Abstract
Introduction: Pectoralis major myo-cutaneous (PMMC) flap continues to be a widely used tool to reconstruct oral cavity defects. But an unreliable and unstable vascular supply can lead to complications like flap loss, Oro-cutaneous fistula and wound dehiscence. Preservation of the lateral thoracic artery (LTA) has been suggested to improve the vascularity of the skin paddle. The present study aspires to compare the complications and flap related outcomes after preserving or sacrificing the LTA while reconstructing oral cavity defects with bi-folded PMMC flap. Materials and Methods: Retrospective analysis of the data of 61 male patients who were reconstructed with bi-folded PMMC flaps between January 2022 and September 2022 was done. 36 patients were reconstructed using a PMMC flap where the LTA was sacrificed, whereas in 25 patients the LTA was preserved. Data was analyzed in terms of patient factors and flap related complications. Results: The overall complication rate including major/minor complications was 44.26% with flap detachment at 22.95% being the commonest complication observed. 13.11% patients developed an Oro-cutaneous fistula and partial and complete flap loss were seen in 9.83% and 4.91% respectively. LTA preservation was significantly associated with only decreased flap detachment rates (p value < 0.05). No significant association was noticed between other flap related complications and LTA preservation. Conclusion: Reconstructing larger defects with a PMMC flap where the LTA is preserved can help improve the vascularity of the flap and decrease various major/minor flap related complications.
Supplementary Information
The online version contains supplementary material available at 10.1007/s12070-023-04123-3.
Keywords: Oral cavity cancers, PMMC flap, Oral cavity reconstruction, Lateral thoracic artery, Head and Neck cancers
Introduction
Oral cavity malignancies pose an enormous burden on the healthcare infrastructure in India. These group of malignancies were the second highest cause of cancer presentations in India and 2nd most common cause (16.2%) of cancer presentations in Indian men in 2020 with 104,661 cases [1].
In the Indian subcontinent, buccal mucosa and GBS are the most common subsites affected in oral cavity cancers followed by cancers of the tongue [2, 3]. Habit of keeping these smokeless tobacco preparations in the pocket between the cheek mucosa and teeth leads to an increased incidence of such lesions in our population.
With the advent and mastery of microvascular anastomotic techniques, free flap reconstruction of oral cavity defects has become the accepted procedure of choice to restore the aesthetic, functional and anatomical properties of the oral cavity post full thickness through and through resections for oral cavity cancers [4, 5].
Described by Ariyan et al. in 1979, the Pectoralis Major Myo-cutaneous (PMMC) flap has withstood the test of time and remains a valuable, dependable and economical option in centers around the world [6]. The PMMC flap continues to be the workhorse for oral cavity reconstructions in resource constrained settings and centers where the microsurgical facilities are either not available or are too expensive to be used for a vast majority of patients [7, 8].
Despite the versatile nature of the flap and wide spectrum of defects for which it can be used, the PMMC flap suffers from certain pitfalls like flap detachments, fistula formation leading to surgical site infections and partial or complete flap loss [9, 10]. These drawbacks have been attributed to an unreliable blood supply of the flap [11, 12]. Yang et al. in 2003 demonstrated that the flap receives its blood supply from three systems. The thoraco-acromial system supplies the upper half of the flap, the anterior intercostal branches arising from the internal mammary artery supply the lower and medial part of the flap. The lower and outer half of the skin paddle, which essentially is used to reconstruct the mucosal defect is supplied by the lateral thoracic artery (LTA) [13]. Although the LTA is normally sacrificed while harvesting the flap to enhance the reach of the flap to reconstruct large distal defects, the importance of preserving the lateral thoracic can be stressed by cadaveric studies which reported that LTA forms the dominant blood supply of the flap in 6% of cases and other reports which state that LTA preservation stabilizes the blood flow to the flap and results in better perfusion of the skin paddle [14, 15].
