Continuous Validity of Pedicled Myocutaneous and Myofascial ... - NCI

Journal of the Egyptian Nat. Cancer Inst., Vol. 21, No. 3, September: 249-263, 2009 

Continuous Validity of Pedicled Myocutaneous and Myofascial 

Flaps in Reconstruction after Surgery for Head and Neck Cancer 

MAGED M. ELSHAFIEY, M.D.; ALI H. MEBED, M.D.; 

ABD ELMAKSOUD M. ABD ELMAKSOUD, M.D. and AMR A. ATTIA, M.D. 

The Department of Surgical Oncology, National Cancer Institute, Cairo University. 

ABSTRACT 

Purpose: The aim of this study was to reevaluate the 

role and effectiveness of pedicled myocutanous and myofascial 

flaps in reconstruction after resection of head and 

neck cancer. 

Patients and Methods: This study represents the 

authors own experience using pedicled myocutanous and 

myofascial flaps in reconstruction after resection of malignant 

tumors of different sites in the head and neck. The 

study included 121 patients with head and neck cancer 

operated upon at the National Cancer Institute, Cairo 

University and Alminia Cancer Center over 3 years duration, 

between July 2005 and the end of July 2008. Four 

types of flaps were used namely the Pectoralis major 

(Group I), lower trapezius (Group II), Latissimus dorsi 

(Group III), and the temporalis ((Group IV) flaps. Utility 

of the different types of these flaps was reevaluated in 

terms of indications, advantages, and postoperative complications. 

Results: This study included 121 patients, 83 males 

and 38 females. The mean age was 56 years (range, 14- 

65 years). Oral malignancies represented most of the cases 

(71 cases). Pectoralis major myocutaneous (PMMC) flap 

was the most commonly used flap (84 cases) and its main 

indication was oral and pharyngeal defects. Lower trapezius 

and Latissimus dorsi myocutaneous flaps were used in 14 

and 12 cases respectively. Their main indications were 

tumors in the occiput, ear pinna, parotid and neck regions. 

The Latissimus dorsi myocutaneous flap was also used 

for reconstruction of oral and pharyngeal defects in 7 

female patients with large breasts and for salvage reconstruction 

after failure of reconstruction by (PMMC) flap 

in one patient and for reconstruction after excision of 

local recurrence on top of previous (PMMC) flap in another 

patient. Temporalis myofascial flap was used in 12 cases 

and the main indication was orbital defects. The overall 

postoperative complications was 19.8% (24/121). It was 

20% (17/84) in group I, 28.6% (4/14) in group II, and 

Correspondence: Dr Maged Mohamed Elshafiey, Surgical 

Department, National Cancer Institute, Cairo University, 

mmelshafiey@Yahoo.com 

25% (3/12) in group III. No flap related complications 

were reported in group IV. All complications were successfully 

managed except for one case in (Group I), in 

which a major flap loss developed and was successfully 

salvaged by pedicled latissimus dorsi myocutaneous flap. 

Conclusion: Pedicled myocutanous and myofascial 

flaps are still indicated in composite head and neck reconstruction. 

Their reliability, safety, and high degree of 

resistance to infection make them essential specially the 

(PMMC) flap previously described as the spare wheel of 

head and neck reconstructive surgery. It is suitable for 

lateral mandibular defects in edentulous patients and in 

partial pharyngeal defects in irradiated patients. Other 

pedicled myocutaneous flaps are still valid in certain 

occasions and sites. 

Key Words: Head and neck cancer – Pectoralis major – 

Trapezius – Latissimus dorsi – Temporalis 

myocutaneous – Myofascial flaps – Reconstruction. 

INTRODUCTION 

A major component of reconstructive surgery 

is coverage of defects after radical surgeries for 

cancer. Surgical treatment of malignant cervicofacial 

tumors often includes vast demolition of 

mucosal, cutaneous, muscular, and bony tissues. 

This requires immediate repair by reconstructive 

pedicled flaps or revascularized free flaps [1]. 

Although microvascular free tissue transfer 

today plays a major role in modern one step 

reconstruction, still pedicled flaps specially 

pectoralis major myocutaneous flaps are of 

clinical importance in the head and neck region 

[1,2,3]. 

