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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 68-71

Three-way pectoralis major osteo-myo-cutaneous flap in oral cancer: An option revisited


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 Submission16-Jul-2020
Date of Acceptance01-Apr-2021
Date of Web Publication9-Aug-2021

Correspondence Address:
Dr. Shreya Bhattacharya
Max Institute of Cancer Care, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijohs.ijohs_27_20

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  Abstract 


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 Top


Composite oromandibular reconstruction, especially for defects of the middle third, presents a unique challenge for the reconstructive surgeon.[1] 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.[2]

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.[1],[3],[4]

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 Top


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 2: Skin island centred over the lower third of the sternum

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Figure 3: Curved osteotome used to separate the anterior and posterior tables

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Figure 4: Bone fixed to the reconstruction plate with 6 mm screws

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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 Top


Free vascularized bone flap is the standard of care for segmental mandibular defects.[3] However, studies have shown that soft-tissue reconstruction of complex resections has an equal or greater significance for functional results.[5] 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.[2]

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.[3],[4]

PM-OMC has been a workhorse flap for head-and-neck reconstruction and has stood the test of time.[1],[3] 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.[6],[7],[8] 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.[4] Good quality skin and sufficient soft tissue help to obliterate the dead space and to overcome the detrimental effects of radiotherapy.[2] 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.[1],[3] Studies have found sternum to be superior to rib in terms of bone survival, obliteration of dead space, and lack of chest complications.[8],[9] 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.[8]

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.[10]


  Conclusion Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Savant DN, Kavarana NM, Bhathena HM, Salkar S, Ghosh S. Osteomyocutaneous flap reconstruction for major mandibular defects. J Surg Oncol 1994;55:122-5.  Back to cited text no. 1
    
2.
Wei FC, Celik N, Yang WG, Chen IH, Chang YM, Chen HC. Complications after reconstruction by plate and soft-tissue free flap in composite mandibular defects and secondary salvage reconstruction with osteocutaneous flap. Plast Reconstr Surg 2003;112:37-42.  Back to cited text no. 2
    
3.
Shunyu NB, Medhi J, Laskar HA, Lyngdoh N, Syiemlieh J, Goyal A. 5th rib osteo-pectoralis major myocutaneous flap-still a viable option for mandibular defect reconstruction. Indian J Otolaryngol Head Neck Surg 2014;66:414-7.  Back to cited text no. 3
    
4.
Selber JC, Ghali S. Pectoralis major flap with sternum: Achieving vascularized osseous reconstruction of the mandible without a free flap. Plast Reconstr Surg 2012;129:389e-391e.  Back to cited text no. 4
    
5.
Komisar A. The functional result of mandibular reconstruction. Laryngoscope 1990;100:364-74.  Back to cited text no. 5
    
6.
Green MF, Gibson JR, Bryson JR, Thomson E. A one-stage correction of mandibular defects using a split sternum pectoralis major osteo-musculocutaneous transfer. Br J Plast Surg 1981;34:11-6.  Back to cited text no. 6
    
7.
Cuono CB, Ariyan S. Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap. Plast Reconstr Surg 1980;65:477-84.  Back to cited text no. 7
    
8.
Robertson GA. A comparison between sternum and rib in osteomyocutaneous reconstruction of major mandibular defects. Ann Plast Surg 1986;17:421-33.  Back to cited text no. 8
    
9.
Kudo K, Miyasawa M, Fujikoka Y, Sasaki J. Immediate repair of mandibular defect following surgery for carcinoma of the alveolus and gingiva using a pectoralis major osteomyocutaneous flap. J Maxillofac Surg 1985;13:116-20.  Back to cited text no. 9
    
10.
Banerjee AR, Westmore GA. Free rib graft reconstruction of the mandible: A forgotten option? Ann R Coll Surg Engl 1995;77:278-82.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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