This retrospective study aims to analyze and compare the complications and outcomes of preserving or sacrificing the lateral thoracic artery while harvesting the bi-folded PMMC flaps to reconstruct large oral cavity lesions in young male patients with cancers of the buccal mucosa and Gingivo-Buccal Sulcus (GBS) in a tertiary care center in Northern India.
Materials and Methods
After approval from the institutional ethics committee, a retrospective analysis was done of the cases in which a bi-folded PMMC flap was used to reconstruct oral cavity defects in male patients treated for biopsy proven cancers of the buccal mucosa and GBS. In our study the most common site affected was the lower GBS with 35 patients (57.37%), followed by lesions spanning from the lower GBS to the upper GBS necessitating a bite resection in 18 patients (29.5%). Lesions involving only the buccal mucosa were seen in only 8 patients (13.11%).
Data of 61 patients who underwent reconstruction with a PMMC flap between January 2021 and September 2022 was analysed of which 36 were reconstructed using a PMMC flap in which the lateral thoracic artery was sacrificed, whereas in 25 patients the lateral thoracic artery was preserved.
Inclusion Criteria
Male patients between 30 and 50 years of age with T4 stage OSCC of the buccal mucosa or GBS reconstructed with a bi-folded PMMC flap.
Exclusion Criteria
Female patients.
Men younger than 30 years of age and older than 50 years of age.
Patients with co-morbidities like diabetes, hypertension or atherosclerotic disease.
Patients who had received previous anti-cancer treatment like chemotherapy or radiotherapy.
Patients who presented with recurrence following previous anti-cancer treatment including surgery, chemotherapy and radiotherapy and were subsequently reconstructed using a PMMC flap.
Patients with metastatic disease.
A total of 134 male patients with cancers of the buccal mucosa and GBS were reconstructed using a bi-folded PMMC flap during the study period. 48 patients were older than 50 years of age and 6 patients were younger than 30 years of age and were excluded from the study. Of the remaining 80 patients, 11 patients were on treatment for diabetes mellitus and 6 were suffering from hypertension and 2 were taking treatment for HIV/AIDS and were excluded from the study. After excluding the above mentioned patients, a final analysis was done from the data of 61 patients.
Data from hospital records and out-patient department sheets was analyzed in terms of patient factors like age, site of disease, size of defect created post resection. Flap related complications like partial/total flap necrosis, flap detachments, Oro-cutaneous fistula (OCF) formation, Surgical Site Infections (SSI) and need for a second surgical intervention, were also analyzed. Statistical analysis was done using SPSS for windows (version 22.0).
Surgical Technique
The PMMC flap is a myo-cutaneous flap based on the pectoral branch of the thoraco-acromial artery along with contribution from the lateral thoracic artery. Both of these vessels originate from the second part of the axillary artery.
Defining the Extent of the Flap
In our institute all oral cavity malignancies undergo resection with a minimum margin of 1 cm along with a modified radical neck dissection (MRND), where the sternocleidomastoid muscle is sacrificed. Post resection the distance between the cranial most part of the defect is measured from the pivot point of the flap which is the mid-clavicular point and the same distance is used to define the caudal most extent of the flap over the patients’ chest surface from the pivot point. The mucosal and the cutaneous width of the defect is measured using a scale and similar marking are made on the breast surface keeping in the mind the caudal most point as described above. The markings are oriented in such a way so that the lateral half of the flap is used to reconstruct the mucosal defect and the medial part near the sternum is used for reconstructing the cutaneous defect. All flaps in our institute are harvested in a transverse orientation.
The release incision is usually placed in an oblique fashion from the medial aspect of the flap extending laterally and upwards. We are careful not to extend the release incision onto the skin surface of the Delto-Pectoral (DP) flap which may be useful for further reconstructive purposes. We also try and avoid including the Nipple area complex (NAC) in the flap for cosmetic purposes (Fig. 1).
Fig. 1.