PATIENTS AND METHODS 

This is a prospective study that represents 

the authors own experience over 3 years using 

pedicled myocutanous and myofascial flaps in 

249

250 

Continuous Validity of Pedicled Myocutaneous & Myofascial Flaps 

reconstruction after resection of malignant tumors 

of different sites in the head and neck. 

The study included 121 patients with head and 

neck cancer operated upon at the National Cancer 

Institute, Cairo University and Alminia 

Cancer Center over 3 years duration, between 

July 2005 and the end of July 2008. 

One hundred and 2 cases receieved no previous 

treatment while 19 cases presented with 

recurrent or persistent disease after previous 

treatment by surgery alone in 3 cases, combined 

surgery and radiotherapy in 4 cases and radiotherapy 

alone in 12 cases. 

Preoperative medical assessment included 

routine complete blood picture, liver and kidney 

functions, fasting blood sugar, bleeding and 

coagulation profile and cardiological assessment. 

All the patients were biopsied before 

surgery and pathological diagnosis was obtained. 

The stage of the disease was evaluated by 

clinical assessment, locoregional (CT or MRI), 

routine CXR and other metastatic workup as 

indicated. 

The extent of surgical resection and the 

technique of reconstruction with its potential 

complications were discussed preoperatively 

with the patient with combined signed consent 

by the patient and the surgeon performing the 

operation. 

Four types of pedicled flaps were used for 

reconstruction namely the Pectoralis major 

myocutaneous (PMMC) flap (Group I), lower 

trapezius myocutaneous flap (LTMC) flap 

(Group II), Latissimus dorsi myocutaneous flap 

(Group III) and the Temporalis myofascial flap 

(Group IV). Immediate reconstruction after 

resection was done in 110 cases while delayed 

reconstruction of anterior pharyngeal defects 

after total laryngectomy was done in 11 cases. 

In one case in (Group I), major flap loss developed 

and was successfully salvaged by pedicled 

latissimus dorsi myocutaneous flap. 

Patients were followed-up in the outpatient 

clinic for detection of local or distant recurrences 

by clinical examination and radiological assessment 

as indicated and for assessment of the 

final functional and aesthetic results. 

Data regarding the type of tumor, site of 

tumor, stage of the disease, the type of myocutaneous 

flap used, postoperative complications 

and the total hospital stay were collected and 

analyzed. Utility of the different types of these 

flaps was reevaluated in terms of advantages, 

indications, and morbidity. 

RESULTS 

This study included 3 types of repair in head 

and neck region using 4 different types of pedicled 

myocutaneous or myofascial flaps ( repair 

of mucosal defects, repair of composite mucosal 

& skin defects and repair of skin only defects). 

Most of the cases were associated with bulky 

soft tissue and bone defects. In cases with combined 

mucosal & skin defects (29 cases) the 

myocuteous flaps mainly the (PMMC) flap 

(used in 28 cases) were used for one of the 

following purposes: 

1- Replacing the inner mucosal layer and using 

the deltopectoral fasciocutaneous flap for 

skin closure (17 cases). 

2- Replacing the outer skin layer, while the 

inner mucosal defect was not reconstructed 

(2 cases) after maxillectomy. 

3- Replacing both the inner mucosal and outer 

skin layers using long skin territory which 

was folded on itself (bipaddle skin flap) in 

9 cases. 

Primary sites of malignancy and types of 

defects left after excision are represented in 

Table (1). Oral carcinoma represented most of 

the cases (71 cases) and the majority were at 

advanced stage (T3 & T4) representing 40.8% 

(29/71) and 33.8% (24/71) respectively. 

Different types of flaps used in our study 

are represented in Table (2). The overall postoperative 

complications was 19.8% (24/121). 

It was 20% (17/84) in group I, 28.6% (4/14) in 

group II, and 25% (3/12) in group III. No flap 

related complications were reported in group 

IV. The mean hospital stay was 14 days (range, 

8-27 days) in group I, 11 days (range, 8-15 

days) in group II, 12 days (range, 8-16 days) 

in group III, and 8 days (range, 5-11 days) in 

group IV. 

