J Plast Surg Hand Surg, 2012; 46: 335338 2012 Informa Healthcare ISSN: 2000-656X print / 2000-6764 online

e DOI: 10.3109/2000656X.2012.718281

ORIGINAL ARTICLE

Salvage for pectoralis major myocutaneous ap failure in head and neck reconstruction by microvascular ap
Chen-Ling Tang1, Yi-Chia Wu2, Ching-Hung Lai2, Chung-Sheng Lai2,3, Chih-Lung Lin3,4, Sin-Daw Lin2 & Kao-Ping Chang2,3
Department of Surgery, 2Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, 3Department of Surgery, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan and 4 Division of Neurosurgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
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Abstract The pectoralis major myocutaneous pedicled ap (PMMPF) the workhorse for head and neck reconstruction is associated with a high incidence of complications in certain cases. This study presents free tissue transfer as an alternative salvage technique after PMMPF failure in head and neck reconstruction. It includes seven consecutive patients who underwent free tissue salvage after PMMPF failure in head and neck reconstruction from January 2008 to September 2010 at Kaohsiung Medical University Hospital, Taiwan. Four vertical rectus abdominis myocutaneous (VRAM) aps were applied for tongue and mouth oor defects, while three anterolateral thigh (ALT) aps were used for mouth oor, buccal, and cheek defects. All aps survived uneventfully, and normal oral feeding was achieved without major complications. Free tissue transfer has several advantages and can be successfully employed in head and neck reconstruction, and it is also a reliable salvage procedure after PMMPF failure in such cases. Key Words: Free tissue transfer, salvage, head and neck, pectoralis major myocutaneous ap, failed ap

Introduction The pectoralis major myocutaneous pedicled ap (PMMPF) is considered the workhorse ap for head and neck reconstruction operations after its introduction in 1979 by Ariyan [14]. Despite advancements in microsurgery, this ap continues to be the primary reconstructive choice for several reasons, such as good coverage, readily identiable and reliable bloody supply, reduced operative time, simple technical aspects, lower patient comorbidity, and proximity to the head and neck region [3,58]. It is also considered a versatile, robust, reliable, and safe option for head and neck reconstruction [68]. However, the disadvantages of the PMMPF include cosmetic deformity, ap bulkiness, lack of arc rotation, morbidity associated with donor and recipient sites, and a high incidence of complications [2,9,10]. The high incidence of complications is associated with smoking, diabetes, previous radiotherapy, obesity, and an inexperienced surgeon; it can be further increased by infection and wound dehiscence [2,6,11]. In these situations, a secondary operation is required, with the incidence of such secondary operations ranging from 10%50% [1114]. However, few studies have reported the management of PMMPF failure. Here, we describe our experience with using free tissue transfer as a salvage technique after PMMPF failure in head and neck reconstruction. Patients and methods In this study, we included seven patients who had free tissue salvage after PMMPF failure in head and neck reconstruction between January 2008 and September 2010 at the Kaohsiung

Medical University Hospital, Taiwan. The medical records of these patients were reviewed. All patients were referred from the Department of Otorhinolaryngology. The indication for previous PMMPF reconstruction was immediate reconstruction after head and neck tumour operation. Debridement and free ap reconstruction were performed simultaneously in every salvage operation by plastic surgeons. However, the time interval from PMMPF to free ap varied and depended upon the referral date. All salvage operations were completed within 1 week after referral consultation. Patient demographics, adjuvant therapy, tumour data, ap details, and the complications for each case of reconstruction were analysed. Results All seven patients were men with a mean age of 45.2 years (range 3952). Each patient had free tissue salvage after PMMPF failure for head and neck reconstruction. Of these, six patients had stage IV squamous cell carcinoma (SCC), and one had stage II SCC. None of them had previously received adjuvant radiotherapy or chemotherapy. Four of them received the vertical rectus abdominis myocutaneous (VRAM) ap as the salvage ap for tongue (Figure 1) and mouth oor defects, while the remaining three received the anterolateral thigh (ALT) ap for a buccal (Figure 2), cheek, and mouth oor (Figure 3) defect each. The superior thyroid artery was used as the recipient artery in all cases. Only one patient suffered from minor wound dehiscence and the wound was left for secondary healing. All aps survived well with OPD follow-up ranging from 725 months. All patients had fair swallowing function to