Flap is marked according to size of the defect over the chest taking into consideration that the release incision doesn’t extend into the area of the Delto-pectoral flap
Raising the Flap While Sacrificing the Lateral Thoracic Artery
Incision is made over the over the markings of the flap and over the release incision and deepened down to the pectoralis major muscle. The skin and the pectoral fascia are raised over the pectoralis major muscle till the clavicle. The dermis of the flap is now fixed to the muscle at various places to avoid injuring the perforators to the skin by the shearing forces which might come into play while raising and tunneling the flap. The lateral edge of the pectoralis muscle is clasped in a Babcock’s forceps and lifted and a plane is created between the pectoralis major muscle and the underlying structures. The muscle around the flap is divided from the inferior and medial sides ensuring that the skin paddle is adequately placed over the muscle. Lifting of the flap begins now. The main pedicle formed by the pectoral branch of the thoraco-acromial artery is identified running on the dorsal surface of the flap. Arising from the lateral edge of the pectoralis minor and running onto the lateral surface of the pectoralis major, the lateral thoracic artery is identified, ligated and divided. Muscle is cut on both sides of the main pedicle along its length ensuring its safety. The lateral pectoral nerve is divided to increase the reach of the flap. Laterally the cephalic vein and deltoid branch of thoraco-acromial vessels is identified in the DP groove and are preserved. Finally, the clavicular portion of the muscle is divided to decrease the bulk of the flap while folding over the clavicle and increase its reach. The flap is now tunneled through the subcutaneous tissues over the clavicle into the neck holding the muscle and skin paddle together to avoid the shearing forces.
Raising the Flap While Preserving the Lateral Thoracic Artery
Initial steps are followed in a similar manner as described above and the lateral thoracic artery is identified arising from the lateral edge of the pectoralis minor muscle (Fig. 2). The pectoralis minor is divided around the lateral thoracic vessels, skeletonizing the lateral thoracic artery in its entirety (Fig. 3). Branches of the lateral thoracic artery supplying the subscapularis and axillary structures and those supplying the serratus anterior are divided. The reach of the flap is not compromised. Muscle is divided lateral to the lateral thoracic artery and medial to the main pedicle consisting of the pectoral branch of the thoraco-acromial artery. The remaining steps are followed in a similar manner as described in the previous section.
Fig. 2.
Lateral thoracic artery is identified arising from the lateral edge of the pectoralis minor muscle
Fig. 3.
Lateral thoracic vessels are exposed and skeletonized after dividing the pectoralis minor muscle around the vessels
The flap is now tunneled through the subcutaneous tissues over the clavicle into the neck holding the muscle and skin paddle together to avoid the shearing forces.
Flap Fixation
The fixation of the flap to the defect is started by initially suturing the flap to the posterior most point of the defect using Vicryl 3 − 0 interrupted sutures. Flap is then sutured to the mucosa by using interrupted vertically placed mattress sutures and then used to cover the bone of the mandible/maxilla with a holding inter-dental fixation suture. Flap is then folded and the area of transition is de-epithelialized to suture it with the cut ends of the lips to form a new commissure. The remaining folded portion is now used to reconstruct the cutaneous part of the defect. The skin of the flap is now fixed to the skin of the face using interrupted Prolene 3 − 0 sutures.
Donor Site Defect Closure
After ensuring there is no active bleeding, a suction drain is placed and subcutaneous tissues are approximated using Vicryl 3 − 0 interrupted sutures and skin is closed using skin staples.
Results
The study population consisted of 61 men with a biopsy proven diagnosis of Squamous Cell Carcinoma of the oral cavity with a T4 stage disease. Mean age of patients in our study was 45.64 years (30–50 years). 35 men (57.37%) underwent resections for tumor placed in lower gingiva-buccal sulcus (GBS) and 18 patients (29.50%) underwent a “bite resection” for tumors involving both the upper and lower GBS. Eight patients (13.11%) had involvement of only the buccal mucosa. Accompanying partial glossectomies were carried out in five patients.