The (PMMC) flap was the most commonly 

used flap (84 cases ). Figs. (1-9) show different 

operative views. The postoperative common 

complications in group I were mild infection

Maged M. Elshafiey, et al. 251 

(15 cases), minor fistulae (11 cases), partial 

skin sloughing of the skin island with the underlying 

muscle healthy (3 cases), minor dehiscence 

and retraction (4 cases). All were properly 

managed by antibiotics, skin debridement and 

ryle feeding and oral hygiene in mucosal fistulae. 

One case with circumferential reconstruction 

of the pharyngeal defect after total laryngopharyngectomy 

developed pharyngeal stenosis and 

required repeated pharyngeal dilatation. In one 

case severe infection and major sloughing of 

the flap developed that was successfully salvaged 

by pedicled latissimus dorsi myocutaneous 

flap reconstruction. 

Table (1): Primary sites of malignancy and type of defect after excision in patients with head & neck cancer. 

Primary site of tumor 

No. of 

cases 

Skin 

defect only 

Mucosal 

defect only 

Combined mucosal & 

skin defects 

Bone 

defect 

Oral cavity: 

Tongue 

Alveolar margin 

Retromolar 

Buccal mucosa 

Mouth floor 

Lip commisure 

71 

24 

18 

11 

9 

6 

3 

– 

– 

– 

– 

– 

– 

– 

58 

24 

15 

10 

4 

5 

– 

13 

– 

3 

1 

5 

1 

3 

71 

24 

18 

11 

9 

6 

3 

Larynx 

Scalp over occipital region 

Maxilla 

Parotid 

Conjunctiva & lids 

Cheek 

Ear pinna 

Neck region 

External auditory meatus 

Post cricoid 

13 

9 

9 

7 

4 

2 

2 

2 

1 

1 

– 

9 

– 

7 

4 

2 

2 

2 

1 

1 

– 

– 

6 

– 

– 

– 

– 

– 

– 

– 

13 

– 

3 

– 

– 

– 

– 

– 

– 

– 

– 

9 

9 

3 

1 

2 

2 

– 

1 

– 

Total 

21 

28 

64 

29 

98 

Table (2): Primary sites of malignancy and type of the used flap in patients with head & neck cancer. 

Primary site of tumor 

No. of 

cases 

(PMMC) flap 

(Group I) 

(LTMC) flap 

(Group II) 

Latissimus dorsi 

myocutaneous flap 

(Group III) 

Temporalis 

myofascial 

flap (Group IV) 

Oral cavity: 

Tongue 

Alveolar margin 

Retromolar 

Buccal mucosa 

Mouth floor 

Lip commisure 

71 

24 

18 

11 

9 

6 

3 

64 

22 

15 

11 

8 

6 

2 

– 

– 

– 

– 

– 

– 

– 

8 

2 

4 

– 

1 

– 

1 

– 

– 

– 

– 

– 

– 

– 

Larynx 

Scalp over occipital region 

Maxilla 

Parotid 

Conjunctiva & lids 

Cheek 

Ear pinna 

Neck region 

External auditory meatus 

Post cricoid 

13 

9 

9 

7 

4 

2 

2 

2 

1 

1 

12 

- 

3 

4 

- 

- 

- 

- 

- 

1 

– 

9 

– 

2 

– 

– 

1 

1 

1 

– 

1 

– 

– 

1 

– 

– 

1 

1 

– 

– 

– 

– 

6 

– 

4 

2 

– 

– 

– 

– 

Total 

121 

84* 

14 

12* 

12 

* Two flaps were used in the same patient.

252 


Table (3): Postoperative complications in different groups according to type of reconstruction. 

Complication 

No. 

Group I 

% 

No. 

Group II 

% 

No. 

Group III 

% 

Infection: 

Mild 

Severe 

15 

1 

17.8 

1.2 

1 

– 

7 

– 

2 

– 

16.6 

– 

Sloughing: 

Partial 

Major 

3 

1 

3.6 

1.2 

1 

– 

7 

– 

1 

– 

8.3 

– 

Flap dehiscence & retraction: 

Minor 

Severe 

4 

1 

4.8 

1.2 

2 

– 

14 

– 

1 

– 

8.3 

– 

Fistula: 

Minor 

Major 

11 

1 

13 

1.2 

– 

– 

– 

– 

2 

– 

16.6 

– 

Wound dehiscence at donor site 

Seroma at donor site 

Hematoma at donor site 

Pharyngeal stenosis 

– 

– 

- 

1 

– 

– 

– 

1.2 

2 

– 

1 

– 

14 

– 

7 

– 

1 

2 

– 

– 

8.3 

16.6 

– 

– 

The (LTMC) flap was used in 14 patients. 

