Search

Total laryngopharyngoesophagectomy defects after surgical ablation for laryngopharyngeal carcinoma with involvement of the cervical esophagus represents a challenge to the reconstructive surgeon. Complicating an already challenging operation is when surgical ablation occurs after failure of primary chemoradiation requiring the surgeon to operate and reconstruct in an irradiated field limiting potential reconstructive options. Due to the advanced stage at diagnosis, some studies have shown that while traditional management with radiotherapy may be considered as an initial treatment modality, often times this has failed to provide sustainable improvement in survival with reported high local recurrence rates. With relatively high local recurrence rates following radiotherapy, movement towards aggressive surgical resection is favored in some institutions. Despite this movement, primary treatment with chemoradiation is still commonly used as a primary modality opening up the opportunity for residual or recurrent disease leading the surgeon to perform salvage surgery to eradicate disease after primary treatment failure. With advanced ablative surgery comes the challenge to find an ideal reconstructive option that will optimize functional outcomes which has shown to be particularly challenging when operating in a post-radiated field with a higher risk for pharyngocutaneous fistulas. The authors present a case where reconstruction of such a defect after local failure with primary chemoradiation was successful using a single stage reconstruction with the gastric pull up technique in combination with a pectoralis major myocutaneous flap. As the risk of anastomotic leak is significantly higher in patients following radiation, this method showed utilizing a prophylactic muscle flap at the time of reconstruction may further bolster the repair and prevent anastomotic leak.

Introduction: Pharyngocutaneous fistula is the most significant complication after salvage total laryngectomy in patients who have received previous treatment with radiotherapy with or without chemotherapy. Objective: Our purpose is to review the fistula rate in radiated patients undergoing salvage total laryngectomy, to determine if the use of pectoralis major flap interposition reduces the incidence and duration of fistula and to examine other risk factors. Methods: We made a retrospective review of patients undergoing salvage total laryngectomy for exclusively larynx cancer after failure of primary curative radiotherapy between 2000 and 2017. General data from patients, risk factors and other complications were analyzed. Results: We identified 27 patients whose mean age was 66.4 years, mainly male (92.5%). The primary closure group without pectoralis major flap included 14 patients, and the group with pectoralis major flap closure included 13 patients. Pharyngocutaneous fistula was present in 15 patients (55.5%). Global pharyngocutaneous fistula rate was higher in the group of patients without pectoralis major flap comparing with those were the flap was interposed (78.6% versus 30.8%, p = 0.047). Also the pharyngocutaneous fistulas which need to be repaired with surgery (64.3% versus 7.7%, p = 0.03) and large pharyngostomes (64.3% versus 0%, p = 0.0004) were present in a higher rate in the group closed primary without pectoralis major flap. We did not find other risk factors with statistical significance. Oral diet initiation (84 days versus 21.5 days, p = 0.039) and the duration of hospitalization (98.3 days versus 27.2 days, p = 0.0041) were much lower in patients with a preventive pectoralis major flap. Two patients died as a consequence of complications of large pharyngostomes. Conclusions: Prophylactic pectoralis major flap reduced the incidence, severity and duration of fistula and should be considered during salvage total laryngectomy. Resumo: Introdução: A fístula faringocutânea é a complicação mais significativa após laringectomia total de resgate em pacientes que receberam tratamento prévio com radioterapia com ou sem quimioterapia. Objetivo: Revisar a taxa de fístula em pacientes irradiados submetidos a laringectomia total de resgate, para determinar se o uso de interposição de retalho do peitoral maior reduz a incidência e a duração da fístula e examinar outros fatores de risco. Método: Fizemos uma revisão retrospectiva de pacientes submetidos à laringectomia total de resgate para câncer exclusivamente laríngeo após falha da radioterapia curativa primária entre 2000 e 2017. Dados gerais dos pacientes, fatores de risco e outras complicações foram analisados. Resultados: Foram identificados 27 pacientes com média de 66,4 anos, principalmente do sexo masculino (92,5%). O grupo de fechamento primário sem retalho de peitoral maior incluiu 14 pacientes e o grupo de fechamento com retalho de peitoral maior incluiu 13 pacientes. Fístula faringocutânea esteve presente em 15 pacientes (55,5%). A taxa global de fístula faringocutânea foi maior no grupo de pacientes sem retalho de peitoral maior em comparação com aqueles que receberam o retalho (78,6% vs. 30,8%, p = 0,047). Além disso, as fístulas faringocutâneas que precisaram ser reparadas através de cirurgia (64,3% vs. 7,7%, p = 0,03) e grandes faringostomias (64,3% vs. 0%, p = 0,0004) apresentaram uma taxa mais alta no grupo fechado primariamente sem retalho do peitoral maior. Não encontramos outros fatores de risco com significância estatística. O início da dieta oral (84 dias vs. 21,5 dias, p = 0,039) e a duração da internação (98,3 dias vs. 27,2 dias, p = 0,0041) foram muito menores nos pacientes com uso preventivo do retalho do peitoral maior. Dois pacientes morreram em consequência de complicações de grandes faringostomias. Conclusões: O uso profilático do retalho do peitoral maior reduziu a incidência, a gravidade e a duração da fístula e deve ser considerado durante a laringectomia total de resgate. Keywords: Salvage total laryngectomy, Pectoralis major flap, Pharyngocutaneous fistula, Radiotherapy, Palavras-chave: Laringectomia total de resgate, Retalho do peitoral maior, Fístula faringocutânea, Radioterapia

