panuganti A, Thankappan K, Balasubramanian D, Iyer S. Pectoralis major myocutaneous flap in females: Report of the technique and literature review. J Head Neck Physicians Surg [serial online] 2021 [cited 2023 Jun 4];9:159-62. Available from: https://www.jhnps.org/text.asp?2021/9/2/159/332727

Introduction

Oral cavity squamous cell carcinoma (OSCC) accounts for 10.3% of all newly diagnosed cancers in India as per GLOBOCAN 2020, accounting for 16% in males and 4% in females.^[1] It is the most common cancer in men and fourth-most common malignancy in females in India.^[1],[2] Recently, there has been a significant disproportionate increase in the incidence of OSCC, in the absence of known carcinogen exposure, in young women.^[3] Ablative surgery with clear margins followed by appropriate adjuvant therapy is the standard of care for OSCC. Globally, the microvascular-free flap is the preferred reconstructive choice in such cases. In India, owing to the huge caseload and resource constraint settings, pedicled flaps are sometimes used as an alternative.^[4] Pectoralis Major Myocutaneous (PMMC) flap has conventionally been considered the workhorse flap for head-and-neck reconstruction due to its reliability and ease of harvest.^[5] The current indications of PMMC lie in the salvage setting secondary to free flap failure and in medically unfit patients.^[6]

There are very few studies reporting the use of PMMC flap in females. The common problems in these cases include less reliability and increased bulk due to the thick breast tissue incorporated in the flap. The other major issue is the distortion of the breast and unsightly scar associated with the flap harvest. In this article, we outline the technical modifications we adopted to reduce donor site morbidity of PMMC in the female patient and provide a review of literature.

Patients and Methods

Eight female patients of OSCC who underwent PMMC flap reconstruction using our technique are included in this case series. Informed written consent was obtained from all the patients.

Surgical technique

The skin over the lower neck and upper chest is elevated in continuity with the lower flap of the neck dissection incision. A major part of the skin overlying the pectoralis major muscle can be raised through the neck dissection incision itself. This makes the dissection of the skin from the chest side easier. The skin paddle is marked entirely in the inframammary crease by lifting up the breast with the other hand [Figure 1]. The incision is made all around the marked skin paddle till the pectoralis major muscle fibers are seen. The upper skin flap is elevated to expose the muscle up to the clavicle. While doing so, the entire breast tissue is retracted upwards and laterally with a large right-angled retractor and a clear plane just above the muscle is followed [Figure 2]. The use of a lighted retractor helps in this step and later on, to secure better hemostasis. The lateral and lower border of the pectoralis major muscle is identified and lifted off the pectoralis minor and the chest wall. The rectus sheath may need to be incorporated with the paddle while making the lower cut depending on the inferior extent. The muscle is lifted up and the vascular pedicle is visualized on the under surface. The pectoralis major muscle is detached, laterally and medially, on either side of the vessel up to the clavicle, depending on the bulk and reach required. The lateral and medial pectoral nerves are sacrificed which later leads to atrophy of the muscle. The deltopectoral perforators are carefully preserved during the medial dissection. The skin flaps from the chest and neck sides are communicated. The PMMC flap is tunneled subcutaneously through the neck and inserted into the defect. Two vacuum drains are placed at the donor site and hemostasis is ascertained. Primary closure with 3-0 vicryl for subcutaneous tissue and monocryl for the skin is done for better cosmesis of the scar [Figure 3].