The most common pathology was squamous 

cell carcinoma diagnosed in 6 patients. Other 

types of pathology included parotid carcinoma 

(2 cases), recurrent basal cell carcinoma (2 

cases), basosquamous cell carcinoma (one case), 

sebaceous adenocarcinoma (one case), fibrosarcoma 

(one case) and malignant peripheral 

nerve sheath tumor (one case). The occiput was 

the most common site for reconstruction (9 

cases). Other sites included the parotid region 

(2 cases), the ear pinna (one case), the external 

auditory meatus (one case) and the posterior 

neck (one case). All wounds were closed primarily 

and preservation of the superior fibres 

of the trapezius enabled almost normal abduction 

of the arm. Only (1 case) developed partial 

distal sloughing of the skin island for which 

debridment was done. Minor dehiscence occurred 

in 4 cases (the recipient area in 2 cases 

and the donor site in 2 cases. All cases were 

properly managed conservatively by repeated 

dressings. Figs. (10-14) show different operative 

views. 

The latissimus dorsi myocutaneous flap was 

used in 12 cases. It was used for reconstruction 

of oral defects in 8 patients of whom 6 cases 

were females with large breasts, one case presented 

with local recurrence on top of previously 

used (PMMC) flap for reconstruction Figs. 

(15A-C) and one case was properly salvaged 

after failure of previous reconstruction by (PM- 

MC) flap. Other indications included major 

defects after excision of advanced parotid carcinoma 

(one case), advanced epithelioma of the 

ear pinna (one case), synovial sarcoma of the 

neck (one case) Figs. (16A-C) and anterior 

pharyngeal defect after salvage laryngectomy 

in a case of laryngeal carcinoma that had failure 

of treatment by radiotherapy. Only one case 

developed minor sloughing of distal skin island. 

Other complications with this flap was seroma 

at the donor site (2 cases), minor fistulae (2 

cases), minor dehiscence at the recipient site 

(one case) and at the donor site (one case). All 

were properly treated conservatively with aspiration 

in seroma cases and repeated dressings 

in the latter. 

The temporalis myofascial flap was used in 

(12 cases). In 6 cases it was used to reconstruct 

the orbital floor after total maxillectomy for 

maxillary carcinoma. In 2 cases it was used to 

reconstruct the lateral and floor of the orbit 

after excision of epithelioma of the cheek invading 

the zygomatic arch. It was used for 

reconstruction after orbital exenteration in 4 

cases. In one case it was used to fill the orbital 

cavity and internal eye prosthesis was put, in 

another case it was used to cover the dura in a 

defect in the orbital roof and in the other 2 cases 

it was used to cover the orbital cavity anteriorly 

with overlying skin graft and external eye prosthesis. 

There was no flap related postoperative 

complications.


Fig. (1-A): Sq.C.C. of the alveolar margin. 

Fig. (1-B): Skin paddle of the (PMMC) flap was sutured to 

the tongue. 

Fig. (2-A): Bipaddle (PMMC) flap, the upper one was 

used for mucosal replacement and the lower 

one was used for skin replacement. 

Fig. (2-B): Composite oral defect with mucosal 

and skin defects replaced with bipaddle 

(PMMC) flap. 

Fig. (3-A): Late postoperative view of bipaddle (PMMC) 

flap seen from outside. 

Fig. (3-B): Late postoperative view of bipaddle (PMMC) 

flap seen from inside.

254 Continuous Validity of Pedicled Myocutaneous & Myofascial Flaps 

Fig. (4-A): Early postoperative view after resection 

of advanced maxillary carcinoma and 

reconstruction by (PMMC) flap. 

Fig. (4-B): Inner fold of the (PMMC) flap replacing the 

mucosal defect. 

Fig. (5): Central mandibular defect 

replaced by Titanium plate 

and (PMMC) flap. 

Fig. (6-A): Lt. parotid carcinoma. 

Fig. (6-B): Reconstruction by (PMMC) flap. 

Immediate postoperative view.


