Received: 25 March 2017

| Accepted: 16 August 2017

DOI: 10.1002/hed.24959

ORIGINAL ARTICLE

Comparison of outcomes with extensive segmental pectoralis

major myocutaneous flap via the anterior axillary line and the
conventional technique in oral and oropharyngeal cancer

Wei-liang Chen DDS, MD, MBA | Da-ming Zhang DDS, PhD |

Zhi-quan Huang DDS, MD, PhD | Yan Wang DDS, PhD | Bin Zhou DDS, PhD |
You-yuan Wang DDS, PhD

Department of Oral and Maxillofacial

Surgery, Sun Yat-sen Memorial Hospital,
Sun Yat-sen University, Guangzhou,
China
Correspondence
Wei-liang Chen, Department of Oral and
Maxillofacial Surgery, Sun Yat-sen
Memorial Hospital of Sun Yat-sen
University, 107 Yan-jiang Road, 510120
Guangzhou, China.
Email: drchen@vip.163.com
Abstract
Background: This study compared the outcomes of an extensive segmental pectora-
lis major myocutaneous flap (esPMMF) and a conventional pectoralis major
myocutaneous flap (PMMF).
Methods: The study enrolled 91 patients with primary oral and oropharyngeal
squamous cell carcinoma (SCC) who underwent radical resection followed by recon-
struction of the defect using either an esPMMF via the anterior axillary line or a
PMMF. The pedicle lengths of the esPMMF and PMMF were 22-28 and 18-22 cm,
respectively. The esPMMF and PMMF had skin paddle dimensions of 5 3 8 to 7 3
14 cm and 6 3 7 to 8 3 17 cm, respectively.
Results: The esPMMF pedicle was longer than that of the PMMF. The range of
shoulder abduction was significantly greater in the esPMMF group and the donor-site
aesthetic results were better.
Conclusion: The esPMMF has a longer pedicle flap, enables a greater range of
shoulder abduction, and has a better aesthetic result than the conventional technique.

KEYWORDS
oral cavity, oropharynx, pectoralis major flap, shoulder morbidity, squamous cell carcinoma

1 | INTRODUCTION skull base.3 Recently, we developed an extensive segmental

In 1979, Ariyan1 described the pectoralis major myocutane-
ous flap (PMMF) based on the thoracoacromial artery. This
technique is a useful alternative in regions of the world with a
high incidence of head and neck malignancies and has been a
workhorse for maxillofacial reconstruction in developing
countries.2 However, the conventional techniques used for
harvesting the PMMF have accompanying disadvantages,
such as flap donor site and shoulder morbidity (see Figure 1),
and the flap may not be long enough for application to the
Wei-liang Chen and Da-ming Zhang shared first authorship.
pectoralis major myocutaneous flap (esPMMF) via the
anterior axillary line for reconstructing defects arising after
the resection of squamous cell carcinoma (SCC) of the oral
cavity and oropharynx. This study compares the outcomes of
esPMMF and traditional PMMF in reconstruction in patients
with oral and oropharyngeal SCC.
2 | PATIENTS AND METHODS
The study evaluated 91 patients with primary oral and oropha-
ryngeal SCC who underwent radical resection followed by
placement of either an esPMMF (see Figure 1) or a PMMF for

Head & Neck. 2017;1–6. wileyonlinelibrary.com/journal/hed V

C 2017 Wiley Periodicals, Inc. | 1
T A BL E 1 Demographics, clinical characteristics, and outcomes of extensive segmental pectoralis major myocutaneous flap and traditional
pectoralis major myocutaneous flap in 91 patients with oral and oropharyngeal squamous cell carcinoma

esPMMF (n 5 51) PMMF (n 5 40)

No. of patients (%) No. of patients (%) P value

Sex .882
Male 47 (92.2) 36 (90.0)
Female 4 (7.8) 4 (10.0)

Age, years, mean 6 SD 58.1 6 12.2 57.9 6 13.1 .863

Tumor site .728

Tongue 24 (47.1) 19 (47.5)
Lower gingiva 10 (19.6) 8 (20.0)
Mouth floor 7 (13.7) 6 (15.0)
Oropharynx 4 (7.8) 3 (7.5)
Palate 4 (7.8) 2 (5.0)
Buccal mucosa 2 (3.9) 2 (5.0)

Clinical stage .736

I 0 (0.0) 0 (0.0)
II 12 (23.5) 9 (22.5)
III 21 (41.2) 17 (42.5)
IVa 12 (23.5) 10 (25.0)
IVb 6 (11.8) 4 (10.0)