Figure 1: The inframammary skin paddle incised all around till the pectoralis muscle fibres are seen

Click here to view

Figure 2: The upper skin flap along with the breast tissue is reflected off the muscle in an upward and lateral direction

Click here to view

Figure 3: The donor site scar with acceptable cosmesis of the breast

Click here to view

Results

The case series consisted of 8 patients. The site of the OSCC was the bucco-alveolar complex in five and tongue in three women. Among these, two patients underwent extensive soft tissue resection with segmental mandibulectomy in the primary setting, two had salvage surgery for recurrence, three had a free flap failure and one had medical comorbidities. The mean age of participants in our study group was 46.3 years (29–58). Two patients had partial flap loss in the inferior aspect, which was debrided and re-sutured. One patient developed a surgical site infection which settled with conservative management. Seroma collection was seen in one patient, which was managed with aspiration and pressure dressing. There was no case of complete flap loss. The mean duration of hospital stay was 6 days ranging from 5 to 12 days.

Discussion

Globally, oral cancer is the sixth most common type of cancer and Indian cases contribute to one-third of the total burden.^[7] SEER data analysis shows a 111% increase in nonhabit cancer in women, commonly of the tongue.^[3] Seventy percentage of the cases in India are reported in advance stages requiring extensive resection and microvascular reconstruction.^[7]

However, in developing countries, owing to the high disease burden, cost and infrastructure constrains, and decreased availability of services with good technical expertise, PMMC still finds its place in the reconstructive armamentarium.^[8] PMMC is technically simple, less time taking, has smaller learning curve and does not require any extra infrastructure.^[8] There is added advantage of coverage of the vital structures in the neck with the muscle.

PMMC flap harvest in females is a technically challenging task owing to the bulky breast tissue interposed between the skin and the muscle. The operative technique of PMMC was first described by Ariyan.^[9] The commonly practiced extension of the standard incision, from the inferolateral corner of the axilla to the superolateral edge of the skin paddle traverses the entire chest area.^[10] Replicating the same in females leads to distortion of the breast and scarring.

We conducted a literature review of the PMMC flap for oral cancers, with respect to complications and donor site morbidity, particularly in female patients. Early reports of showed overall complication rates ranging from 8.9% to 40% with a low incidence of total flap loss, 1.5% to 4.4%. The female gender emerged as a significant factor for flap necrosis in few of these series.^[8],[11] Various other large series of PMMC flap have included the small number of female patients and gender-specific statistics have not been specified.^{[12],[13],[14],[15]} The series by Baek et al. (n = 133) included only 14 female patients and reported a major flap loss rate of 8%.^[12] McLean et al.^[14] included 50 female harvests and showed a complication rate of 13%.

Studies that comprised exclusively of female patients are scarce. In a study by Jena et al. of 140 patients, the complication rate was 21%. Two patients had a complete flap loss (1.4%) and 11 patients (7.9%) had a partial loss.^[5] Jayaprakash et al. studied 80 female harvests and found that 3.75% had complete flap loss and 11.25% had partial flap loss.^[16] Univariate analysis failed to outline any significant factor for flap loss. They suggested a paramedian flap harvest to include less amount of breast tissue and limit the disfigurement of the breast. Mehta et al. have advocated the use of a parasternal skin paddle and Wise pattern reduction mammoplasty for better aesthetics. Their study has shown a complete flap loss of 2.1% and partial flap loss of 8.5%.^[17]

Our technique is based on designing a purely inframammary skin paddle without any further extension. In this small series of 8 patients, this technique has yielded acceptable outcomes. The inframammary skin paddle leads to less distortion of the female breast by avoiding medial displacement following closure. Lower placement improves the arc of rotation. Avoiding the extension to the axilla maintains a fairly good cosmesis of the breast. Finally, as the breast tissue is almost completely reflected off the flap, the reliability of the skin paddle is maintained.

There are few drawbacks to this technique. Since the inferior portion of the skin paddle over the rectus is random, the size that can be reliably harvested is limited. The method may seem cumbersome technically because one member of the surgical team must retract the breast constantly. Furthermore, due to the limited exposure, early identification of the lateral and lower border is relatively difficult which may be problematic to evaluate the random component of the skin paddle.