Fig. (7-A): Vascular pedicle of the (PMMC) flap. 

Fig. (7-B): Reconstruction by (PMMC) flap after 

excision of Rt parotid carcinoma. Immediate 

postoperative view. 

Fig. (8-A): Pharyngeal fistula after total laryngectomy. 

Fig. (8-B): Skin paddle of the (PMMC) flap was 

used to replace the pharyngeal mucosal 

defect and the deltopectoral flap was 

used to replace the skin defect. 

Fig. (9-A): Salvage laryngectomy after failed treatment 

by radiotherapy. 

Fig. (9-B): Operative view after laryngectomy and primary 

pharyngeal T shaped closure.


Fig. (9-C): Pedicled (PMMC) flap was used as a 

buttress to the pharyngeal closure and 

for skin defect replacement. 

Fig. (10-A): Fibrosarcoma of the occiput. 

Fig. (10-B): Reconstruction by (LTMC) 

flap. Late postoperative 

view. 

Fig. (11): Reconstruction by (LT- 

MC) flap (Early postoperative 

view). 

Fig. (12): Reconstruction by (LT- 

MC) flap. Late postoperative 

view. 

Fig. (13): Reconstruction by rotational 

full paddle (LT- 

MC) flap. Early postoperative 

view. 

Fig. (14): Partial sloughing of the 

distal end of the (LTMC) 

flap.


Fig. (15-A): Recurrent Sq.C.C. of the buccal mucosa. 

Fig. (15-B): Scar of previously used Rt. (PMMC) 

flap for reconstruction. 

Fig. (15-C): Skin paddle of the latissimus 

dorsi myocutaneous flap is 

sutured to the tongue. 

Fig. (16-A): Synovial sarcoma of the neck. 

Fig. (16-B): The latissimus dorsi myocutaneous flap 

is passing superficial to the pectoralis 

minor and deep to the pectoralis major. 

Fig. (16-C): Early postoperative view.


Fig. (17-A): Operative view showing lateral and 

lower orbital defects. 

Fig. (17-B): The temporalis flap was used to reconstruct 

the lateral and lower orbital walls and a 

piece of the Lt. ear cartilage was used to 

reconstruct the lower eyelid tarsus. 

Fig. (18-A): Operative view of radical maxillectomy with 

lower orbital defect. 

Fig. (18-B): Lt. temporalis flap was used 

to reconstruct the Lt. lower 

orbital defect. 

Fig. (19-A): Operative view after excision of 

advanced recurrent B.C.C. with 

defect in the orbital roof. 

Fig. (19-B): The temporalis flap was used to cover 

the exposed dura in the orbital roof.


DISCUSSION 

Radical head and neck surgery may leave 

mucosal or skin defects and sometimes with 

exposed large vessels, dura mater, cartilage or 

bones. It should be coupled with good reconstructive 

surgery [4]. An ideal flap should provide 

high success rate, few complications, low 

morbidity, short hospitalization and the greatest 

potential for best aesthetic and functional outcome 

[5]. 

Local neck skin flaps and fasciocutaneous 

flaps as forehead flap described by Mc Gregor 

(1963) [6] and deltopectoral flap described by 

Bakamjian (1965) [7] were the only method for 

head and neck reconstruction in the 1960s and 

1970s although they have many disadvantages. 

They have been markedly replaced by the pedicled 

myocutaneous flaps in the early 1980s 

since the pedicled pectoralis major flap was 

first described by Ariyan in the late 1979 [8]. 

Many myocutaneous flaps were described 

for head and neck reconstruction including 

pectoralis major, latissimus dorsi, trapezius, 

sternomastoid, temporalis and platysma [9]. 

The use of pedicled myocutaneous flaps and 

free microvascular flaps in head and neck reconstruction 

started early in our institute in the 

early 1980s and late 1980s respectively [4,10,11]. 

Choice of reconstructive options depends 

on various factors such as site of the defect, 

type of tissue required, functional and cosmetic 

implications of the defect, associated co–morbidity 

and availability of resources [9]. 