The size of the defect ranged from 5 × 3.5 cm to 6 × 4.5 cm for the mucosal defect and from 4 × 3 cm to 10 × 8.5 cm for the cutaneous defect. Average operating time was 207 min (195–265 min) for the whole procedure and 96 min (85–125 min) for harvesting and in-setting of the PMMC flap. Table 1 details the patient, disease and procedure related characteristics of our study.
Table 1.
Patient, disease and procedure related characteristics of the study
| Characteristic | Divisions | Number | % of Total (n = 61) |
|---|---|---|---|
| Age | 30—40 years | 23 | 37.70 |
| 40–50 years | 38 | 62.29 | |
| Site of Disease | Lower GBS only | 35 | 57.37 |
| Buccal Mucosa only | 8 | 13.11 | |
|
Upper + lower GBS (Bite Resection) |
18 | 29.5 | |
| Size of Defect | |||
| Mucosal Defect | Minimum = 5 × 3.5 cm | ||
| Maximum = 6 × 4.5 cm | |||
| Cutaneous Defect | Minimum = 4 × 3 cm | ||
| Maximum = 10 × 8.5 cm | |||
| Operating Time | Complete Procedure | Minimum = 195 min | Average = 207 min |
| Maximum = 265 min | |||
| PMMC Harvest | Minimum = 85 min | Average = 96 min | |
| Maximum = 125 min | |||
| Time to oral intake of meals | Liquids | 5 days (2–12 days) | |
| Solids | 7 days (5–14 days) | ||
| Length of hospital stay (post operative) | 7.5 days (4–16 days) | ||
| Adjuvant Therapy | Only RT | 56 patients | 91.80 |
| Combined CT/RT | 5 patients | 8.19 | |
|
Time to start of adjuvant therapy |
</= 6 weeks | 60 | 98.36 |
| > 6 weeks | 1 | 1.63 |
In our study, 27 patients (44.26%) reported some form of major/minor complications associated with the procedure. Of these 27 patients, 16 (59.25%) were those in which the lateral thoracic artery was sacrificed and in the remaining 11 patients (40.74%) the lateral thoracic artery was preserved. The most common complication was that of flap detachment which was seen in 14 patients (22.95%) overall. All of these instances of detachment occurred at the site of the superior mucosal attachment of the flap. 12 of these 14 patients were those in which the LTA was sacrificed, whereas in two other patients the LTA was preserved.
Oro-cutaneous fistula formation was seen in 8 patients (13.11%) of which 5 developed (8.19%) a Surgical Site Infection (SSI) of the neck wound due infection of the saliva trickling down into the neck. All of these 5 patients developed an SSI of the posterior neck flap. Out of the 8 patients who developed an OCF, 5 were managed conservatively. Two patients had to undergo reconstruction of the posterior neck flap with a DP flap and one patient with a bigger defect was reconstructed with a Latissimus Dorsi (LD) flap. Amongst the 8 patients who developed an OCF, the LTA was sacrificed in 5 patients and preserved in 3 patients.
Three of our patients (4.91%) suffered a complete flap loss [2 patients had their LTA sacrificed and 1 patient lost the flap where the LTA was preserved]. Six patients (9.83%) suffered a partial flap loss of the outer half in varying amounts of the part of the flap used to reconstruct the cutaneous defect. Amongst these 6 patients who suffered a partial flap loss, 4 had their LTA sacrifice and 2 patients had their LTA preserved. Patients suffering from a complete flap loss were reconstructed with a free fibula Osseo-myo-cutaneous flap within ten days of the initial procedure. Patients with loss of the outer half were reconstructed with a forehead flap in 4 cases and DP flap in two cases. Four cases of partial flap loss were only marginal and were managed with debridement and secondary suturing.
Post operatively 10 patients (16.39%) complained of difficulty in maintaining the competence of the new oral commissure created and complained of persistent drooling of saliva from the new angle of the mouth. All of these 10 patients underwent a commissuroplasty procedure, where the lifting up of the commissure was done to maintain its competence.
