Pectoralis major musculocutaneous flap in oropharyngeal reconstruction: revisited

Free tissue transfer is now favored for head and neck reconstruction following cancer resection. Its success rate is rising with the obvious advances in microsurgery. The pectoralis major musculocutaneous flap, a former workhorse in head and neck reconstruction, has been overlooked and criticized because of its seemingly high rate of complications and cosmetic inferiority, but it is still being used by many surgeons and plays an important role in head and neck reconstruction.

The authors reviewed 34 pectoralis major musculocutaneous flap cases and 18 free flap cases (12 radial forearm flaps, six rectus abdominis flaps) involving oropharyngeal reconstruction. Flap necrosis, fistula formation, and operative times were compared. The pectoralis major musculocutaneous flap was elevated in true island type with maximal skeletonization of the pectoral branch of the thoracoacromial vessels.

In pectoralis major musculocutaneous cases, all defects were reconstructed successfully, with only two cases of partial necrosis that were managed conservatively. Among the free flaps, two resulted in total flap loss and were subsequently replaced with pectoralis major musculocutaneous flaps. Fistula formation did not occur in any case in either group. Mean operative time for pectoralis major musculocutaneous flap preparation was 76 +/- 7 minutes; that for free flap preparation was 145 +/- 11 minutes.

Technical refinements and meticulous procedures minimized necrosis of the pectoralis major musculocutaneous flap and guaranteed the success of the reconstruction. The free flap is an excellent method for oropharyngeal reconstruction, but the refined pectoralis major musculocutaneous flap can also produce acceptable results with minimal complications. In some instances, the pectoralis major musculocutaneous flap is not only an alternative to the free flap but a better choice that presents less risk to the patient.