INTRODUCTION
The pectoralis major myocutaneous flap is often used in reconstruction after head
and neck tumor resection. Ariyan et al. first described this technique in
19791.
Few reports have described the use of this flap in reconstruction above the
orbits, due to the risk of necrosis and the difficulty of flap mobilization,
rotation, and extension.
Defects in the scalp and upper third of the face remain a challenge for surgeons.
Advances in surgery have included use of perforating arteries and improved
techniques of dissection of the pectoral pedicle. These have allowed release and
lengthening of the pectoralis major muscle, augmentation of its arc of rotation,
and gain in the extension of the flap (cutaneous island) to obtain more distal
coverage in the head and upper third of the face.
OBJECTIVE
This study reported the use of an extended pedicled muscle flap to cover defects
in the right orbitofrontal-parietal region after resection of invasive squamous
cell carcinoma.
CASE REPORT
A 63-year-old male with an ulcerated, grade III, poorly-differentiated squamous
cell carcinoma presented 6 months after initial resection and grafting with a
recurrent tumor in the right parietal region. The patient had a 5.0-cm right
parietal ulcerated lesion with an adjacent osteolytic component, another frontal
lesion measuring 3.0 cm, and another 4.0-cm lesion in the right lower frontal
region with signs of adjacent bone involvement. Invasion of the paranasal sinus
and right superomedial orbit had occurred (Figure 1).
Figure 1 - Invasive squamous cell carcinoma, lateral view.
Figure 1 - Invasive squamous cell carcinoma, lateral view.
The case was evaluated by the oncological surgery and neurosurgery teams of the
Guilherme Álvaro Hospital, Santos, SP, for tumor resection with curative
intention, in collaboration with the plastic surgery team for immediate
reconstruction. The lesion was resected with lateral margins of 15 mm, with
resection of the affected bone in the parietal and upper frontal regions and
anterior and posterior walls of the right frontal sinus, leaving the dura mater
exposed.
The superomedial bony portion of the right orbit was resected, revealing
communication with the right frontal sinus and right nasal cavity; the globe,
ocular muscles, and 1.0 cm of the upper eyelid were preserved. The final defect
measured 12.0 × 18.0 cm in the right orbitofrontal-parietal region, with
dura mater, frontal sinus, and right upper orbit exposure (Figure 2).
Figure 2 - Partial resection of the frontoparietal bone and superomedial
orbit, with dura mater exposure.
Figure 2 - Partial resection of the frontoparietal bone and superomedial
orbit, with dura mater exposure.
For reconstruction, we marked a pectoralis major flap measuring 12.0 ×
18.0 cm in the right parasternal area, from the fourth intercostal space to the
subcostal region (extended), to enable coverage of the defect without lateral
traction on the head (Figure 3).
Figure 3 - Pectoralis flap and perforating area (in blue) markings.
Figure 3 - Pectoralis flap and perforating area (in blue) markings.
We detached the pectoralis muscle, while preserving the thoracoacromial pedicle,
leaving only a long muscular band in the axis of the vascular pedicle, and
performed total section of the muscle at the base of the flap; a cutaneous band
on the pedicle was left for protection and maintenance of the perforating
cutaneous thoracoacromial pedicle.
We performed total section of the superior pectoral nerve, partial section of the
deltoid muscle insertion in the clavicle to reduce rotation tension in the
external pedicle, and released the vascular pedicle to the thoracoacromial trunk
at the origin of the axillary artery. The closure of the donor area was
performed with tension-free advancement flaps (Figure 4).
Figure 4 - Flap dissection and suturing of donor area.
Figure 4 - Flap dissection and suturing of donor area.
To obliterate the frontal-orbital-nasal communication, a contralateral frontal
muscle flap was created and sutured in place.
During recovery, the patient developed a 3.0-cm necrotic area at the distal edge
of the flap; this was resected together with the pedicle 4 weeks later. Wet
dressings were applied to the area of resected necrosis until granulation tissue
was observed, with subsequent grafting. The coverage was effective, with no
major complications or hematomas, and a satisfactory aesthetic result was
achieved despite the extensive oncologic surgery. The patient remains under
follow-up, and is receiving radiotherapy because of high risk of recurrence and
infiltration of the dura mater and frontal sinus mucosa (Figure 5).
Figure 5 - Postoperative appearance 10 days after pedicle resection and 40
days after oncological surgery
Figure 5 - Postoperative appearance 10 days after pedicle resection and 40
days after oncological surgery
DISCUSSION
The pectoralis major flap is commonly used for head and neck reconstruction, but
its applicability in the supraorbital area has a risk of failure and necrosis
due to tension. Its use depends largely on patient anatomy. The cutaneous island
on the pectoralis muscle typically measures 6.0 × 12.0 cm. The skin flap
should not be extended more than 20% beyond the edge of the muscle2. This type IV flap with a thoracoacromial
dominant pedicle is easy to monitor and dissect.
Most reports on this flap discuss a musculocutaneous or muscular type, with a
mostly minor complication rate of 33% and a 2% risk of necrosis3.
Cadaver studies by Rikimaru et al.4,5 identified the
main cutaneous perforating arteries of the second and third intercostal area
using microvascular angiography. Based on these studies, Nishi et al.6 described flaps using pectoral and
deltopectoral perforating arteries.
