Forty patients who underwent transposition of pectoralis major myocutaneous flapfor the immediate reconstruction of defects after resection of head and neck cancer were reviewed. In our series, 18 patients experienced 30 complications related to flap usage. Those were 2 partial flap necrosis, 9 marginal flap necrosis, 6 suture line separations and 13 orocutaneous fistulas. Although most complications were minor and healed with local wound care, 5 orocutaneous fistulas associated with infection around the mandibular bone required removal of reconstruction plate, wire and grafted bone to achieve healing of fistulas. There were 30 patients that resulted in acceptable disability. However, 6 patients could not take peroral feedings and 4 patients could not successfully take an adequate amount of oral feedings as a result of persistent aspiration.
There is no question that the pectoralis major myocutaneous flap has various advantages as a one-stage reconstructive technique. However, recent reports have suggested that the incidence of complications is far greater than previously considered. In our series, overall incidence (45%) was also high as described above.
Of 40 patients, 27 received preoperative irradiation which ranged from 40 to 250 Gy and 30 patients received preoperative chemotherapy. Based on our experiences, we concluded that pathological changes of mandibular bone induced by irradiation was, at least in part, related to the postoperative infections which preceded the formation of orocutaneous fistulas.
Recent analysis on the vascular system of the skin has revealed that there are few cutaneous branches derived from thracoacrominal artery in the chest skin. Thus, we believe this anatomical character is closely related to the high incidence of complications.
10 patients were treated with salvage operation combined with planned perioperative irradiationand chemotherapy, It seemed likely that the immediate reconstruction with pectoralis major myocutaneous flap contributed to the development of such a combination therapy in the management of advanced head and neck cancer.