Correspondence: Kao-Ping Chang, MD, PhD, Division of Plastic and Reconstructive Surgery, Kaohsiung Medical University Hospital, 100 ShihChuan 1st Road, Kaohsiung 807, Taiwan. Tel: 886-7-3121101 Ext 7675. Fax: 886-7-3111482. E-mail: kapich@kmu.edu.tw (Accepted 21 May 2012)

336 C.-L. Tang et al.

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Figure 1. (a, b) A 45-year-old man with tongue carcinoma, T2N2M0 Stage II, had a wide excision with mandibulectomy and functional neck dissection. The defect was reconstructed using a PMMPF ap. However, progressive partial necrosis was noted. At 26 days after the rst operation, a VRAM ap was used to salvage the failed PMMPF.

Figure 2. (a, b) A 39-year-old man with right buccal squamous cell carcinoma, T4N0M0 Stage IVa, had a wide excision with maxillectomy, segmental mandibulectomy, and right radical neck dissection, with PMMPF being used for reconstruction. Congestion was noted in the ap on postoperative day 2. Exploration was performed but no obvious cause was found; therefore, an ALT ap was used to salvage the failed PMMPF.

tolerated regular oral intake well and their communication function was also acceptable (Table I). Discussion Although the PMMPF has been widely used in head and neck reconstruction since its rst introduction by Ariyan in 1979 [14], many studies have revealed the reliability of free tissue transfer since the 1980s. Therefore, the role of the PMMPF in head and neck reconstruction has been supplanted by free tissue transfer in several situations [3,4,9]. However, free tissue

transfer requires a specialised team since it is a complex operation entailing rigorous postoperative care; it is thus expensive and not available in many hospitals [7]. Moreover, the advantages of PMMPF include relatively easy technique, proximity of the head and neck region, readily identiable and reliable blood supply, abundant soft tissue volume for good coverage, protection of the great vessels in the neck, unchanged patient position during harvest and use of the ap, and reduced operating time as compared with that for the free ap technique [3,6,7,15,16]. Therefore, the PMMPF remains an excellent

Figure 3. (a, b) A 41-year-old man with tongue carcinoma, T2N0M0 Stage II, had a wide excision with mandibulectomy and functional neck dissection. The defect was reconstructed using a PMMPF ap. However, necrotic ap with tongue and mouth oor defect were noted postoperatively. At 17 days after the initial operation, an ALT ap was used to salvage the failed PMMPF.

Salvage for failed PM ap by free ap

Table I. Details of patients. Case no. 1 2 3 4 5 6 7 Age/ sex 39/M 45/M 41/M 42/M 47/M 51/M 52/M Tumour site Buccal Tongue Tongue Mouth oor Mouth oor Cheek Tongue Tumour stage T4N0M0 T2N2M0 T2N0M0 T4N1M0 T4N1M0 T4N2M0 T4N1M0 Adjuvant therapy Nil Nil R/T Nil Nil Nil Nil Day of secondary reconstruction 6 26 17 15 14 10 8 Flap used in reconstruction ALT VRAM ALT VRAM VRAM ALT VRAM Recipient vessels Superior thyroid a Superior thyroid a Superior thyroid a Superior thyroid a Superior thyroid a Superior thyroid a Superior thyroid a Complication No No No Minor wound dehiscence No No No

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Patients satisfaction Good Good Good Good Good Good Good

ALT = anterolateral thigh ap; VRAM = vertical rectus abdomins myocutaneous ap; Superior thyroid a = Superior thyroid artery.

