Jha RK, Jami S, Tiwari RVC, Purohit J, Vipindas AP, Ibrahim M, Binyahya FA. The Effectiveness of the Bilobed Pectoralis Major Myocutaneous Flap at a Tertiary Care Hospital: A Retrospective Analytical Study. J Pharm Bioallied Sci. 2021 Nov;13(Suppl 2):S1291-S1294. doi: 10.4103/jpbs.jpbs_111_21. Epub 2021 Nov 10. PubMed PMID: 35017973; PubMed Central PMCID: PMC8686951

1. S1291
© 2021 Journal of Pharmacy and Bioallied Sciences | Published by Wolters Kluwer - Medknow
Background: Cosmetic defects after the major orofacial disease corrections
may have an effect on the overall well‑being of the patient. Head‑and‑neck
cosmetic surgeries after a major episode of oral cancer impact the functional
ability of the individual in several ways. In general, two types of flap are
used in reconstructive surgery: microvascular free flaps and regional pedicle
flaps. In socioeconomically poor countries like India, bilobed pectoralis major
myocutaneous (PMMC) flap has been seen as a mainstay in facial reconstructive
surgeries. Materials and Methods: The present study was conducted on
100 individuals with oral neoplasm who underwent resective surgery had a
soft‑tissue defect. All the complications that arose after reconstructive surgery
were noted. Simple proportions were recorded. Results: Majority of the
individuals had the buccal mucosa as the common site of oral neoplasm, and
the tumor nodes and metastases staging was I + II. One individual sustained
total flap necrosis. Wound infection and dehiscence were the most common
complications. Conclusions: PMMC is best proven for flap reconstruction in
oral neoplasm cases. It is established to be effective with good acceptability and
very few complications. Due to these reasons, in spite of the known advances in
facial reconstructive surgeries, this technique is widely followed in developing
countries.
Keywords: Bilobed pectoralis major myocutaneous, complications, flap necrosis
The Effectiveness of the Bilobed Pectoralis Major Myocutaneous Flap at
a Tertiary Care Hospital: A Retrospective Analytical Study
Rohit Kumar Jha1
, Sreeja Jami2
, Rahul V. C. Tiwari3
, Jayendra Purohit4
, A. P. Vipindas5
, Mohammed Ibrahim6
, Fatima
Abdullah Binyahya7
Access this article online
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Website: www.jpbsonline.org
DOI: 10.4103/jpbs.jpbs_111_21
Address for correspondence: Dr. Rohit Kumar Jha,
Department of Surgical Oncology, Rajendra Institute of Medical
Sciences, Ranchi, Jharkhand, India.
E‑mail: rohitjhaonco@gmail.com
accessibility, and abilities of the maxillofacial surgeons
in developing countries; the free flap has emerged as a
preferred mode of operation and has remained a gold
slandered. In these conditions, bilobed pectoralis major
myocutaneous (PMMC) flap may be employed. These
flap designs can be used in various procedures such
as compromised patient status, failure of free flaps, or
Introduction
Oral cancer is a known burden worldwide, and in
particular, due to late recognition in developing
countries like India, reconstruction of the deficit in
facial region is a challenge.[1]
Cosmetic defects after
the major orofacial disease corrections may have
an effect on the overall well‑being of the patient.
Head‑and‑neck cosmetic surgeries after a major episode
of oral cancer impact the functional ability of the
individual in several ways.[2]
In general, two types of
flap are used in reconstructive surgery: microvascular
free flaps and regional pedicle flaps. It is possible now
with the global access to knowledge, improved clinical
1
Department of Surgical
Oncology, Rajendra Institute
of Medical Sciences, Ranchi,
Jharkhand, India, 2
Oral
and Maxillofacial Surgery,
Redmond, Washington, US,
3
Department of OMFS,
Narsinhbhai Patel Dental
College and Hospital,
Sankalchand Patel University,
Visnagar, Gujarat, India,
4
Department of Oral and
Maxillofacial Surgery, College
of Dental Sciences and
Hospital, Bhavnagar, Gujarat,
India, 5
Malabar Dental
College and Research Centre,
Malappuram, Kerala, India,
6
Department of Oral and
Maxillofacial Surgery, College
of Dentistry, King Khalid
University, Abha, 7
Ministry of
Health, Riyadh, Saudi Arabia
Abstract
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com
How to cite this article: Jha RK, Jami S, Tiwari RV, Purohit J, Vipindas AP,
Ibrahim M, et al. The effectiveness of the bilobed pectoralis major
myocutaneous flap at a tertiary care hospital: A retrospective analytical
study. J Pharm Bioall Sci 2021;13:S1291-4.
