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

Maged M. Elshafiey, et al. 259
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].