Type of neck dissection .866

iRND 43 (84.3) 35 (87.5)
bRND 8 (15.7) 5 (12.5)

Pedicle length, cm .046

Range, median 22-28, 26.6 18-22, 19.6
Skin paddle of the flap, cm 5 3 8 to 7 3 14, 5.3 3 8.9 6 3 7 to 8 3 17, 6.3 3 12.6 .637
Range, median 49, 96.1 39, 95.1
Successful no. % .864
Hematomas .787
Donor site 0, 0 1, 2.5
Recipient site 1, 2.0 0, 0

Adjuvant radiotherapy .918

Yes 8 (15.7) 5 (12.5)
No 43 (84.3) 35 (87.5)

Internal/external rotation scores .039

1 10 (19.6)/4 (7.9) 15 (37.5)/16 (40.0)
2 18 (35.3)/18 (35.3) 16 (40.0)/16 (40.0)
3 23 (45.1)/29 (56.8) 9 (22.5)/8 (20.0)

Aesthetic results of the donor site .043

1 0 (0.0) 12 (30.0)
2 20 (39.2) 24 (60.0)
3 31 (60.8) 4 (10.0)

Follow-up range, median, months 6-36, 21.2 6-32, 20.0 .923

Status, months .836

AND 41 (80.4) 30 (80.0)
AWD 6 (11.8) 3 (7.5)
DOD 4 (7.8) 5 (12.5)

Abbreviations: AND, alive with no disease; AWD, alive with disease; bRND, bilateral radical neck dissection; DOD, died of disease; esPMMF, extensive segmental
pectoralis major myocutaneous flap; iRND, ipsilateral radical neck dissection; PMMF, pectoralis major myocutaneous flap.
CHEN ET AL.
F I G U R E 1 The donor site morbidity and shoulder morbidity on the
treated side 10 months after cancer ablation and harvesting of a pectoralis
major myocutaneous flap in a 66-year-old man with oral squamous cell
carcinoma [Color figure can be viewed at wileyonlinelibrary.com]
reconstructive purposes between January 2013 and May 2016
at the Hospital of Sun Yat-sen University. The Institutional
Review Board of Sun Yat-sen University approved this study.
We included 83 men and 8 women ranging in age from 39 to
78 years (median 58.0 years). The site of the primary tumor
was the oral cavity (tongue, buccal mucosa, floor of mouth,
palate, or gingiva) in 84 patients (92.3%) and the oropharynx
in 7 patients (7.7%). According to the 2010 American Joint
Committee on Cancer staging guidelines,4 the clinical stages
were I, II, III, IVa, and IVb in 0 patients, 21 patients (23.1%),
38 patients (41.8%), 22 patients (24.2%), and 10 patients
(11.0%), respectively. All cases of oral and oropharyngeal
SCC underwent radical resection, including ipsilateral radical
neck dissection in 78 cases and bilateral radical neck dissection
in 13 cases, with reconstruction using an esPMMF in 51 cases
(56.0%) and a PMMF in 40 cases (44.0%).
The lengths of the esPMMF and PMMF pedicles were in
the ranges of 22-28 cm (median 26.6 cm) and 18-22 cm
(median 19.6 cm), respectively. The esPMMF and PMMF
skin paddle dimensions were 5 3 8 to 7 3 14 cm (median
5.3 3 8.9 cm) and 6 3 7 to 8 3 17 cm (median 6.3 3 12.6
cm), respectively. The mean flap harvesting times in the
esPMMF and PMMF groups were 56 and 54 minutes,
respectively. Thirteen patients with stage IVb or IVa disease
were treated with adjuvant radiotherapy after surgery
(median dose 60 Gy).
| 3
All patients were followed for at least 6 months postoper-
atively by a surgeon to evaluate the range of shoulder
motion, including internal and external rotation, and by a
panel of 3 surgeons to assess the donor-site deformity. The
degree of internal rotation was rated using the following
scoring system: dorsal side of hand reaches the 1 5 coccyx
region; 2 5 lower back; and 3 5 area between the scapulae.
The degree of external rotation was rated using the following
scoring system: palm of the hand reaches the 1 5 forehead;
2 5 occipital area; and 3 5 neck.5 The aesthetic result
for the donor site was rated as 1 5 unsatisfactory, 2 5
satisfactory, and 3 5 excellent.6 Table 1 summarizes the
data for the esPMMF and PMMF groups.
2.1 | Statistical analysis
The statistical analyses were performed using SPSS 20 (IBM,
Armonk, NY). The chi-square test, independent samples
t test, and Mann-Whitney U test were used to analyze data. A
P value < .05 was considered to indicate statistical
significance.
2.2 | Technique
Ultrasonography was used to detect the thoracoacromial ves-
sels. The flap is outlined; the skin paddle is located 1 cm
inferior to the areola in the seventh intercostal space (Figure
2A). The skin incision is extended along the anterior axillary
line and the skin of the chest is raised, the pectoralis major
muscle is exported, and the esPMMF is designed using the
superomedial sternocostal part of the pectoralis major muscle
(Figure 2B). First, the anterior rectus sheath is elevated with
the flap and the skin paddle over the anterior rectus sheath
and the sternocostal part of the muscle. Then, the thoracoa-
cromial vessels and pectoral branch of the vessels are identi-
fied under the pectoralis major muscle and the clavicular and
upper sternocostal parts of the pectoralis major muscle at the
level of the third intercostal space to preserve the medial pec-
toral nerve (Figure 2C). Finally, the flap is elevated and
moved to the head and neck region through a tunnel in the
deltopectoral groove (Figure 2D). To obtain a longer pedicle,
the periosteum on the inferior clavicle is spared, the subcla-
vian artery and vein are dropped, a subclavicular tunnel is
created, and then the vascular pedicle of the sternocostal
segment of the pectoralis major muscle is transferred under
the clavicle to reconstruct the craniomaxillary defect (see
Figure 3). The donor site is closed primarily.
3 | RESULTS
There was no significant difference between the esPMMF
and PMMF groups in terms of age, sex, tumor site, clinical
4 | CHEN ET AL.