Conclusion

PMMC flap still remains a viable reconstructive option in today's era of free flaps, in salvage setting or in high-risk cases. Raising PMMC flap in females has been challenging due to the intervening breast tissue and causes significant breast deformity. However, literature review shows that this flap can yield acceptable outcomes in women with certain modifications to the technique of harvest. Our novel approach of flap harvest ensures a skin paddle of better vascularity and restores the breast contour preventing donor site morbidity.

Disclosure

This material has never been published and is not currently under evaluation in any other peer-reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee before starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Available from: https://gco.iarc.fr/today/data/factsheets/populations/356-india-fact-sheets.pdf. [Last accessed on 2021 Sep 20].
2.	Mishra A, Meherotra R. Head and neck cancer: Global burden and regional trends in India. Asian Pac J Cancer Prev 2014;15:537-50.
3.	Patel SC, Carpenter WR, Tyree S, Couch ME, Weissler M, Hackman T, et al. Increasing incidence of oral tongue squamous cell carcinoma in young white women, age 18 to 44 years. J Clin Oncol 2011;29:1488-94.
4.	Sen S, Gajagowni JG, Pandey JK, Dasgupta P, Sahni A, Gupta S, et al. Effectiveness of pectoralis major myocutaneous flap in the surgical management of oral cancer: A retrospective study. J Stomatol Oral Maxillofac Surg 2019;120:21-7.
5.	Jena A, Patnayak R, Sharan R, Reddy SK, Manilal B, Rao LM. Outcomes of pectoralis major myocutaneous flap in female patients for oral cavity defect reconstruction. J Oral Maxillofac Surg 2014;72:222-31.
6.	Patel K, Lyu DJ, Kademani D. Pectoralis major myocutaneous flap. Oral Maxillofac Surg Clin North Am 2014;26:421-6.
7.	Borse V, Konwar AN, Buragohain P. Oral cancer diagnosis and perspectives in India. Sens Int 2020;1:100046.
8.	Chaturvedi P, Pathak KA, Pai PS, Chaukar DA, Deshpande MS, D'Cruz AK. A novel technique of raising a pectoralis major myocutaneous flap through the skin paddle incision alone. J Surg Oncol 2004;86:105-6.
9.	Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979;63:73-81.
10.	Urken ML, Biller HF. Pectoralis major. In: Urken ML, Cheney ML, Sullivan MJ, Biller HF, editors. Atlas of Regional and Free Flaps for Head and Neck Reconstruction. New York: Raven Press; 1995. p. 3-28.
11.	Kroll SS, Goepfert H, Jones M, Guillamondegui O, Schusterman M. Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. Ann Plast Surg 1990;25:93-7.
12.	Baek SM, Lawson W, Biller HF. An analysis of 133 pectoralis major myocutaneous flaps. Plast Reconstr Surg 1982;69:460-9.
13.	Mehrhof AI Jr., Rosenstock A, Neifeld JP, Merritt WH, Theogaraj SD, Cohen IK. The pectoralis major myocutaneous flap in head and neck reconstruction. Analysis of complications. Am J Surg 1983;146:478-82.
14.	McLean JN, Carlson GW, Losken A. The pectoralis major myocutaneous flap revisited: A reliable technique for head and neck reconstruction. Ann Plast Surg 2010;64:570-3.
15.	Zou H, Zhang WF, Han QB, Zhao YF. Salvage reconstruction of extensive recurrent oral cancer defects with the pectoralis major myocutaneous flap. J Oral Maxillofac Surg 2007;65:1935-9.
16.	Jayaprakash D, Nandy K, Tripathi U, Mithi MT, Vyas R, Sadangi S. Bilobed PMMC in females: Our challenging yet meritorious experience. Indian J Surg Oncol 2021;12:39-47.
17.	Mehta S, Agrawal J, Pradhan T, Goel A, Kumar K, Dewan AK, et al. Preservation of aesthetics of breast in pectoralis major myocutaneous flap donor site in females. J Maxillofac Oral Surg 2016;15:268-71.