A major advantage of pedicled flaps over 

free flaps is their simple and standardized surgical 

technique requiring no further surgical 

qualification compared to micro vascular free 

flaps. Also they are reliable, safe and have high 

degree of resistance against infection and so 

can be used in irradiated patients. Free flaps 

are also associated with some drawbacks like 

the need for vigorous monitoring and reexploration 

if required [3]. However, all these 

flaps have limitations. Firstly, they have a limited 

reach because of which there are more 

chances of distal flap failure and wound gap 

due to tension by the downward pull of the 

flaps. Secondly, the type of tissue in the flap, 

its bulk and pliability does not always suit the 

defect to be reconstructed. Thirdly, it may not 

be possible to contour the flap to the defect in 

different planes. Another advantage of the (PM- 

MC) flap is filling the emptied side of the neck 

due to concomitant block neck dissection thus 

preserving the normal cervical contour and 

protect the major vessels of the neck [4]. 

The use of pedicled flaps is still indicated 

for patients in whom microsurgery is contraindicated 

due to the general condition of the 

patient or in cases of unsuccessful microsurgical 

flaps [1]. 

Despite the increasing use of microvascular 

reconstruction, the (PMMC) flap continues to 

be the most universal major flap in head and 

neck reconstruction [3,12]. 

The (PMMC) flap dimensions can be varied 

from a small island to a large one overlying the 

whole medial two thirds of the muscle, depending 

upon the site and size of the defect to be 

repaired [4]. 

Some modifications were described that 

maintains maximal donor-site function and 

morphology of the (PMMC) flap. Musclepreserving 

procedure was described taking the 

pectoralis major as an island flap with no muscle 

around the vascular pedicle and preserving the 

nerve supply to the clavicular and the upper 

sternocostal parts of the muscle [13,14]. 

When large skin paddle is needed some 

modifications were done to preserve blood 

supply to the skin island. Inclusion of nippleareola 

complex on the skin paddle stabilizes 

the blood circulation in the skin island [15]. The 

pectoralis minor muscle can be divided to preserve 

the lateral thoracic artery and its blood 

supply to the lateral distal skin island of (PM- 

MC) flap without compromising the pedicle 

length [16]. 

With large full thickness cheek defects. The 

modification adopted in bipaddling the flap was 

based on anatomical location of perforators to 

ensure good blood supply to both paddles of 

the flap. Placing the flap horizontally with 

inclusion of nipple and areola increased the 

reach and size of available flap. Precautions 

should include proper assessment of reach of 

the paddle, placing not more than one-third of 

the paddle outside the muscle and securing the 

skin paddle to the muscle to avoid shearing of 

perforators during flap raising [17].

260 


In our study (PMMC) flap was used in 84 

cases with a very high success rate (98.8%), 

whether this success was primary without any 

complications (79.8%) or secondary to successful 

management of minor complications that 

delayed healing (19%). Major flap loss requiring 

salvage reconstruction by latissimus dorsi flap 

occurred in only one case. Different series had 

reported varying incidences of complications, 

63% [18], 58% [19], 36.1% [2]. Fewer complications 

were reported when using the myofascial 

flap only [18,20]. The incidence of major or total 

flap loss was varying from 0% [21], to 1.5% [4], 

to 2.4% [2,18]. 

The main indications in our study were oral 

and partial pharyngeal defects. 

In an old series done in the Egyptian NCI 

in 1985 [4], pedicled (PMMC) flap was used 

for pharyngoplasty after total laryngopharyngectomy 

in 50 patients and in another series 

done in 1986 [10], latissinus dorsi myocutaneous 

flap was used for the same purpose in 28 cases. 

In our study, pedicled (PMMC) flap was used 

in only one case for reconstruction after this 

kind of surgery in a patient with poor general 

condition that could not withstand neither free 

jejunal flap nor gastric pull up. 

Pedicled myocutaneous flaps are rarely used 

nowadays to reconstruct the pharynx after total 

laryngopharyngectomy as this method has many 

disadvantages that includes development of 

fistula and stenosis and due to the evolution of 

gastric pull up and free jejunal flaps and their 

established use in such cases. 

Gastric transposition is more commonly 

used after pharyngolaryngo-oesophagectomy 

in our institute, owing to increased multidisciplinary 

experience in this form of surgery and 

in relation to the advanced pathological stage 

of hypopharyngeal carcinoma at presentation 

in which total esophagectomy is needed to 

obtain proper lower safety margin [22]. 