F I G U R E 2 A 56-year-old man with tongue squamous cell carcinoma. A, Design of the skin paddle and skin incision. B, An extensive segmental
pectoralis major myocutaneous flap (esPMMF) is designed. C, The thoracoacromial vessels were identified on the under surface of the upper medial
sternocostal part of the pectoralis major muscle and were separated from the muscle and adjacent tissue. D, An esPMMF was elevated, including the skin
paddle and distal part of the pectoralis major muscle, and moved to the defect through the deltopectoral groove. E, The donor site at 2 months after surgery.
Deformation of the thoracic region is minimal and there are no limitations to the range of motion of the upper limbs [Color figure can be viewed at
wileyonlinelibrary.com]

stage, type of neck dissection, flap harvesting duration, rate 4 | DISCUSSION

of flap failure or skin paddle of the flap, and adjuvant
radiotherapy. However, the pedicle was longer in the
esPMMF group (median 26.6; range 22-28 cm) than in the
PMMF group (median 19.6; range 18-22 cm; P 5 .046).
Only 2 patients developed hematomas: one at the donor site
in the esPMMF group and one at the recipient site in the
PMMF group. No major complications developed in any
patient.
The range of shoulder motion (flap side) was evaluated
at least 6 months after the reconstructive surgery. The range
of shoulder abduction was significantly (P 5 .039) greater in
the esPMMF group than in the PMMF group and the donor
site aesthetic results were also better in the esPMMF group
(Figures 1, 2E, and 3C; P 5 .043). The patients were fol-
lowed for 6-36 months (median 21.2 and 20.0 months in the
esPMMF and PMMF groups, respectively). At the final
follow-up, 41 patients (80.4%) in the esPMMF group and 30
patients (80.0%) in the PMMF group were alive with no evi-
dence of disease, 6 patients (11.8%) in the esPMMF group
and 3 patients (7.5%) in the PMMF group were alive with
disease, and 4 patients (7.8%) in the esPMMF and 5 patients
(12.5%) in the PMMF group had died of local recurrence or
distant metastases between 6 and 30 months. There was no
significant survival difference between the esPMMF and
PMMF groups. Table 1 summarizes the data for the
esPMMF and PMMF groups.
The PMMF continues to play an important role in head and
neck reconstruction, even in the era of microvascular sur-
gery,7,8 and is not only an alternative to a free flap but also
involves less risk to the patient.9 However, the PMMF for
head and neck reconstruction is associated with a reduction
in shoulder strength and reduced range of motion and flexion
have been reported.5,10,11
To reduce the donor-site morbidity, a modified PMMF
with partial preservation of the muscle12 and so-called seg-
mentally split pectoralis major flaps were developed.13,14 In
1 study, 73.7% of the patients with preserved muscle func-
tion at the donor site were manual workers and 26.3%
returned to normal activity.13 The segmentally splitting flap
technique provides a method both for leaving innervated
muscle segments in situ to preserve donor motor function
and for deriving 2 independent flaps from 1 muscle.14 Corten
et al15 reported that the clavicular and upper medial
sternocostal parts of the pectoralis major muscle and their
nerve supply can be preserved; this technique provides
maximal donor-site function.
In this study, we compared the esPMMF via the anterior
axillary line and the conventional PMMF used for recon-
struction in patients with oral and oropharyngeal SCC. The 2
groups were similar in terms of patient characteristics (age,
sex, tumor site, clinical stage, type of neck dissection, flap
CHEN ET AL.
F I G U R E 3 A 66-year-old woman with palate squamous cell carcinoma involving the skull base. A, The flap transferred under the upper medial