In total secondary surgical interventions were needed in 22 patients (36.06%). Table 2 documents the various procedure and flap related complications reported in our study and Table 3 highlights the comparison of complications seen between flaps in which the lateral thoracic artery was preserved and those in which the vessel was sacrificed. LTA preservation was significantly associated with only decreased flap detachment rates (p value < 0.05). No significant association was noticed between other flap related complications and LTA preservation.
Table 2.
Procedure and flap related complications encountered during the study
| Complications | Number | % of Total (n = 61) |
|---|---|---|
| Flap Detachment | 14 | 22.95 |
| Oro-cutaneous fistula (OCF) | 8 | 13.11 |
| Surgical Site Infection (SSI) | 5 | 8.19 |
| Partial flap loss | 6 | 9.83 |
| Complete flap loss | 3 | 4.91 |
| Oral Incontinence | 10 | 16.39 |
| Overall Complication Rate | 27 | 44.26 |
Table 3.
Comparison of complications in flaps where the LTA was sacrificed against those where the LTA was preserved
| Complications Assessed | Lateral Thoracic Artery Sacrificed (36) | Lateral Thoracic Artery Preserved (25) | P value |
|---|---|---|---|
| Flap Detachment (14) | 12 (33.33%) | 2 (8%) | 0.0206 |
| Oro-cutaneous Fistula (8) | 5 (13.8%) | 3 (12%) | 0.8298 |
| Complete Flap Loss (3) | 2 (5.55%) | 1 (4%) | 0.78231 |
| Partial Flap Loss (6) | 4 (11.11%) | 2 (8%) | 0.6882 |
Average time to starting oral intake of liquids was 5 days (Day 2- Day 12) and for solid foods it was 7 days (Day 5- Day 14). Average length of stay in the hospital post operatively was 7.5 days (Day 4- Day 16). All our patients received post operative adjuvant radiotherapy and five.
patients received combined radio and chemotherapy in view of extra nodal extension found in neck nodes. All patients were able to start adjuvant therapy within six weeks except one who was reconstructed after with a fibular free flap after loss of the PMMC flap and required prolonged ICU support in view of a poor chest condition.
Discussion
Restoration of the form and function of the oral cavity post resection for cancers of the buccal mucosa continues to constitute a challenge for surgeons. Improper reconstruction can lead to compromised oral cavity function post-surgery affecting the speech, swallowing, cosmesis and oral continence of the patient. More importantly flap and procedure related complications can lead to multiple secondary corrective surgeries and prolonged surgical management which can delay initiation of adjuvant therapy. Delay in adjuvant therapy, especially radiotherapy predisposes patients with advanced disease to an early development of loco regional recurrence.
Despite being extensively used in centers in the developing world for reconstruction of large oral cavity defects, complications of the PMMC flap like flap detachment, partial or complete flap loss and formation of OCF have led to authors questioning the unstable vascular supply of the flap [12, 16].
We chose a study population consisting of young male patients without co-morbidities to nullify the effects of various confounding factors which may compromise the vascularity of the flap like women undergoing reconstruction with a PMMC flap, where the bulkiness of the flap due to large amount of intervening fatty breast tissues can affect the vascularity of the skin paddle. Patients with co-morbidities like diabetes, hypertension and history of coronary artery disease were excluded to ensure optimum quality of the vasculature of the flap.
Our study consisted of young men between 30 and 50 years of age reconstructed with a bi-folded PMMC flap for large defects of the oral cavity created after resections for oral cavity malignancies. Majority of our patients (38, 62.29%) were between 40 and 50 years of age whereas 23 patients (37.70%) patients were between 30 and 40 years of age. The mean age of our study population was 45.64 years. Although we chose a fixed age range for our study, it is important to note that in recent years there has been a trend towards an earlier presentation of oral cavity cancer in the Indian population [2, 3]. These can be attributed to an extremely high proportion of people in our country consuming and being addicted to cigarettes and smokeless forms tobacco like ghutka and khaini [17].
