Acta Otorrinolaringológica Española 73 (2022) 151---156

www.elsevier.es/otorrino

ORIGINAL ARTICLE

Analysis of the efficacy of the pectoralis major

myocutaneous flap in reconstructive head and neck
surgery
Arun Parkash Sharma, Junaid Malik, Seema Monga ∗ , Shamsheer Alam,
Shahid Rasool, Deepti Agarwal, Sudhir Bahadur

Department of Otorhinolaryngology and Head & Neck Surgery, Hamdard Institute of Medical Sciences & Research and HAHC
Hospital, Jamia Hamdard University, Hamdard Nagar, Delhi, India

Received 19 June 2020; accepted 21 November 2020

Available online 21 January 2021

KEYWORDS Abstract
Oral cancer; Introduction: Although free flaps have been used predominantly in past decades for the soft tis-
Pectoralis major sue reconstruction of head and neck malignancies, Pectoralis major myocutaneous flap (PMMF)
myocutaneous flap; is still a reliable workhorse for patients with co-existing co-morbidities or low economic status
Head & neck where free flaps are not feasible.
reconstruction Patients and methods: It was a retrospective study done on 36 patients of head and neck malig-
nancies over the period of 5 years in which PMMF was used as a method of reconstruction in
our hospital. Patients were followed up for a period of one year and outcome of PMMF was
evaluated.
Results: Out of 36 patients 31 were of oral cancer and 5 were of carcinoma hypopharynx.
Incidence of total flap necrosis was nil and partial flap necrosis was 16.6%. Orocutaneous fistula
was found in 16.6%, wound dehiscence was in 19.4% and infection was found in 13.5% of patients.
Non-flap related complications were found in 13.8% of patients. 35 out of 36 patients (97.2%)
eventually achieved satisfactory surgical outcome of PMMF reconstruction.
Conclusion: PMMF is a reliable method of reconstruction for head and neck malignancies
especially in basic healthcare settings. With minimal expertise and groundwork, it is still a
cost-effective workhorse flap for head and neck reconstruction.
© 2021 Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza y Cuello. Published by
Elsevier España, S.L.U. All rights reserved.

Abbreviations: PMMF, pectoralis major myocutaneous flap.

∗ Corresponding author.
E-mail address: dr.seema.monga@gmail.com (S. Monga).

https://doi.org/10.1016/j.otorri.2020.11.007
0001-6519/© 2021 Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza y Cuello. Published by Elsevier España, S.L.U. All rights
reserved.
 A.P. Sharma, J. Malik, S. Monga et al.

PALABRAS CLAVE Análisis de la eficacia del colgajo miocutáneo de pectoral mayor en cirugías
Cáncer oral; reconstructivas de cabeza y cuello
Colgajo miocutáneo
Resumen
de pectoral mayor;
Introducción: Aunque se han utilizado colgajos libres, fundamentalmente en las últimas
Reconstrucción de
décadas, para la reconstrucción de tejido blando en tumores malignos de cabeza y cuello,
cabeza y cuello
el colgajo miocutáneo de pectoral mayor (PMMF) sigue siendo un método fidedigno para los
pacientes con comorbilidades coexistentes o baja situación económica en la que no se tiene
acceso a los colgajos libres.
Pacientes y métodos: Estudio retrospectivo realizado en 36 pacientes con tumores malignos de
cabeza y cuello a lo largo de un periodo de 5 años, en los que se utilizó PMMF como método
de reconstrucción en nuestro hospital. Se realizó un seguimiento a los pacientes durante un
periodo de un año, evaluándose el resultado de PMMF.
Resultados: De los 36 pacientes, 31 tenían cáncer oral y 5 cáncer de hipofaringe. La incidencia
de necrosis total del colgajo fue nula, y la de necrosis parcial fue del 16,6%. Se encontró fístula
orocutánea en el 16,6% de los casos, dehiscencia de la herida en el 19,4% e infección en el
13,5% de los pacientes. Se encontraron complicaciones no relacionadas con el colgajo en un
13,8% de los pacientes. Treinta y cinco de los 36 pacientes (97,2%) lograron finalmente un
resultado quirúrgico satisfactorio de reconstrucción con PMMF.
Conclusión: El PMMF es un método de reconstrucción fiable para los tumores malignos de cabeza
y cuello, especialmente en los entornos sanitarios básicos. Con experiencia y base preparatoria
mínimas sigue siendo un colgajo fiable para la reconstrucción de cabeza y cuello.
© 2021 Sociedad Española de Otorrinolaringologı́a y Cirugı́a de Cabeza y Cuello. Publicado por
Elsevier España, S.L.U. Todos los derechos reservados.