sternocostal parts of the muscle and subclavicular tunnel. B, The craniomaxillary defect after tumor resection. C, Intraoral view 10 months after surgery.
D, The donor site 6 months after surgery; deformation of the thoracic region is minimal and there are no limitations to the range of motion of the right upper
limb [Color figure can be viewed at wileyonlinelibrary.com]
harvesting duration, rate of flap failure or skin paddle of the
flap, and adjuvant radiotherapy) and survival. Only 2 patients
developed hematomas and no major complications occurred
in any patient. The 1 case of esPMMF failure was in a patient
who developed a major hematoma in the neck, which pressed
on the flap pedicle. We believe that both types of flap have
major roles in surgery and both are safe and easy to harvest.
The esPMMF pedicle was longer than that of the conven-
tional PMMF. The range of the esPMMF can be extended by
about 7 cm compared to the PMMF. The esPMMF may be
used to reconstruct craniomaxillary defects. Extending the arc
of rotation of the PMMF enabled the reconstruction of defects
up to and above the level of the oral commissure16; an exter-
nalized pedicle allows the PMMF to reach the periorbital area
and anterior skull base, but the pedicle needs to be protected
and wrapped 2-3 weeks after flap division.17 We believed that
the range was extended by designing the skin paddle inferior
to the areola to the seventh intercostal space; and the flap is
transferred under the clavicle, which permits safe, easy passage
of the flap while giving it a large arc of rotation and achieving
an increased pedicle length and decreased pedicle bulk. The
pectoralis major muscle consists of 2 anatomic vascular territo-
ries in which the choke vessels in the muscle at the level of the
fourth costal cartilage divide into the cranial and caudal sides.
The chest skin area on the caudal side where the skin island of
the flap is prepared receives its blood supply from a dense
anastomotic network formed by the fourth, fifth, and sixth
intercostal perforating branches.18 However, when preparing
the flap transfer route under the clavicle, care must be taken to
avoid damaging the subclavian artery and vein.19
| 5
There was a significantly greater range of shoulder
abduction (flap side) in the esPMMF group than in the
PMMF group and the aesthetic results at the donor site were
also better in the esPMMF group 6 months after the recon-
structive surgery. We believed that preservation or restora-
tion of the upper medial sternocostal parts of the pectoralis
major muscle and their nerve supply (the medial pectoral
nerve) can preserve their function; motor nerve preservation
delays muscle atrophy and the skin incision in the anterior
axillary line designed for harvesting this flap provides maxi-
mal donor site function and there were no visible depressions
in the infraclavicular area or loss of the anatomic configura-
tion in the anterior axillary line. This highlights the benefits
of this technique. However, the reconstruction of the defects
arising after wide resection of advanced oral and oropharyn-
geal SCC is a major problem.3 We believe that the PMMF or
esPMMF may not be large enough to allow reconstruction of
major through-and-through defects.
O R CI D
Wei-liang Chen, DDS, MD, MBA http://orcid.org/0000-
0001-6892-3993
Zhi-quan Huang, DDS, MD, PhD http://orcid.org/0000-
0002-9262-2477
R EFE RE NC ES
[1] Ariyan S. The pectoralis major myocutaneous flap. A versatile
flap for reconstruction in the head and neck. Plast Reconstr
Surg. 1979;63(1):73-81.
6 |
[2] Gadre KS, Gadre P, Sane VD, Halli R, Doshi P, Modi S.
Pectoralis major myocutaneous flap–still a workhorse for