Original Article
Submitted: 26‑Feb‑2021
Revised: 12-Mar-2021
Accepted: 26‑Mar‑2021
Published: 10-Nov-2021
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2. S1292 Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 2 ¦ August 2021
Jha, et al.: Effectiveness of bilobed PMMC
in combination with free flaps as soft‑tissue filler.[3,4]
Reconstruction with free flaps in nonindustrial nation
is troublesome because of significant expense, much
time, infrastructure lapses, and trained manpower
deficit. Flaps can be of two types myocutaneous flap
(latissimus dorsi, pectoralis major, trapezius flaps) or
fasciocutaneous flap (deltopectoral flap). Myocutaneous
flaps have an advantage over the other designs as it is
easy to learn. For this reason, it is employed in most
of the reconstruction surgeries. In the study of Arlyan
and Cuono, myocutaneous flaps, mainly pectoralis
major, and its application were described.[1,5]
PMMC has
the following advantages. Has adequate blood supply,
preserves, and protects the major structures even when
they have been compromised due to the irradiation or
other medical conditions, viability is good,[1,6,7]
There
has been a vast range of the success and associated
complications of the PMMC reported from the various
studies.[8]
The complications commonly seen in the
other reconstruction techniques are also reported with
this design, however, the rate is not uniform.[9,10]
Hence,
in the present study, we aim to evaluate the reliability
of PMMC flap in head‑and‑neck reconstruction. The
technique, complications, and the functional as well as
esthetic outcome of the flap utilization were evaluated.
Materials and Methods
A retrospective analytic study was conducted among
100 individuals with cosmetic defects post tumor
resection in the head‑and‑neck region. The individuals
were selected only after the histopathological and
radiographic confirmation of oral squamous cell
carcinoma (SCC) was done and the stage was
established. All the routine diagnostic tests were done.
In the established participants, the wide local excision
of the tumor (with 2 cm safety margin) with or without
hemimandibulectomy with modified radical neck
dissection was done and the bilobed PMMC flap was
done for the reconstruction. Finally, the parameters
such as the success and viability of the flap, functional
restoration, and all the complications were noted. The
patients who underwent chemoradiation were excluded
from our study. Only the simple proportions for the site,
stage, and complications were calculated.
Procedure
Demarcations
A line was drawn from the same side acromion to the
xiphisternum for the vascular pedicle and alternative line
vertically from the median of the clavicle to interconnect
the first line.
Skin paddle design
The skin paddle was planned and set apart over the
chest caudally‑medially to the nipple with saving of
the areola. The shape of the skin paddle coordinated
the defect, principally elliptical, and it is situated over
the pectoralis major muscle along the course of pectoral
part of thoracoacromial artery. The distance between the
highest point of the skin pedicle and inferior edge of the
clavicle should equal to or surpass the distance between
the receiving site for the flap and the inferior edge of the
clavicle.
Skin paddle elevation
The skin is chiseled around the skin paddle, and the
dissection is expanded onto the surface of pectoralis
significant muscle. During flap rise, care was taken not
to undermine the skin paddle, but instead to bevel it, in
order to incorporate myocutaneous perforators.
The skin paddle was stitched to the hidden pectoralis
muscle with a couple of stitches to limit the danger
of shearing injury to myocutaneous perforators. The
dissection plane between the pectoralis minor and
pectoralis significant muscles with its vascular pedicle
was found by line by dissecting the lateral border of
pectoralis major muscle. Once in the plane, we could
undoubtedly free the pectoralis major with its vascular
pedicle from pectoralis minor muscle. The pectoralis
major muscle was separated laterally to the pedicle
while keeping the pedicle in view, along these lines
liberating it from the humerus.
Skin tunnel over clavicle
A segment of the clavicular strands of the muscle was
divided to accommodate just the neurovascular pedicle
and its adventitia, disposing of the supraclavicular hump.
The flap was presently passed into the neck through a
subcutaneous passage made shallow to the clavicle.
The passage was made wide enough to allow simple
conveyance of the fold into the neck with no pressure.
Donor site defect closure
Stitching of the fold was made with 3‑0 vicryl intruded
on stitches. Drains were put in the neck and chest, and
the injuries were shut in layers. The contributor site
was constantly shut basically, which required extensive
mobilization fasciocutaneous flaps.[11,12]
Results
Majority in our study were men followed by women.