In our study the (PMMC) flap was used to 

reconstruct the anterior wall of the pharynx 

after total laryngectomy in 12 cases receiving 

prior radiotherapy (In 2 cases the mucosa was 

closed primarily & the muscle flap was used as 

a buttress to augment the suture line and replace 

the skin defect, and in 10 cases the skin island 

was used to repair the mucosal defect). In the 

latter group, intentional pharyngostomy was 

done after resection in 7 cases, and 3 cases 

developed major fistulae after trial of primary 

closure. In these 10 cases, the skin island of the 

(PMMC) flap was used to reconstruct the mucosal 

defect and the skin defect was reconstructed 

by deltopectoral fasciocutaneous flaps. The 

latissimus flap was used for this purpose in only 

one case in a female with large breast. 

Iginio Tansini in 1896 [23] was the first 

surgeon who performed the pedicled latissimus 

myocutaneous flap. He used it in reconstructing 

skin defects after surgery of breast cancer. 

However, this procedure was put to rest when 

Halsted started his radical mastectomy using 

thin skin flaps instead of removing wider skin 

area. Olivari in 1976 [24] rediscovered this flap 

and since then it gained its popularity in reconstruction 

of major defects that occurred after 

radical surgery for malignancies in the breast, 

chest wall and head & neck areas. 

Its blood supply is based on the thoraco 

dorsal vessels that run 8-14cm before entering 

the muscle just above the mid point of its free 

border. Its cranial vascularity allows it to have 

wide arc of rotation that it can cover any defect 

from the sternum anteriorly to the midline posteriorly 

and it can reach to the upper border of 

the ear [10]. 

When the donor site is less than 10x12 cm, 

it can be closed primarily but wider defects will 

need skin grafts. The largest reported size of 

this flap was 35x20 cm [25]. Olivari 1979 [26] 

proved the presence of 27 perforating arteries 

going between the muscle and the overlying 

skin. 

One of the greatest advantages of the latissimus 

dorsi flap over other regional myocutaneous 

flaps as the pectoralis major flap is that 

one can control the thickness of the muscle due 

to the anatomical fact that the main arterial 

supply runs along the lateral thin border of the 

muscle and gives its branches to the bulk of the 

muscle medially [10]. 

Elevation of the skin island overlying the 

latissimus dorsi muscle and dissecting the dominant 

perforating vessel, permit independent 

positioning of the skin island in relation to the 

muscle (razor flap) thus decreasing the donor 

site morbidity [27].


The indications of this flap in our study were 

those cases in whom the bulky (PMMC) flap 

were not satisfactory (8 cases), the (PMMC) 

flap was previously used and the patient developed 

local recurrence (1 case), the (PMMC) 

flap was used and the patient developed major 

fistula and retraction that needed salvage reconstruction 

(1 case) or the defect was out of the 

reach of the (PMMC) flap (2 cases). 

The inclusion of osseous parts had been 

described in pedicled myocutaneous flaps to be 

used in mandibular reconstruction including 

the pectoralis major osteomusculocutaneous 

flap including full thickness anterior bony part 

of the 5 th rib [11,28] and the sternocleidomastoid 

clavicular osteomusculocutaneous flaps whether 

ipsilateral [29-30] or contralateral in cases necessitating 

radical neck dissection [31]. The main 

disadvantage of the above mentioned osteocutaneous 

flaps is osteonecrosis of the bony part 

reaching 40-50% [11]. 

Myoosseous flaps and osteocutaneous flaps 

whether pedicled or free vascularized have 

several advantages when compared with other 

methods of mandibular reconstruction. Mandibular 

deviation and temporo-mandibular joint 

ankylosis can be prevented in contrast to techniques 

in which soft tissue replacement only is 

used. Also the functional and cosmetic deformity 

can be avoided when mandibular symphysis is 

included in resection [11,31]. Central complete 

mandibular defects should be immediately reconstructed 

by osseous flaps [9]. Free vascularized 

fibular graft is the mostly used flap for this 

purpose nowadays in our institute. One disadvantage 

of the fibula free flap is the limitations 

of the soft tissue component of the flap, however 

in anterior oral cavity defects, less tissue volume 

replacement is desired. 