In the present study, flap or procedure related complications were seen in 27 patients (44.26%). Our overall complication rates were slightly higher than other studies from India which studied reconstruction of oral cavity defects using a bi-folded PMMC flap [18, 19]. It was substantially higher than the 16.93% complication rate reported by Gadre et al. while using the PMMC flap [20]. While comparing with studies from around the world, our complication rates were lower than those reported by Kroll et al. and El-Marakby et al. and similar to the results reported by Ethier et al. in 2009 [21–23].
Flap detachment was seen in 14 patients (22.95%) and was the most common complication seen in our study. All cases of flap detachment occurred at the superior mucosal attachment of the flap. Tripathi et al. while analyzing the results of PMMC flaps used for reconstruction of head and neck malignancies reported a wound dehiscence rate of about 26% [10]. But other studies from India while studying PMMC reconstruction for complex oral cavity defects for advanced malignancies reported a much lower incidence [18, 19, 24]. We encountered an OCF formation in 8 patients (13.11%) of which five patients (8.19%) eventually went on to develop an SSI of the neck wound due to the infection of the saliva which trickled down into the neck. In all of these five cases, it was the posterior flap which was affected and had to be debrided. Although other Indian authors reported a slightly lower or similar incidence of OCF [10, 24], the prevalence of SSI was lower in our study as compared to other reports [10, 19, 20]. Advanced presentations of malignancies and poorer pre-operative nutritional status of the patients might be factors responsible for a higher OCF rate in our study. Six patients (9.83%) suffered a partial necrosis of the outer half of the flap which was used to reconstruct the cutaneous defect and a complete flap loss was noticed in three patients (4.91%) overall. Numerous studies from the subcontinent have reported varied results in terms of flap survival post PMMC reconstruction. Our rates of partial flap loss were similar to reports by Konduru et al. and Pradhan et al. [18, 24]. But complete flap loss rates in our study were higher than the outcomes reported by Konduru et at from Vellore and Neville et from Varanasi who reported complete flap loss rates of 0% and 0.9% respectively [18, 19]. Differences in flap harvesting techniques, patient factors and disease factors may be responsible for these slightly varied results.
While reviewing the literature we could not find any study which compared the results of the PMMC flaps in cases where the lateral thoracic artery was preserved against the ones where it was sacrificed. Papers by Yuen et al., Lyu et al. and Kanno et al. documented no instances of complete or partial flap loss, wound dehiscence or fistula formation when they studied the PMMC flaps where the LTA was preserved [16, 25, 26]. Kumegawa et al. while studying the blood circulation of the PMMC flap using indocyanine green also did not document any flap related complications. Rather they stated that in their second case, preservation of the LTA was essential to maintain the vascularity of the skin paddle [27].
While analyzing flap related complications in our study, complete or partial flap loss and OCF formation did not have any significant association with LTA preservation. The only association which was statistically significant in our study was that between superior intra-oral mucosal site wound dehiscence and LTA preservation (p < 0.05). This can probably be explained by the fact that the inner mucosal lining is reconstructed using the lateral half of the skin paddle which does derive its blood supply from the LTA. Further research and studies with more participants can help clarify the role of preserving the LTA while harvesting the PMMC flap.
Conclusion
PMMC flap continues to maintain its place as the “go to” reconstructive option in settings where the facility of the free flap is not available or not affordable. As we ambitiously aim to reconstruct bigger and higher defects with the PMMC flap, it is only prudent to preserve the LTA in as many cases as possible. LTA preservation may help in not only stabilizing the blood flow of the flap, but also help in preventing minor or major flap related complications.
Electronic Supplementary Material
Below is the link to the electronic supplementary material.