The mean age was observed 35 ± 12 years. With
region of the presence of the lesion, the most common
site observed was buccal mucosa (59%) followed by
sulcus. The least common site was lower lip [Table 1].
With regard to the TNM stage of oral SCC, the stage
that was seen in most of the participants was at the
time of the reconstruction was Stages I + II (52%),
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3. S1293
Journal of Pharmacy and Bioallied Sciences ¦ Volume 13 ¦ Supplement 2 ¦ August 2021
Jha, et al.: Effectiveness of bilobed PMMC
nearly similar percentage of participants were seen at
Stage III (42%), the least percentage was seen in Stage
IV (6%) [Table 2]. The complications were noted in
69% of the participants. Overall good survival of the
flap was observed in the present study. In only a single
participant, total necrosis was seen (1%). Partial skin
necrosis, orocutaneous fistula, and wound hematoma
were the next least distributed complications (<10%).
Wound infections and wound dehiscence were the
major complications seen in the participants in our
study. Spontaneous healing was observed in the minor
dehiscence. Resuturing was done in the participants
with larger dehiscence. No fatality was reported in the
present study. Appropriate treatments were done for
all the complications [Table 3]. Furthermore, in few
participants, hair growing intraorally was observed.
This was observed in male participants particularly.
Other complications that are not related to the PMMC
were also observed. They were pleural empyema, neck
seroma, chyle leak, parotid leaks and fistula, and neck
skin dehiscence. However, they were seen in very
few patients (<10%). All these complications were
thoroughly managed later.
Discussion
In developing countries like the USA, there has been a
paradigm shift in reconstructive surgeries. However, in
developing countries like India, PMMC flap designs
are still practiced due to the less economic, time for the
procedure, ease of learning, safe to the major structures
passing near the surgical site, viability, and good
functional and cosmetic results. PMMC flap design has
been appreciated for the reliability in many studies as it
is most commonly used to treat the cosmetic defects that
arose from the tumor respective surgeries. This was also
supported in the study done by Brusati et al., where they
observed a lower complication and a greater survival
rate.[13]
There have been several variations suggested in
the flap design. In the study of Ahmad et al., bipedicle
PMMC flap was performed with a good success rate.[14]
In our study similar to the above study, all the participants
were treated with the bipedicle PMMC flap for the
reconstruction of the defect. In our study, 69% of the
participants had complications related to the flap. In the
study conducted by Pinto, the complications after a PMMC
flap were identified to be due to external compression to
flap, injudicious use of the electrocautery, the general
condition of the patient improper infection control, flap
extended past the seventh rib, and longer pedicle.[15]
Total necrosis was seen in 1% of the participants. Similar
observations were seen in Mehrhof et al., where 4% flap
necrosis was noticed.[16]
In the study of Brusati et al., 2%
were seen to have necrosis.[13]
Our study was in unison
with the above study. Along with the total flap necrosis,
other complications such as partial necrosis, dehiscence,
fistula, and infections were observed. Flap unrelated
complications were noted in few. The noted complications
were 69% which is in concurrence with the literature.
Satisfactory outcome was observed in the present study,
with the greater acceptability of the flap.
Conclusions
PMMC is best proven for flap reconstruction in oral
neoplasm cases. It is established to be effective with
good acceptability and very few complications. Due
to these reasons in spite of the known advances in
facial reconstructive surgeries, this technique is widely
followed in developing countries.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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Table 1: The site of oral squamous cell carcinoma
distribution
Site of malignancy n=100, n (%)
Lateral border of tongue 7 (7)
Buccal mucosa 59 (59)
Lower lip 4 (4)
Gingivobuccal sulcus 21 (21)
Buccal mucosa + gingiva + RMT 9 (9)
RMT: Retromolar trigone
Table 2: Staging among the participants
Disease staging n=100, n (%)
I+II 52 (52)
III 42 (42)
IV 6 (6)
Table 3: Complications related to permanent magnet
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PMMC‑related complications n=69, n (%)
Wound infections 27 (27)
Wound dehiscence 20 (20)
Total flap necrosis 1 (1)
Orocutaneous fistula formation 6 (6)
Partial skin necrosis 6 (6)
Wound hematoma 9 (9)
Common surgical complications noted distinct to PMMC.
PMMC: Pectoralis major myocutaneous
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