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A Post Operative Case Presentation On
Reconstruction With Pectoralis Major
Myocutanious Flap

Dr Mahbub Hussain
MS Phase B Resident
Oral And Maxillofacial Surgery Department
BSMMU
Pectoralis Major Myocutanious Flap
• History
• Pickerel , then Hueston & McConchie

• Ariyan in 1979
• Mandible
• Floor of mouth
• Tongue
• Cheek
• Neck
• Skin of mid & lower
third of face
• Pharynx and laryngeal
reconstruction
 Types Pectoralis Major Flap

1)PMMC Flap
a) Full Paddle
b) Island
c) Muscle Paddle
d) Free
2) Osteomyocutaneous
3) Muscle Only Axial
Pattern Flap
Surgical anatomy
• It is a fan shaped muscle of the
anterior chest wall.

• Origin, insertion:
Blood Supply :
Pectoralis Major Myocutanious Flap
contd…
Advantage Disadvantage
• Large skin territory. • In female person breast
• Rich vascular supply, can be transferred distortion/cosmetic deformity.
without delay.
• Heavy body hair in male limits the
• Large arc of rotation.
indication in reconstruction of oral
• Can be harvested in supine position. cavity and larynx.
• Can be used as a muscle only, skin and
muscle paddle. • Difficult in use in obese individual.
• Primary donor site closure is easily achieved. • Bulkiness of the flap compromising to
• The flap requires no microvascular intra-oral resurfacing.
anastomosis. • Compromising to shoulder function.
Pectoralis Major Myocutanious Flap
contd…
True Contraindication Relative Contraindications
• A prior history of radical axillary node • A history of breast surgery.
dissection. • Prior flap reconstruction of the breast.
• Morbidly obese or large breasted
individuals.
• Smoking, uncontrolled diabetes,
peripheral vascular disease, poor
nutritional status, prior radiation, may
reduce success of cutaneous tissue
survival.
Flap harvest
Positioning, prepping and draping

• The patient is placed in a supine

position with the chest exposed
and prepped up to the midline,
and inferiorly to the costal
margin. The upper arm is
abducted slightly to expose the
anterior axillary fold and lateral
chest wall.
Flap Harvest
Surface markings of vascular
pedicle
The surface markings of the
vascular pedicle are determined
by drawing a line from the
acromioclavicular joint to the
xiphisternum and another line
vertically from the midpoint of the
clavicle to intersect the 1st line.
Flap Harvest Contd.
Skin paddle design
The skin paddle is positioned over
the pectoralis major muscle along
the course of the pectoral branch
of the thoracoacromial artery . In
order to ensure that the pedicle is
of adequate length, the distance
between the top of the skin
paddle and the inferior edge of
the clavicle should be equal.
Flap Harvest Contd.
Incision
The skin paddle should be incised
through subcutaneous fat to
underlying muscle.
Flap Harvest Contd.
Raising the flap
Dissection starts infero-laterally
and through avascular loose
areolar plane between pectoralis
minor and major muscle. Pectoral
branch identified on the under
surface lies medial to superior
aspect of P. minor.
Lateral extension identified and
raised upto its insertion.
Medially minimum 2 cm muscle
attachment is left over body of
sternum.
Flap Harvest Contd.
Making the tunnel
A tunnel should be made above
the clavicle into the neck which is
created by subplatysmal plane of
dissection. The space within the
tunnel can be assessed by
inserting four finger of hand.
Flap Harvest Contd.
Insetting the flap
The flap placed must not be
closed in tension. The flap should
be secured in muscle
subcutaneous and skin layers.
Drain placed and donor site can
usually be closed Primarily.
Particulars of the patient
• Name: Taijul Islam
• Age: 40 years
• Sex : Male
• Address: Raipur, Lakshmipur.
Chief complaints
• Ulceration on left posterior cheek for 6 months.
• Restricted mouth opening for 3 months.
 Salient feature
Mr. Taijul Islam 40 years old male normotensive non diabetic hailing
from Raipur, Lakshmipur; presented in OMFS Department BSMMU,
with the complaints of ulceration on left side of retro-molar area for 6
months and restricted mouth opening for 3 months. He has given
history of previous surgery at thyroid region 7 years back followed by
radiotherapy. On examination, mouth opening was restricted 10-12
mm. There was an ulceration on left retro-molar area measuring 3x2
cm(sq), which was nontender, margin was everted shape, irregular,
floor was sloughy and base was indurated. There was a lump on left
cheek measuring 2x2 cm, tender on palpation, firm in consistency,
surface was irregular, fixed with overlying skin and underlying
structures. No palpable lymph node was found.
Investigations
• All investigation for G/A fitness was done and found within normal
limit.
• Incisional biopsy revealed
Squamous cell Carcinoma Grade I.
• CT Scan.
CT Scan Axial View
CT Scan Coronal View
Treatment Plan
• Wide excision with 1 cm healthy margin with segmental
mandibulectomy with disarticulation.
• Left sided Supra-Omohyoid Neck Dissection.
• Margins are ensured by frozen section biopsy.
• Reconstruction by Pectoralis Major myocutaneous flap.
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Thank
you