In our study, we had only one case with 

central mandibular defect that was reconstructed 

with titanium plate and (PMMC) flap. It was a 

case of advanced carcinoma of the alveolar 

margin invading the lower lip and floor of 

mouth. Partial lateral mandibulectomy and primary 

soft tissue closure without osseous reconstruction 

is a satisfactory treatment in good 

hands [32,33]. This is suitable for lateral defects 

especially edentulous patients as deviation of 

the jaw is not a concern as there is no occlusion 

to be maintained. This is a safe, rapid and 

reliable procedure that leads to rapid healing 

and does not delay the adjuvant radiotherapy. 

The trapezius myocutaneous flap was first 

described by Demergasso and Piazza [34]. Several 

variations of this flap had been described. 

One of these variations is the lower vertical 

trapezius island flap [35]. Although the superior 

fibers have been designed as the basis for a flap 

for head and neck reconstruction, this flap has 

limited arc of rotation. However, it is possible 

to use only the middle and inferior portions of 

the trapezius as a musculocutaneous flap. This 

flap is based on the descending branch of the 

transverse cervical artery and associated veins. 

Further several detailed studies of the vascular 

anatomy of the human cadavers found that the 

trapezoidal branch of the dorsal scapular artery 

is a constant vessel to the lower trapezius muscle 

[5]. 

Its location makes it frequently the flap of 

choice for defects of the occipital, parotid & 

cervical spine areas. In addition it may be used 

for intraoral & anterior neck coverage but the 

main disadvantage is the need to change the 

position to the lateral decubitus [36]. 

If an inadequate arc of the rotation is obtained 

after elevation of the trapezius to the 

level of the first thoracic vertebra, it is possible 

to divide the fibers of origin and insertion of 

the superior portion of the trapezius muscle 

from the occiput and acromio-clavicular joint. 

This maneuver markedly increases the arc of 

rotation [5]. 

In our study, 14 cases were reconstructed 

by the lower (vertical) trapezius flap. The occiput 

was the most common site for reconstruction 

(9 cases). Other sites included the parotid 

region (2 cases), the ear pinna (one case), the 

external auditory meatus (one case) and the 

posterior neck (one case). 

In our current series the lower trapezius flap 

had many advantages. The donor site functional 

deficits were minimal and primarily closure 

was feasible in all cases. The resulting donor 

scar on the back had been favored over anterior 

chest scars by some female patients. The wide 

arc of rotation makes it suitable source for skin 

and muscle replacement for the entire neck, 

face and occipital region of the scalp. Its design 

could be the workhorse myocutaneous flap in

262 


regions not reached by the pectoralis major or 

in women in whom prevention of distortion of 

the breasts is desirable. The main disadvantage 

of this flap is the need to change the position 

in some cases to the lateral decubitus position 

during surgery. 

The temporalis muscle was used in facial 

reconstruction for more than 100 years. Many 

surgeons use the temporalis muscle for various 

defects in the craniomaxillofacial region. It has 

some limitations because of its pedicle. It cannot 

reach the midline defects of the face, only a 

small volume of the muscle can reach the defect, 

and most of the muscle bulk is used in the 

pedicle [37]. 

In our study the temporalis muscle flap was 

used in 12 cases. It was effective in reconstructing 

the lower or lateral orbital wall defects in 

8 cases to support the eye globe. Other effective 

indications was to cover the dura in the orbital 

roof defect and to facilitate the use of eye 

prosthesis after orbital exenteration. 

Conclusion: 

Pedicled myocutanous and myofascial flaps 

are still indicated in composite head and neck 

reconstruction. Their reliability, safety, and high 

degree of resistance to infection make them 

essential specially the (PMMC) flap previously 

described as the spare wheel of head and neck 

reconstructive surgery. It is suitable for lateral 

mandibular defects in edentulous patients and 

in partial pharyngeal defects in irradiated patients. 

Other pedicled myocutaneous flaps are 

still valid in certain occasions and sites. Surgeons 

must be acquainted with the different 

pedicled myocutaneous flaps that could be used 

for head and neck reconstruction. The proper 

choice of the type of flap that suites every case 

and the proper surgical technique got by experience 

will give the best functional and aesthetic 

results with the least morbidity. 

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Continuous Validity of Pedicled Myocutaneous and Myofascial ... - NCI

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