Funding
The present study was conducted after obtaining clearance from the institutional ethics committee. No source of external/internal funding was utilized to conduct this study
Declarations
Conflicts of interests
The authors have no conflicts of interests to declare.
Informed consent
An informed consent was obtained from every participant before enrolling them in the study.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Sung H, Ferlay J, Siegel RL, Laversanne M, Soerjomataram I, Jemal A, Cancer, et al. J Clin. 2021;71:209–249. doi: 10.3322/caac.21660. [DOI] [PubMed] [Google Scholar]
- 2.Sharma RG, Bang B, Verma H, Mehta JM. Profile of oral squamous cell Cancer in a Tertiary Level Medical College Hospital: a 10 yr study. Indian J Surg Oncol. 2012;3:250–254. doi: 10.1007/s13193-012-0165-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Aggarwal V, Rao D, Mathur A, Batra M, Makkar D. Prevalence of head and neck and oral cancer in Rajasthan: an infirmary based retrospective study. Clin Cancer Investig J. 2015;4:339–343. doi: 10.4103/2278-0513.154537. [DOI] [Google Scholar]
- 4.Urken ML, Weinberg H, Buchbinder D, Moscoso JF, Lawson W, Catalano PJ, et al. Microvascular free flaps in Head and Neck Reconstruction: report of 200 cases and review of complications. Arch Otolaryngol Head Neck Surg. 1994;120:633–640. doi: 10.1001/archotol.1994.01880300047007. [DOI] [PubMed] [Google Scholar]
- 5.Pinto FR, Malena CR, Vanni CMRS, Capelli F, de Matos A, de Kanda LL. Pectoralis major myocutaneous flaps for head and neck reconstruction: factors influencing occurrences of complications and the final outcome. Sao Paulo Med J. 2010;128:336–341. doi: 10.1590/S1516-31802010000600005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979;63:73–81. doi: 10.1097/00006534-197901000-00012. [DOI] [PubMed] [Google Scholar]
- 7.Liu M, Liu W, Yang X, Guo H, Peng H. Pectoralis Major Myocutaneous Flap for Head and Neck defects in the era of free flaps: harvesting technique and indications. Sci Rep. 2017;7:46256. doi: 10.1038/srep46256. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Petruzzelli GJ, Brockenbrough JM, Vandevender D, Creech SD. The influence of reconstructive modality on cost of care in head and neck oncologic surgery. Arch Otolaryngol Head Neck Surg. 2002;128:1377–1380. doi: 10.1001/archotol.128.12.1377. [DOI] [PubMed] [Google Scholar]
- 9.Leite AKN, de Matos LL, Belli M, Kulcsar M, a V, Cernea CR, Garcia Brandão L, et al. Pectoralis major myocutaneous flap for head and neck reconstruction: risk factors for fistula formation. Acta Otorhinolaryngol Ital. 2014;34:389–393. [PMC free article] [PubMed] [Google Scholar]
- 10.Tripathi M, Parshad S, Karwasra R, Singh V. Pectoralis major myocutaneous flap in head and neck reconstruction: an experience in 100 consecutive cases. Natl J Maxillofac Surg. 2015;6:37. doi: 10.4103/0975-5950.168225. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Harrison B, Khansa I, Janis JE (2016) Evidence-based strategies to reduce postoperative complications in plastic surgery: plastic and reconstructive surgery. 137:351–360. 10.1097/PRS.0000000000001882 [DOI] [PubMed]
- 12.Liu R, Gullane P, Brown D, Irish J. Pectoralis major myocutaneous pedicled flap in head and neck reconstruction: retrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital. J Otolaryngol. 2001;30:34–40. doi: 10.2310/7070.2001.21011. [DOI] [PubMed] [Google Scholar]
- 13.Yang D, Marshall G, Morris SF. Variability in the vascularity of the pectoralis major muscle. J Otolaryngol. 2003;32:12–15. doi: 10.2310/7070.2003.35357. [DOI] [PubMed] [Google Scholar]