reconstructive choice in head and neck reconstruction, especially in high-risk patients (elderly, signicant comorbidity, advanced tumour, previous extended head and neck operation, and radiation) and in developing countries that need costeffective care [7,11,17]. Another common (~ 25%) and important indication for PMMPF reconstruction is salvage procedure after free ap failure [5,17]. Reconstructions comprise donor site disgurement, excessive bulk, restricted arc of rotation, gravitational displacement with time, technical difculties in women, and high complication rates [2,4,10,15,17]. Its complications include wound dehiscence, infection, stula formation, and partial and total ap loss; the incidence of such high-risk complications varies from 14% [18] to 69% [1]. The incidence of partial ap loss, complete ap loss, and salivary stulas ranges from 4%29%, 0%16%, and 5%20%, respectively [1,6,7,16,17]. Moreover, a secondary operation is required in 10%50% of cases [11-14]. Liu et al. [17] reported that 17% of ap necrosis cases required another ap for salvage, while Milenovic et al. [16] reported that only 2% of those who required surgical intervention for postoperative complications received a new ap. McLean et al. [14] showed that 7% (1/15) of patients who received a secondary operation required contralateral PMMPF reconstruction. In our hospital, the failure rate of complete PMMPF loss was about 10%. Smoking and an inexperienced surgeon were regarded as the main causes of ap failure. Further, several authors have reported signicant donor site morbidity, including neck pain (33%), sensory loss (65%), limited lateral exion away from the operation site, impaired neck mobility, limited range of motion of shoulder, and impairment of arm strength [4,19,20]. Because of these critical morbidities, using the contralateral PMMPF for salvaging a failed PMMPF can cause further grievous disability. However, the use of a free ap for salvaging a failed PMMPF would reduce neighbouring tissue contracture and preserve the function of the opposite shoulder. Therefore, in this study, we proposed using free ap transfer as an alternative method for salvaging failed PMMPF reconstruction. Wei et al. [21] reported the next reconstructive ladder after failed free ap transfer, considering a secondary free tissue transfer as an effective and reliable procedure after free ap reconstruction failure in head and neck reconstruction, with the only contraindication being the deteriorating condition of the patient. Further, they mentioned that regional aps used in the head and neck region had higher complication rates than

secondary free aps, with one-third of them requiring substitution by another free ap. As compared with free ap failure, PMMPF failure has certain advantages, such as recognisable and good-quality recipient vessels that would aid in successful secondary surgery involving free ap reconstruction. Secondary free tissue transfer for PMMPF failure in head and neck reconstruction entails certain challenges, e.g., the commonly used cervical vessels are often buried in the scar, the defect itself is frequently scarred, and the failed ap is associated with tissue oedema, inammation, vascular trauma, malnutrition, or infection, all of which would delay wound healing [22]. Adequate debridement to remove devitalised tissue, including removal of failed ap and residual debris, is thus a necessity for ensuring bacterial control [21]. The best time for secondary reconstruction by the free ap was recommended once when the ap failure was noted, the patient has recovered from previous operation, and infection was under control. Further, the PMMPF is generally used in advanced oral cancer patients with large skin and mucosal loss, total or subtotal glossectomies, and removal of the muscles in the oral oor [11]. Therefore, the secondary ap needs to have good vascularity, a long pedicle, and bulky volume. Although a pedicled latissimus dorsi ap has good vascularity and bulky volume, the difculties associated with its relatively short arc should be considered. Further, although the radial forearm free ap has a long and relatively large vascular pedicle vessel, its volume is usually insufcient to restore function and cosmesis [23]. Based on these considerations, we regard the free VRAM and ALT aps as good choices in salvage procedures after PMMPF failure owing to their long pedicle vessels, as well as the low functional loss at the donor site noted in our patient series. However, VRAM and ALT aps have drawbacks similar to other free ap operations, such as the need for an experienced surgical and postoperative care team, expensive instruments, and longer operating time and higher expense as compared with PMMPF reconstruction. Despite these disadvantages, we consider immediate free tissue transfer as a reliable salvage alternative for PMMPF failure, except in elderly patients or those with signicant comorbidity. In conclusion, the high complication rate, especially total ap loss, associated with the use of PMMPF in head and neck reconstruction, often requires secondary reconstruction. In this situation, free VRAM and ALT aps are robust and reliable reconstructive strategies in non-high-risk patients.