Introduction access.7 In this study we evaluate the reliability of PMMF

Head and neck cancers account for 20---30% of all cancers
and oral cancer itself accounts for 50% of these cancers in
India.1,2 Most common type of oral cancer is Squamous Cell
Carcinoma and the most common site of location of oral
cancer in India is buccal mucosa.3
After surgical excision of oral cancer reconstruction
should be carefully planned considering a range of fac-
tors like site of primary malignancy, size of defect, general
condition of the patient, his financial status, skill and
availability of surgical as well as anesthesia team.
The main aim of reconstruction is to restore functional
integrity of oral cavity which includes swallowing, chew-
ing, speech while giving a good scar and speedy recovery.
Reconstruction of the defect can be achieved by any of the
following: healing by secondary intention, Primary closure of
the wound, skin grafting, local flaps, regional pedicle flaps
or free flaps.4
Generally free flaps are the first choice as a method
of reconstruction in most of the cases, except in patients
with comorbidities and poor recipient site factors, due
to various advantages like long term lower morbidity and
better cosmetic and functional results.5 However, free flaps
have limitations like prolonged operating time and high
cost, in addition to the expertise and facilities are not being
available at all centers. In such situations on the other hand
PMMF is still considered a virtual work horse of pedicle flaps
for head and neck reconstruction.6 It was popularized by
Stephen Ariyan in 1979 and is still widely popular especially
in developing countries due to its versatility and ease of
used in our head and neck cancer patients and study the
complications arising in these patients.
Material methods
Out of total 98 head and neck cancer patients who presented
to our hospital over a period of 5 years duration, 36 patients
underwent PMMF reconstruction after tumor resection. Only
patients with resectable head and neck carcinoma in whom
PMMF reconstruction method was used were included in this
retrospective study. Those patients who had unresectable
tumor, distant metastasis or had locoregional failure were
excluded from the study.
All included patients were retrospectively evaluated on
the basis of history & clinical examination, Karnofsky scale,
radiological, histopathological examination and TNM stag-
ing. Records of surgical data in terms of flap details,
operating time, postoperative complications were analyzed.
Surgical excision and reconstruction surgery were performed
in all patients by the same surgical team. The type of recon-
struction method was noted in each patient and regular
follow up for a period of one year was done regarding the
reliability and complications of the flaps.
Results
The PMMF was used as a method of reconstruction in 36
cases of head and neck cancer cases during the period of
2014 to 2019 in our hospital. Out of these 34 were males