maxillofacial reconstruction in developing countries. J Oral
Maxillofac Surg. 2013;71(11):2005.e1-2005.e10.
[3] Chen WL, Wang YY, Zhang DM, Fan S, Lin ZY. Extended ver-
tical lower trapezius island myocutaneous flap versus pectoralis
major myocutaneous flap for reconstruction in recurrent oral and
oropharyngeal cancer. Head Neck. 2016;38 Suppl 1:E159-E164.
[4] Edge SB, Byrd DR, Compton C, Fritz AG, Greene FL, Trotti A
III, eds. AJCC Cancer Staging Manual. 7th ed. New York, NY:
Springer; 2010.
[5] Refos JW, Witte BI, de Goede CJ, de Bree R. Shoulder morbid-
ity after pectoralis major flap reconstruction. Head Neck. 2016;
38(8):1221-1228.
[6] Chen W, Li J, Yang Z, Yongjie W, Zhiquan W, Wang Y.
SMAS fold flap and ADM repair of the parotid bed following
removal of parotid haemangiomas via pre- and retroauricular
incisions to improve cosmetic outcome and prevent Frey’s
syndrome. J Plast Reconstr Aesthet Surg. 2008;61(8):893-899;
discussion 899-900.
[7] Avery CM, Crank ST, Neal CP, Hayter JP, Elton C. The use of
the pectoralis major flap for advanced and recurrent head and
neck malignancy in the medically compromised patient. Oral
Oncol. 2010;46(11):829-833.
[8] Schneider DS, Wu V, Wax MK. Indications for pedicled pectoralis
major flap in a free tissue transfer practice. Head Neck. 2012;34(8):
1106-1110.
[9] Koh KS, Eom JS, Kirk I, Kim SY, Nam S. Pectoralis major
musculocutaneous flap in oropharyngeal reconstruction: revisited.
Plast Reconstr Surg. 2006;118(5):1145-1149; discussion 1150.
[10] Merve A, Mitra I, Swindell R, Homer JJ. Shoulder morbidity
after pectoralis major flap reconstruction for head and neck
cancer. Head Neck. 2009;31(11):1470-1476.
[11] Moukarbel RV, Fung K, Franklin JH, et al. Neck and shoulder
disability following reconstruction with the pectoralis major
pedicled flap. Laryngoscope. 2010;120(6):1129-1134.
CHEN ET AL.
[12] de Azevedo JF. Modified pectoralis major myocutaneous flap
with partial preservation of the muscle: a study of 55 cases.
Head Neck Surg. 1986;8(5):327-331.
[13] Tobin GR. Pectoralis major segmental anatomy and segmentally split
pectoralis major flaps. Plast Reconstr Surg. 1985;75(6):814-824.
[14] Morain WD, Colen LB, Hutchings JC. The segmental pectoralis
major muscle flap: a function-preserving procedure. Plast
Reconstr Surg. 1985;75(6):825-830.
[15] Corten EM, Schellekens PP, Bleys RL, Kon M. The nerve supply
to the clavicular part of the pectoralis major muscle: an anatomical
study and clinical application of the function-preserving pectoralis
major island flap. Plast Reconstr Surg. 2003;112(4):969-975.
[16] Poh EH, Xu LQ, Yin XL, Shen SK. Extending the arc of rotation
of the pectoralis major myocutaneous flap for orofacial reconstruc-
tion via a modified subclavicular route through the clavipectoral
fascia. J Oral Maxillofac Surg. 2017;75(1):222.e1-222.e6.
[17] Kadlub N, Shin JH, Ross DA, et al. Use of the external pectora-
lis myocutaneous major flap in anterior skull base reconstruc-
tion. Int J Oral Maxillofac Surg. 2013;42(4):453-457.
[18] Rikimaru H, Kiyokawa K, Inoue Y, Tai Y. Three-dimensional
anatomical vascular distribution in the pectoralis major myocuta-
neous flap. Plast Reconstr Surg. 2005;115(5):1342-1352.
[19] Kiyokawa K, Tai Y, Tanabe HY, et al. A method that preserves cir-
culation during preparation of the pectoralis major myocutaneous
flap in head and neck reconstruction. Plast Reconstr Surg. 1998;102
(7):2336-2345.
How to cite this article: Chen W-l, Zhang D-m,
Huang Z-q, Wang Y, Zhou B, Wang Y-y. Comparison
of outcomes with extensive segmental pectoralis major
myocutaneous flap via the anterior axillary line and the
conventional technique in oral and oropharyngeal can-
cer. Head & Neck. 2017;00:1–6. https://doi.org/10.
1002/hed.24959