Zhang et al.7 described a pectoral region
flap in an anatomical study of the perforating branches of the thoracoacromial
artery, and reported the existence of 1 or 2 main perforators within 4.0 cm of
the point of union of the acromioxiphoid and midclavicular lines. These
perforators allowed a pedicle flap using thoracoacromial artery perforators to
be performed. This flap can be performed with microsurgical technique for
superior defects8-10.
With this anatomical knowledge of the perforators of the thoracoacromial vascular
pedicle, a large cutaneous island can be maintained, and the muscle can be
partially or totally resected. The flap rotation arc may improve with muscle
detachment, careful dissection of the pedicle, and section of deltoid muscle
bands, and infraclavicular tunneling has been described. Surgery is ideally
performed in a single session, but an external pedicle is needed to obtain
coverage distant from the donor bed, as in the present case. The literature to
date has not reported a pedicled pectoralis major flap that has been extended
this far while remaining viable.
The extended pedicle flap was an excellent surgical option for reconstruction of
the upper third of the head following extensive tumor resection, in an area with
limitations to microsurgery; with anatomical knowledge and careful dissection,
we obtained a satisfactory result.
COLLABORATIONS
AOE
|
Conception and design study, data curation, methodology, realization
of operations and/ or trials, writing - original draft
preparation.
|
DCL
|
Methodology, realization of operations and/or trials, writing -
review & editing.
|
AFC
|
Data Curation, realization of operations and/ or trials, writing -
review & editing.
|
CFG
|
Data curation, realization of operations and/or trials, writing -
review & editing.
|
LG
|
Realization of operations and/or trials, writing - review &
editing.
|
RGN
|
Writing - original draft preparation, writing - review &
editing.
|
ORS
|
Final manuscript approval, methodology, writing - review &
editing.
|
REFERENCES
1. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap
for reconstruction in the head and neck. Plast Reconstr Surg. 1979;63(1):73-81.
PMID: 372988
2. Part II Regional Flaps: Anatomy and Basic Techniques, section 6E:
Pectoralis Major Flap. In: Zenn MR, Jones G. Reconstructive Surgery: Anatomy,
Technique, and Clinical Applications. St. Louis: Quality Medical Publishing;
2012. p. 520-41.
3. Milenović A, Virag M, Uglesić V, Aljinović-Ratković N. The
pectoralis major flap in head and neck reconstruction: first 500 patients. J
Craniomaxillofac Surg. 2006;34(6):340-3. DOI: http://dx.doi.org/10.1016/j.jcms.2006.04.001
4. Rikimaru H, Kiyokawa K, Inoue Y, Tai Y. Three-dimensional anatomical
vascular distribution in the pectoralis major myocutaneous flap. Plast Reconstr
Surg. 2005;115(5):1342-52. DOI:
http://dx.doi.org/10.1097/01.PRS.0000156972.66044.5C
5. Rikimaru H, Kiyokawa K, Watanabe K, Koga N, Nishi Y, Sakamoto A. New
method of preparing a pectoralis major myocutaneous flap with a skin paddle that
includes the third intercostal perforating branch of the internal thoracic
artery. Plast Reconstr Surg. 2009;123(4):1220-8. PMID: 19337090 DOI:
http://dx.doi.org/10.1097/PRS.0b013e31819f2967
6. Nishi Y, Rikimaru H, Kiyokawa K, Watanabe K, Koga N, Sakamoto A.
Development of the pectoral perforator flap and the deltopectoral perforator
flap pedicled with the pectoralis major muscle flap. Ann Plast Surg.
2013;71(4):365-71. DOI:
http://dx.doi.org/10.1097/SAP.0b013e3182503c5d
7. Zhang YX, Yongjie H, Messmer C, Ong YS, Li Z, Zhou X, et al.
Thoracoacromial artery perforator flap: anatomical basis and clinical
applications. Plast Reconstr Surg. 2013;131(5):759e-70e. PMID:
23629115
8. Li Z, Cui J, Zhang YX, Levin LS, Zhou X, Spinelli G, et al.
Versatility of the thoracoacromial artery perforator flap in head and neck
reconstruction. J Reconstr Microsurg. 2014;30(7):497-503. DOI:
http://dx.doi.org/10.1055/s-0034-1370359
9. Zhang YX, Li Z, Grassetti L, Lazzeri D, Nicoli F, Zenn MR, et al. A
new option with the pedicle thoracoacromial artery perforator flap for
hypopharyngeal reconstructions. Laryngoscope. 2016;126(6):1315-20. DOI:
http://dx.doi.org/10.1002/lary.25675
10. Song D, Pafitanis G, Pont LEP, Yang P, Koshima I, Zhang Y, et al.
Chimeric thoracoacromial artery perforator flap for one-staged reconstruction of
complex pharyngoesophageal defects: A single unit experience. Head Neck.
2018;40(2):302-11. DOI: http://dx.doi.org/10.1002/hed.24962
1. Serviço de Cirurgia Plástica Osvaldo Saldanha,
Cirurgia Plástica Reconstrutiva e Estética, Santos, SP, Brazil
2. Hospital Santa Casa, Serviço de Cirurgia
Plástica, Santos, SP, Brazil.
Corresponding author: Andres Ordenes
Evensen Av. Ana Costa, nº 146, conjunto 1201 - Santos, SP, Brazil Zip
Code 11060-000 E-mail: aordenese@gmail.com /
carlosgoye.m@gmail.com
Article received: April 8, 2018.
Article accepted: October 1, 2018.
Conflicts of interest: none.