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 Acta Otorrinolaringológica Española 73 (2022) 151---156
Figure 1 Tumor location in patients who underwent PMMF reconstruction.
Table 1 Clinical profile of the patients.
Demographics No. of patients
Sex Male 34
Female 2
Mean age of patients (in years) 48.6
Tobacco use Yes 98%
No 2%
Stage IV 100%
I, II, III Nil
Squamous cell carcinoma 35 (97.22%)
Spindle cell carcinoma 1 (2.78%)
and 2 were females. (M: F is 17:1). Majority were in the
age group of 40 to 50 years with a range of 24 to 72 years.
None of the patients had received neoadjuvant chemother-
apy or radiotherapy. Majority of patients (98%) used some
form of tobacco. Out of these 36 cases, 31 cases (86.1%)
were of oral cancer, and 5 (13.8%) cases were of cancer of
hypopharynx. Buccal mucosa (n = 12, 33.3%) was the most
common site of malignancy in head and neck cancer cases
(Fig. 1). All the cases (100%) had advanced (Stage IV) dis-
ease as per the AJCC TNM classification and majority of
cases had squamous cell carcinoma (n = 35, 97.2%) while
only 1 case (2.78%) had spindle cell carcinoma (Table 1).
Preoperatively 8 cases had Diabetes mellitus, 11 cases had
hypertension and 5 cases were emaciated. There were no
other significant comorbidities in our patient and correlation
could not be found between preoperative comorbidities and
chances of complications in our patients. Post-operatively 8
patients developed anemia and 7 patients developed hypoal-
buminemia in our patients which was managed successfully.
Unfortunately one patient expired in the postoperative
period due to tracheostomy tube blockage.
All cases underwent wide local excision of primary
tumor with radical/modified radical neck dissection.
Segmental/hemi-mandibulectomy was done in all cases
of oral cancer patients due to involvement of cortical
bone of mandible. PMMF was used as a primary procedure
in 35 cases while it was salvage procedure in one case
153
(reconstruction of fistula arising from surgical excision and
primary suturing of oral cancer). Bipadled PMMF was used
only in 2 (5.5%) cases where it was used to cover both
mucosal and skin defects (Fig. 2). The range of skin paddle
size in our study varied from 6 cm × 4 cm---9 cm × 7 cm.
The mean duration of surgery was 355.41 ± 25.21 minutes
(range of 260---430 min). Flap harvesting and insert time was
around two hours in most of the surgeries.
The PMMF reconstruction was well taken in majority of
the cases (Fig. 3a---c) and in none of our cases total flap loss
was encountered (Table 2). Partial flap loss was categorized
as major partial loss wherein there was full thickness partial
loss requiring surgical intervention with hospital stay and
minor partial loss which was managed with conservative
management without hospital stay. Major partial loss was
seen in 2 cases (5.5%) which were managed by wound
debridement and secondary suturing (Fig. 3d). Minor partial
loss was seen in 4 (11.1%) cases which was managed conser-
vatively. Suture line wound dehiscence was seen in 7 (19.4%)
cases, 5 (13.8%) at the primary site and 2 (5.5%) at the donor
site which was managed conservatively. Infection was found
in 11 (13.5%) cases, 7 (19.4%) at primary site and 4 (11.1%)
at donor site. Infection was managed by adequate wound
care under the cover of antibiotics selected on the basis
of sensitivity results and secondary suturing. Orocutaneous
fistula was found in 6 (16.6%) cases, 2 (5.5%) were in cases
of major flap necrosis and 4 (11.1%) at the region of anterior
tripointer suture area in oral cavity. Fistula was managed
by wound care and in some cases secondary suturing. In
13.8% patients complications unrelated to flap reconstruc-
tion were seen (Table 3). 35 (97.2%) patients eventually
reported satisfactory surgical outcome (one patient
expired).
Discussion
Currently free flap reconstruction is undoubtedly the gold
standard for head & neck reconstruction as it gives a bet-
ter cosmetic and functional outcome with minimal donor
site morbidity. However PMMF is still the workhorse of head
and neck reconstruction especially in institutions with lim-
 A.P. Sharma, J. Malik, S. Monga et al.

Figure 2 Images showing use of PMMF reconstruction in oral cancer.

Figure 3 Images of satisfactory results at primary recipient sites (a), (b) & donor site (c) and showing complication of flap loss
with wound dehiscence (d).

ited resources & man power with immense patient load.6
PMMF are being used in a lot of cancer institutions for a wide
range of defects in oral cavity, neck, hypopharynx, maxilla
and temporo-orbital area due to its benefits and versatility.8
Being bulky, it is also suitable for advanced head and neck
carcinoma involving the skin when larger volume of tissue
transfer is required to reconstruct the defect and also for
protection of carotid artery.9
Furthermore PMMF also plays an important role in
institutions where defects are managed predominantly with
free tissue transfer. In a study done by Schneider et al.,
PMMF was successfully used as secondary reconstruction
for complication resulting from free flap combined with
free flap for large tissue defects.10 In a similar study
Avery et al. mainly used PMMF in secondary reconstruction
following free flap failure and in advanced oral cancers

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 Acta Otorrinolaringológica Española 73 (2022) 151---156

Table 2 Details of PMMF reconstruction complications.

