Case Presentation On Reconstruction With Pectoralis Major Myocutanious Flap
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Reconstruction after cancer surgery in the orofacial region is far the most important thing. hence Pectoralis Major Myocutanious Flap is termed as life boat flap.
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Case Presentation On Reconstruction With Pectoralis Major Myocutanious Flap
- 1. A Post Operative Case Presentation On Reconstruction With Pectoralis Major Myocutanious Flap Dr Mahbub Hussain MS (OMFS) BDS Lecturer Dhaka Dental College
- 2. Pectoralis Major Myocutanious Flap • History • Pickerel , then Hueston & McConchie • Ariyan in 1979
- 3. • Mandible • Floor of mouth • Tongue • Cheek • Neck • Skin of mid & lower third of face • Pharynx and laryngeal reconstruction
- 4. Types Pectoralis Major Flap 1)PMMC Flap a) Full Paddle b) Island c) Muscle Paddle d) Free 2) Osteomyocutaneous 3) Muscle Only Axial Pattern Flap
- 5. Surgical anatomy • It is a fan shaped muscle of the anterior chest wall. • Origin, insertion:
- 7. Pectoralis Major Myocutanious Flap contd… Advantage • Large skin territory. • Rich vascular supply, can be transferred without delay. • Large arc of rotation. • Can be harvested in supine position. • Can be used as a muscle only, skin and muscle paddle. • Primary donor site closure is easily achieved. • The flap requires no microvascular anastomosis. Disadvantage • In female person breast distortion/cosmetic deformity. • Heavy body hair in male limits the indication in reconstruction of oral cavity and larynx. • Difficult in use in obese individual. • Bulkiness of the flap compromising to intra-oral resurfacing. • Compromising to shoulder function.
- 8. Pectoralis Major Myocutanious Flap contd… True Contraindication • A prior history of radical axillary node dissection. Relative Contraindications • A history of breast surgery. • Prior flap reconstruction of the breast. • Morbidly obese or large breasted individuals. • Smoking, uncontrolled diabetes, peripheral vascular disease, poor nutritional status, prior radiation, may reduce success of cutaneous tissue survival.
- 9. Flap harvest Positioning, prepping and draping • The patient is placed in a supine position with the chest exposed and prepped up to the midline, and inferiorly to the costal margin. The upper arm is abducted slightly to expose the anterior axillary fold and lateral chest wall.
- 10. Flap Harvest Surface markings of vascular pedicle The surface markings of the vascular pedicle are determined by drawing a line from the acromioclavicular joint to the xiphisternum and another line vertically from the midpoint of the clavicle to intersect the 1st line.
- 11. Flap Harvest Contd. Skin paddle design The skin paddle is positioned over the pectoralis major muscle along the course of the pectoral branch of the thoracoacromial artery . In order to ensure that the pedicle is of adequate length, the distance between the top of the skin paddle and the inferior edge of the clavicle should be equal.
- 12. Flap Harvest Contd. Incision The skin paddle should be incised through subcutaneous fat to underlying muscle.
- 13. Flap Harvest Contd. Raising the flap Dissection starts infero-laterally and through avascular loose areolar plane between pectoralis minor and major muscle. Pectoral branch identified on the under surface lies medial to superior aspect of P. minor. Lateral extension identified and raised upto its insertion. Medially minimum 2 cm muscle attachment is left over body of sternum.
- 14. Flap Harvest Contd. Making the tunnel A tunnel should be made above the clavicle into the neck which is created by subplatysmal plane of dissection. The space within the tunnel can be assessed by inserting four finger of hand.
- 15. Flap Harvest Contd. Insetting the flap The flap placed must not be closed in tension. The flap should be secured in muscle subcutaneous and skin layers.
- 16. Drain placed and donor site can usually be closed Primarily.
- 17. Particulars of the patient • Name: Taijul Islam • Age: 40 years • Sex : Male • Address: Raipur, Lakshmipur.
- 18. Chief complaints • Ulceration on left posterior cheek for 6 months. • Restricted mouth opening for 3 months.
- 20. Salient feature Mr. Taijul Islam 40 years old male normotensive non diabetic hailing from Raipur, Lakshmipur; presented in OMFS Department BSMMU, with the complaints of ulceration on left side of retro-molar area for 6 months and restricted mouth opening for 3 months. He has given history of previous surgery at thyroid region 7 years back followed by radiotherapy. On examination, mouth opening was restricted 10-12 mm. There was an ulceration on left retro-molar area measuring 3x2 cm(sq), which was nontender, margin was everted shape, irregular, floor was sloughy and base was indurated. There was a lump on left cheek measuring 2x2 cm, tender on palpation, firm in consistency, surface was irregular, fixed with overlying skin and underlying structures. No palpable lymph node was found.
- 21. Investigations • All investigation for G/A fitness was done and found within normal limit. • Incisional biopsy revealed Squamous cell Carcinoma Grade I. • CT Scan.
- 22. CT Scan Axial View
- 23. CT Scan Coronal View
- 24. Treatment Plan • Wide excision with 1 cm healthy margin with segmental mandibulectomy with disarticulation. • Left sided Supra-Omohyoid Neck Dissection. • Margins are ensured by frozen section biopsy. • Reconstruction by Pectoralis Major myocutaneous flap.
- 37. 2nd POD
- 38. 4th POD
- 39. 7th POD
- 40. 10th POD
- 41. 12th POD
- 42. 12th POD
- 43. Thank you