- 14.Nakajima K, Ide Y, Abe S, Okada M, Kikuchi A, Ide Y. Anatomical study of the pectoral branch of thoracoacromial artery. Bull Tokyo Dent Coll. 1997;38:207–215. [PubMed] [Google Scholar]
- 15.Onoda S, Azumi S, Miura Y, Kimata Y. Head and Neck Reconstruction by using extended Pectoralis Major Myocutaneous Flap. J reconstr Microsurg. 2015;31:300–304. doi: 10.1055/s-0034-1396788. [DOI] [PubMed] [Google Scholar]
- 16.Po-Wing Yuen A. Preservation of lateral thoracic artery to improve vascular supply of distal skin without compromising pedicle length in harvesting pectoralis major myocutaneous flap. J Plast Reconstr Aesthet Surg. 2006;59:1433–1435. doi: 10.1016/j.bjps.2006.02.007. [DOI] [PubMed] [Google Scholar]
- 17.Grover S, Anand T, Kishore J, Tripathy JP, Sinha DN. Tobacco Use among the Youth in India: evidence from global adult Tobacco Survey-2 (2016–2017) Tob Use Insights. 2020;13:1179173X20927397. doi: 10.1177/1179173X20927397. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Konduru V, Tirkey AJ, Samy K, Devarakonda KK, Janakiraman R. The folded, bipaddled pectoralis major myocutaneous flap for complex oral cavity defects: undiminished relevance in the era of free flaps. JPRAS Open. 2021;27:108–118. doi: 10.1016/j.jpra.2020.11.007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Neville JF, Tilak M, Kumar J, Mishra N, Singh A, Sharma N, et al. 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. Natl J Maxillofac Surg. 2022;13:216. doi: 10.4103/njms.njms_374_21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Gadre KS, Gadre P, Sane VD, Halli R, Doshi P, Modi S. 2013. :2005.e1-2005.e10. [DOI] [PubMed]
- 21.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;25:93–97. doi: 10.1097/00000637-199008000-00003. [DOI] [PubMed] [Google Scholar]
- 22.El-Marakby HH. The reliability of pectoralis major myocutaneous flap in head and neck reconstruction. J Egypt Natl Canc Inst. 2006;18:41–50. [PubMed] [Google Scholar]
- 23.Ethier JL, Trites J, Taylor SM. Pectoralis major myofascial flap in head and neck reconstruction: indications and outcomes. J Otolaryngol Head Neck Surg. 2009;38:632–641. [PubMed] [Google Scholar]
- 24.Pradhan P, Samal S, Preetam C, Samal DK, Parida PK. Pectoralis Major Myocutaneous Flap Reconstruction for the Mandibular Defects in Advanced oral cavity malignancies: a retrospective study of 30 cases. Indian J Otolaryngol Head Neck Surg. 2018;70:415–420. doi: 10.1007/s12070-018-1429-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Lyu X, Liu S, Zheng L, Huang M, Zhang J, Zhang J. A Modified Design of the Pectoralis Major Myocutaneous Flap for Reconstruction of Head and Neck defect. J Craniofac Surg. 2021;32:1762–1764. doi: 10.1097/SCS.0000000000007287. [DOI] [PubMed] [Google Scholar]
- 26.Kanno T, Nariai Y, Tatsumi H, Karino M, Yoshino A, Sekine J. A modified pectoralis major myocutaneous flap technique with improved vascular supply and an extended rotation arc for oral defects: a case report. Oncol Lett. 2015;10:2739–2742. doi: 10.3892/ol.2015.3696. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Kumegawa S, Miyazaki H, Sakata Y, Uemura K, Ueno K, Wada Y, et al. Lateral thoracic artery can stabilize circulation in the Pectoralis Major Myocutaneous Pedicle Flap: Single-center, prospective, uncontrolled Case Series. Plast Reconstr Surg - Global Open. 2021;9:e3860. doi: 10.1097/GOX.0000000000003860. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.