Flap-related complications

Major complications Total flap loss Nil

Partial flap loss Partial major flap loss 2 (5.55%)
6 (16.6%)
Partial minor flap loss 4 (11.11%)
Minor complications Wound dehiscence At primary site 5 (13.88%)
7 (19.4%)
At donor site 2 (5.55%)
Wound infection At primary site 7 (19.4%)
11 (13.5%)
At donor site 4 (11.1%)
Fistula Due to partial flap loss 2 (5.5%)
6 (16.6%)
Due to minor complications 4 (11.1%)

Table 3 Complications other than related to flap.

or oropharynx.18 In our study correlation between any of
these risk factors and complications could not be associated
Complications Number of Management as our sample size was not large enough. Careful handling
unrelated to patients of the flap is very important as rough handling hampers vas-
flap (13.8%) cularity of the flap which can further lead to flap failure.19
Tracheostomy 1 Fatal In our study wound dehiscence was seen in 19.4% which
tube block is similar to study done by Tripathi et al.19 26% while it was
Parotid fistula 1 Conservative 8.3% by Satio et al.16 Tripathi et al. reported a total of 12%
Chyle leak 3 Conservative fistula formation whereas Leite et al.18 reported as high as
36% in their patients treated with PMMF while in our study
fistula developed in 16.6% patients. Probable reason for fis-
tula formation is contamination by saliva leading to delayed
with significant comorbidities.11 In the present study, PMMF
wound healing and is more common in tripointer suture area
has been successfully used to reconstruct mandible defects
in the oral cavity.17 Surgical wound site infection occurred
in oral cancer surgeries as in many previously done studies.
in 13.5% in our cases compared 32% by Tripathi et al. In our
In these patients segmental/hemi-mandibulectomy was
study no case developed hematoma as extra attention was
performed as cortical bone was involved.12 In our patients
given to maintain adequate hemostasis especially to cut the
free flap was not used due to two reasons, one we did not
edge of muscle.
have the required infrastructure and microvascular team,
Despite having patients with high tobacco usage (98%)
secondly most of the patients because of some form of
and advanced stage (100%) in our study, the majority
comorbidities or due to financial constraints free flap was
of patients had good functional and cosmetic surgical
an unsuitable choice for them.
outcomes. We were very careful about precautions to be
With regards to flap survival, PMMF has been reported by
taken to prevent flap failure which have been mentioned
many authors to have nearly 100% flap uptakes with minimal
in many studies like using ties instead of cautery, cutting
complications.12,13 Similar result was seen in our study in
muscle with mayo scissors than electrosurgical knife,
which no patient had total flap necrosis. On the other hand
transecting the pectoralis major muscle horizontally at
Mehrhof et al. in14 his study on 73 patients reported total
the level where the terminal of pectoral branch could be
flap loss of 4%, similarly Brusati et al. in his study on 100
identified and skeletonize the vascular pedicle to its origin
patients documented/found total flap necrosis to be around
(this elongates vascular pedicle length).20---22 Also to prevent
2%.13 Partial flap loss in our study was 16.66% out of which
donor site complications maximum attempt was made to
5.55% had major partial loss and 11.11% had minor partial
make a tension free closure if possible as suggested by many
loss. This is similar to studies done by Mehrhof et al.14 and
authors.23
Schuller et al.15 On the contrary Nagral et al.8 and Saito
Limitation of our study is it was a retrospective study
et al.16 reported partial flap loss of 32% and 33% in their
and sample size was not large with a short follow up, and
study respectively. Many factors have also been associated
correlation between various risk factors and occurrence of
with occurrence of flap necrosis such as presence of comor-
complications could not be assessed.
bidities like advanced age, hypoalbuminemia, diabetes,
anemia, previous radiotherapy, different surgical techniques
like use of electrocautery, removal of clavicular attachment Conclusion
of pectoralis muscles.17 Varied results of complications may
also depend on the type of defect reconstructed i.e. higher Although free flaps are the gold standard of reconstruction
complications of PMMF reconstruction have been associated of defects in head and neck malignancies, PMMF is an excel-
if subsite of tumor is in tongue, hypopharynx, floor of mouth lent option in developing countries especially in patients

155
 A.P. Sharma, J. Malik, S. Monga et al.
with poor Karnofsky performance. Being bulky it is very
effective particularly for advanced oral cancers to patch-
up bony defects. Overall complications are usually minimal
which can be managed conservatively. Since reconstruction
with PMMF gives satisfactory results we recommend this
basic technique be well versed with Otolaryngologists and
Head & neck surgeons.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflict of interests
The authors have no conflict of interests to declare.
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