Extending the Arc of Rotation of the Pectoralis Major Myocutaneous Flap for Orofacial Reconstruction via a Modified Subclavicular Route Through the Clavipectoral Fascia

Abstract

Purpose: Drawbacks of the conventional supraclavicular overlay of the pectoralis major myocutaneous flap (PMMF) include the resultant unesthetic cervical bulge and the limited cephalad extension that limits its use to mandibular or cervical defects. This study discusses the technique and comparative advantages of a more esthetic subclavicular route through the clavipectoral fascia that allows an increased arc of rotation to reconstruct orofacial defects.

Materials and methods: Patients with orofacial defects that were reconstructed with a PMMF through the modified subclavicular route were included in this retrospective cohort study, which aimed to compare the gain in extension accorded through the modified subclavicular tunnel over an initial conventional supraclavicular overlay. Outcome variables included the dimension of each skin paddle and the cross-sectional area of each flap. Other variables, such as age and gender, also were investigated. Complications that arose from this technique were statistically compared with these variables and with those from previously reported studies. All data analyses were performed using Pearson χ² and correlation tests.

Results: Twelve patients (7 women and 5 men) who underwent a primary reconstruction with the PMMF during a 1-year period from November 2010 to November 2011 were selected for this study. All 12 flaps survived; 3 developed minor postoperative complications that resolved within the 3-month review period. A PMMF with an average dimension of 12.75 × 6.0 × 3.725 cm and cross-sectional area of 20.65 cm² could pass through this modified tunnel, achieving an average gain in extension of 3.2 cm that enabled the reconstruction of defects up to and above the level of the oral commissure. Apart from skin paddle dimension, all other variables were not found to be statistically related to the extension accorded by the modified route. Complications that occurred appeared to be related only to the cross-sectional area of the flap.

Conclusion: The increased cephalad extension afforded by this modified subclavicular route through the clavipectoral fascia permitted the reconstruction of orofacial defects that would otherwise have required free vascularized grafts with microvascular surgery and avoided the unesthetic cervical bulge from conventional supraclavicular overlays of the PMMF.