|Year : 2021 | Volume
| Issue : 1 | Page : 68-71
Three-way pectoralis major osteo-myo-cutaneous flap in oral cancer: An option revisited
Shreya Bhattacharya1, Sunil Singh Lourembam2, Harit Chaturvedi2
1 Department of Surgical Oncology, Cancer Institute Adyar, Chennai, India
2 Department of Surgical Oncology, Max Institute of Cancer Care, New Delhi, India
|Date of Submission||16-Jul-2020|
|Date of Acceptance||01-Apr-2021|
|Date of Web Publication||9-Aug-2021|
Dr. Shreya Bhattacharya
Max Institute of Cancer Care, New Delhi
Source of Support: None, Conflict of Interest: None
While free flap is the standard of care for bony reconstruction of the mandible, complex oro-mandibular defects after oral cancer ablation require adequate skin and soft-tissue replacement for optimum functional results. We report a case of multifaceted oral cavity resection effectively reconstructed in single stage by the three-way pectoralis major osteomyocutaneous flap. The technical aspects, benefits, deficiencies, and literature review are discussed. In the background of multiple recurrences and comorbidities, this flap is a viable alternative and should be given due reconsideration in oral cancer surgery. This gains more relevance in the context of developing countries.
Keywords: Composite, flap, oro-mandibular, pectoralis major, reconstruction
|How to cite this article:|
Bhattacharya S, Lourembam SS, Chaturvedi H. Three-way pectoralis major osteo-myo-cutaneous flap in oral cancer: An option revisited. Int J Oral Health Sci 2021;11:68-71
|How to cite this URL:|
Bhattacharya S, Lourembam SS, Chaturvedi H. Three-way pectoralis major osteo-myo-cutaneous flap in oral cancer: An option revisited. Int J Oral Health Sci [serial online] 2021 [cited 2021 Nov 28];11:68-71. Available from: https://www.ijohsjournal.org/text.asp?2021/11/1/68/323529
| Introduction|| |
Composite oromandibular reconstruction, especially for defects of the middle third, presents a unique challenge for the reconstructive surgeon. Although free osteocutaneous flap is the standard of care for restoration of bony continuity, the best functional results can only be achieved with adequate mucosal and soft tissue replacement. This, more often than not, necessitates the use of double flaps or staged reconstruction.
A subset of these cases is poor candidates for free tissue transfer due to certain patient and disease factors, and logistic restraints in developing countries.,,
Hereby, we present a case of multifaceted oro-mandibular restoration with pectoralis major muscle with vascularized split sternum as a three-way pectoralis major osteomyocutaneous (PM-OMC) flap.
| Case Report|| |
The patient was a 52-year-old laborer with history of carcinoma of midline floor of mouth (FOM) in 2011. Previous treatment included wide local excision, bilateral neck dissections and free flap reconstruction, followed by radiation therapy (RT) to the oral cavity and neck. He subsequently developed a local recurrence in 2015, treated with marginal mandibulectomy, second free flap surgery and re-RT.
He first presented to our institution in 2017 with a loco-regionally advanced second recurrence involving full-thickness FOM, central mandible, entire lower lip and chin with bilateral neck nodes and no distant metastases [Figure 1]. His neck was woody hard from previous RT and the skin was completely plastered with no identifiable tissue planes. Owing to the multidimensional nature of the defect, his previous treatment history and financial limitations, we opted for a PMC-OMC in this case.
|Figure 1: Multifaceted defect encompassing the full thickness floor of the mouth, central mandible, lower lip, and chin|
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The technique involved a skin island designed to match the defect and centred over the lower third of the sternum [Figure 2]. The skin incision continued along the costal margin to create a rotation flap to close the donor site. The pectoralis muscle was elevated in the standard fashion until the ipsilateral sternal edge was encountered. The skin paddle was incised all around and the contralateral sternal edge was exposed by elevating off the muscle on the opposite side. The anterior table of the lower third of the sternum was osteotomized with the oscillating saw, staying just medial to the ribs. Care was taken not to avulse the attachments of the overlying muscle to the bone segment. A curved osteotome was used to separate the anterior and posterior tables [Figure 3]. The bone was fixed to the reconstruction plate with 6 mm screws. The skin paddle was draped over the bone to achieve intraoral skin lining and external skin cover [Figure 4].
|Figure 3: Curved osteotome used to separate the anterior and posterior tables|
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The patient had an uneventful hospital course and was discharged on postoperative day 8. Bone scan done after 3 weeks found the bone to be viable. At the 6-month follow–up postcompletion of treatment, the patient was taking total oral diet with specific food limitations and had satisfactory cosmetic appearance [Figure 5]. Drooling was present and speech was impaired, though intelligible. He is planned for subsequent lower lip reconstruction and denture placement for articulation and cosmesis.
|Figure 5: Appearance at 6 months follow-up, after the completion of treatment|
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| Discussion|| |
Free vascularized bone flap is the standard of care for segmental mandibular defects. However, studies have shown that soft-tissue reconstruction of complex resections has an equal or greater significance for functional results. The use of two free flaps, one for the bone and inner lining and one for the skin and soft tissue, is not uncommon in this setting.
Subsets of these cases fail to qualify for such aggressive reconstruction such as patients with no recipient vessels or donor sites and those who are medically inoperable. Moreover, the technological and financial restraints in a developing country make such procedures less practically feasible.,
PM-OMC has been a workhorse flap for head-and-neck reconstruction and has stood the test of time., Historically, pectoralis major incorporating rib or sternum has been reported. The PM-OMC was described by Green et al. in 1981 and further refined by Robertson but has been lost to history in the era of free tissue transfer.,, We feel that that this pedicled flap is a potential alternative in the above-mentioned subset of patients with certain obvious advantages.
The PM-OMC flap provides adequate lining to the oral cavity, bony support, external skin cover and protective muscle cover for the major neck vessels. Good quality skin and sufficient soft tissue help to obliterate the dead space and to overcome the detrimental effects of radiotherapy. The simplicity of the technique, short learning curve, acceptable cosmesis and function, no major procedure-related complication and no logistic concerns make it a lucrative option for these patients., Studies have found sternum to be superior to rib in terms of bone survival, obliteration of dead space, and lack of chest complications., Robertson reported that 5 out of 6 patients encountered problems with bone survival in the rib group compared to 2 out of 22 in the sternum group.
The biggest disadvantage of the PM-OMC flap is the inability to place osseointegrated dental implants. Although, true to our experience, very few patients in this subset are willing for such a procedure. Furthermore, the flexibility of positioning the skin paddles with respect to the bone is restricted resulting in a bulky appearance. Finally, the follow-up here is too short to comment on long-term bone survival. Interestingly, there are hypothesis-generating reports in the literature which state that once the contour of the mandible has been secured, the fibrosis in the tissues surrounding the bone acts to maintain its shape, even if the bone undergoes resorption.
| Conclusion|| |
The three-way PM-OMC provides an acceptable alternative for composite oro-mandibular defects in poor candidates for free tissue transfer. It helps to achieve intraoral skin lining, external skin cover, vascularized bony reconstruction, and neck protection in this subset of patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]