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338 C.-L. Tang et al. Acknowledgement We thank the Department of Otorhinolaryngology for all the tumour ablations that they performed. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper. References
[1] Corten EM, Schellekens PP, Hag JJ, Kon M. Clinical outcome after pedicled segmental pectoralis major island aps for head and neck reconstruction. Ann Plast Surg 2009;63:2926. [2] ONeill JP, Shine N, Eadie PA, et al. Free tissue transfer versus pedicled ap reconstruction of head and neck malignancy defects. Ir J Med Sci 2010;179:33743. [3] Yeh JT, Chen HC, Laverty LA, et al. Conversion from pedicled to free ap for salvage of the compromised pectoralis major myocutaneous ap in head and neck reconstruction. Plast Reconstr Surg 2004;114:1527. [4] Moukarbel RV, Fung K, Franklin JH, et al. Neck and shoulder disability following reconstruction with the pectoralis major pedicled ap. Laryngoscope 2010;120:112934. [5] Avery CM, Crank ST, Neal CP, et al. The use of the pectoralis major ap for advanced and recurrent head and neck malignancy in the medically compromised patient. Oral Oncol 2010;46: 82933. [6] Liu R, Gullane P, Brown D, Irish J. Pectoralis major myocutaneous pedicled ap in head and neck reconstruction: retrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital. J Otolaryngol 2001;30: 3440. [7] Vartanian JG, Carvalho AL, Carvalho SM, et al. Pectoralis major and other myofascial/myocutaneous aps in head and neck cancer reconstruction: experience with 437 cases at a single institution. Head Neck 2004;26:101823. [8] Koh KS, Eom JS, Kirk I, et al. Pectoralis major musculocutaneous ap in oropharyngeal reconstruction: revisited. Plast Reconstr Surg 2006;118:114550. [9] Mallet Y, El Bedoui S, Penel N, et al. The free vascularized ap and the pectoralis major pedicled ap options: comparative results of reconstruction of the tongue. Oral Oncol 2009;45: 102831. [10] Chaturvedi P, Pai PS, Pathak KA, et al. Simultaneous reconstruction of large skin and mucosal defect following [14] [15] head and neck surgery with a single skin paddle pectoralis major myocutaneous ap. J Laryngol Otol 2005;119: 3035. El-Marakby HH. The reliability of pectoralis major myocutaneous ap in head and neck reconstruction. J Egypt Natl Canc Inst 2006;18:4150. von Biberstein SE, Spiro JD. The pectoralis major myocutaneous ap in reconstructive head and neck surgery revisited: a recent experience. Conn Med 1994;58:71114. Righi PD, Weisberger EC, Slakes SR, et al. The pectoralis major myofascial ap: clinical applications in head and neck reconstruction. Am J Otolaryngol 1998;19:96101. McLean JN, Carlson GW, Losken A. The pectoralis major myocutaneous ap revisited: a reliable technique for head and neck reconstruction. Ann Plast Surg 2010;64:5703. Bianchi B, Ferri A, Ferrari S, et al. Free and locoregional ap associations in the reconstruction of extensive head and neck defects. Int J Oral Maxillofac Surg 2008;37: 7239. Milenovic A, Virag M, Uglesic V, Aljinovic-Ratkovic N. The pectoralis major ap in head and neck reconstruction: rst 500 patients. J Craniomaxillofac Surg 2006;34:3403. Liu HL, Chan JY, Wei WI. The changing role of pectoralis major ap in head and neck reconstruction. Eur Arch Otorhinolaryngol 2010;267:175963. Talesnik A, Markowitz B, Calcaterra T, et al. Cost and outcome of osteocutaneous free-tissue transfer versus pedicled soft-tissue reconstruction for composite mandibular defects. Plast Reconstr Surg 1996;97:116778. van Wilgen CP, Dijkstra PU, van der Laan BF, et al. Shoulder and neck morbidity in quality of life after surgery for head and neck cancer. Head Neck 2004;26:83944. Nowak P, Parzuchowski J, Jacobs JR. Effects of combined modality therapy of head and neck carcinoma on shoulder and head mobility. J Surg Oncol 1989;41:1437. Wei FC, Demirkan F, Chen HC, et al. The outcome of failed free aps in head and neck and extremity reconstruction: what is next in the reconstructive ladder? Plast Reconstr Surg 2001;108: 115462. Iseli TA, Yelverton JC, Iseli CE, et al. Functional outcomes following secondary free ap reconstruction of the head and neck. Laryngoscope 2009;119:85660. de Bree R, Reith R, Quak JJ, et al. Free radial forearm ap versus pectoralis major myocutaneous ap reconstruction of oral and oropharyngeal defects: a cost analysis. Clin Otolaryngol 2007; 32:27582.

[11] [12] [13]

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[16] [17] [18]

[19] [20] [21]

[22] [23]