Journal of Surgical Oncology 2004;86:105–106

HOW I DO IT

A Novel Technique of Raising a Pectoralis

Major Myocutaneous Flap Through the Skin
Paddle Incision Alone
PANKAJ CHATURVEDI,* KUMAR A. PATHAK, PATHAMESH S. PAI, DEVENDRA A. CHAUKAR,
MANDAR S. DESHPANDE, AND ANIL K. D’CRUZ
Department of Surgical Oncology, Head and Neck Service, Tata Memorial Hospital, Mumbai, India

A good reconstruction should not only be functionally and aesthetically sound at the
recipient site but also cause least possible cosmetic aberration of the donor site.
The pectoralis major myocutaneous (PMMC) flap continues to be one of the most
commonly used flap for head and neck reconstruction in this part of the world.
Conventionally, once the skin paddle over the pectoralis major muscle is marked, a line
is drawn joining the outer edge of the skin flap extending to the apex of the anterior
axillary skin fold or midclavicular point to expose the underlying pectoralis major
muscle and harvest the flap. We intend to suggest a novel technique, in which the
pectoralis major muscle is exposed by raising the skin around the skin paddle incision
alone without making any further extension.
J. Surg. Oncol. 2004;86:105–106. ß 2004 Wiley-Liss, Inc.

KEY WORDS: pectoralis major myocutaneous flap; skin paddle; technique;

oral region; cancer; reconstruction

Cancers of the oral region remain common in this part
of the world, due to rampant consumption of tobacco and
general dental neglect. Majority of the patients present
with advanced lesions, requiring aggressive surgical
excision and challenging reconstructions. Although free
tissue transfer has revolutionized the reconstruction in
cancers of the oral region, very few patients in most
developing nations can be offered this form of treatment
due to the cost, time, expertise, and infrastructural con-
straints. Pectoralis major myocutaneous (PMMC) flap
continues to be the most commonly used flap for head
and neck reconstruction. It has stood the test of time
and offers acceptable cosmesis in reconstruction of the
head neck cancers. The PMMC flap is reliable with
acceptable complications, the learning curve is small and
therefore no specialized training in microvascular surgery
is needed. A PMMC flap can take maximum of 1–2 hr
even by a novice surgeon whereas a free flap may take 4–
5 hr depending on the experience of surgeon. This flap
does not require any additional equipment other than
those used for primary surgery. A prospective study of
220 consecutive PMMC flaps in our institute for recons-
truction of the oral region reported 40.5% flap related
complications. Twenty seven percent developed varying
degree of flap necrosis, of which only 3% had total flap
loss. Major flap loss occurred in 9% patients and minor
flap loss occurred in 15.5%. Flap necrosis was signifi-
cantly lower in the purely myocutaneous flaps (P < 0.0000)
vis-à-vis the bipedicled and osteomyocutaneous flaps.
The female gender, primary tongue cancer, subtotal or
total glossectomy, bipedicled flaps, prior chemotherapy/
radiotherapy, and presence of co-morbid conditions
(diabetes) emerged as a significant factor for flap necrosis
on multivariate analysis (P < 0.005) [1].
*Correspondence to: Dr. Pankaj Chaturvedi, Assistant Surgeon, Depart-
ment of Surgical Oncology, Tata Memorial Hospital, Parel, Mumbai 400
012, India. Fax: 91-22-2414 6937. E-mail: pankajch37@yahoo.com
DOI 10.1002/jso.20048
Published online in Wiley InterScience (www.interscience.wiley.com).

ß 2004 Wiley-Liss, Inc.

106 Chaturvedi et al.
Fig. 1. Marking of pectoralis major myocutaneous (PMMC) flap
(conventional way): Line drawn from outer edge of the skin paddle to
the apex of the anterior axillary fold or joining the midclavicular point.
Conventionally, once the skin paddle over the pecto-
ralis major muscle is marked, a line is drawn joining the
outer edge of the skin flap extending to the apex of the
anterior axillary skin fold or midclavicular point (Figs. 1
and 2) to expose the underlying pectoralis major muscle
and harvest the flap. The chest can get significantly
disfigured in this procedure and leave a large post-
operative scar. We intend to suggest a novel technique, in
which the pectoralis major muscle is exposed by raising
the skin around the skin paddle incision alone without
making any further extension.
OUR TECHNIQUES
* Raise the skin over the lower neck and chest wall
through the lower edge of the neck dissection incision.
A significant part of the skin overlying the pectoral
muscle flap can be raised through the neck dissection
incision itself. This simplifies the dissection of the skin
over the pectoral muscle from the chest side.
* Mark the skin paddle. Cut along the marked skin
paddle incision all around till the pectoralis major
muscle fibers are seen. The skin paddle is hitched to
the muscle with interrupted catgut. Raise the upper
skin flap to expose the pectoralis muscle upto the
clavicle. At this stage, we will communicate with
the skin flap already raised from the neck side. Put a
Fig. 2. Marking of the PMMC flap when using the skin paddle
incision alone for raising the flap.
large right angled retractor through this tunnel and
retract the entire skin upwards.
* Identify the lateral and lower border of the pectoralis
major and lift it off the pectoralis minor and the chest
wall. Visualize the vascular pedicle and cut pectoralis
major muscle atleast one inch away on either sides of
the vessel and rest of the flap is raised in the con-
ventional way.
* Vacuum drains are placed. Hemostasis is achieved
and the flap is inserted in the defect subcutaneously
through the neck.
CONCLUSION
A good reconstruction should not only be functionally
and aesthetically sound at the recipient site but also cause
least possible cosmetic aberration of the donor site. The
technique used by us in raising a PMMC flap in patients
may be a bit difficult but maintains a fairly good cosmesis
of the chest. It is easier whenever the skin paddle required
is large.
REFERENCE
1. Mehta S, Sarkar S, Kavarana N, et al.: Complications of the
pectoralis major myocutaneous flap in the oral cavity: A prospective
evaluation of 220 cases. Plast Reconstr Surg 1996;98: 31–37.