Highlights • Pedicled flap reconstruction in the head and neck is still an alternative if free flaps are not possible. • Angiography of the subclavian artery is not a standard procedure in the surgical planning of pedicle flap harvesting. • In exceptional cases, we recommend angiography of the neck and thoracic vessels. • The application of a temporary pharyngostoma is still an option in extraordinary circumstances., Introduction Pedicled flap reconstruction still plays an essential role in head and neck surgery as an alternative to free grafts. Two standard methods are the pectoralis major and the deltopectoral flap, which are generally characterized by their reliable perfusion. This case describes bilateral arteriosclerosis of the subclavian artery as a possible cause of flap failure. Presentation of case We report on a 65-year-old patient with a multilevel carcinoma of the right pharynx. Due to the unique patient history, a free flap reconstruction was not possible. After resection of the primary, we performed reconstruction with a pedicled pectoralis major flap. Discussion Postoperatively, we observed necrosis of the pectoralis major flap. Secondary defect reconstructions were performed with a deltopectoral flap first from the right and then, in the case of necrosis, from the left side. Stenosing arteriosclerotic plaques of the subclavian artery on both sides were the cause of flap failure. Conclusion Preoperative angiography of the subclavian artery is not a standard diagnostic procedure in the surgical planning of pedicled flap reconstruction in the head and neck region. In exceptional cases, we recommend angiographic imaging of the supplying vessels to make a more precise flap selection and avoid complications.

INTRODUCTION: Breast conservation is the standard of care for early breast cancer. Several oncoplastic approaches have been described for the reconstruction of partial breast defects. The multiplicity of techniques indicates that the ideal reconstructive technique is yet to be identified. There has been a recent emphasis on minimizing the magnitude of surgery. In this report, we describe our experience using the pectoralis major muscle to fill relatively large post-tumorectomy breast defects. PATIENTS AND TECHNIQUE: Nine patients were operated on for malignant breast lesions. Tumorectomy resection with surgical margin rendered a 40–50% breast defect. The parenchymal defect was repaired with an advancement muscle flap of the ipsilateral pectoralis major muscle. RESULTS: All patients experienced a non-eventful postoperative course. The early cosmetic outcome was excellent in four patients, good in another four, and fair in one patient. CONCLUSION: The pectoralis major flap is useful for local repair of upper half partial breast defects in non-ptosed, cup A–B breasts.

Introduction Ewing sarcoma/primitive neuroectodermal tumour (ES/PNET) is the most common malignant tumour of the chest wall in children and young adults. Chest wall defect left after complete resection of the involved ribs and chest wall defect requiring reconstruction, is surgically challenging for cosmetic as well as for functional purposes especially in growing children. Importance A rare but feasible and simple technique for a case of chest wall tumour reconstruction has been described here with its successful outcome with available composite muscular vascularised flap., Highlights • Well localised ewings sarcoma of the ribs can be managed with complete excision with adequate margins. • Chest wall reconstruction with synthetic graft with or without pectoralis muscle flap is optimal. • Use of composite vascularised pectoralis muscle flap with or without synthetic grafts can be attempted for the chest wall reconstruction.

Skin cancers are common in head and neck region particularly Basal cell carcinoma and Squamous cell carcinoma. Treatment options includes wide local excision with neck dissection followed by adjuvant radiation/chemo/chemoradiation. We report a case of a huge skin cancer of the neck about 8.5 cm in its greatest dimensions and reconstructive techniques of the defect using pectoralis major flap in a 61-years old Albino patient, what’s important is good understanding of anatomy and surgical land marks to identify the thoracoacromial artery which is the main feeder to the flap. Reconstruction was successful with acceptable morbidity and the patient was sent for chemoradiation with no reported recurrence. Presentation from this case demonstrates that the pectoralis major flap still remains the ‘workhorse’ of reconstruction in Tanzania. It is advocated to be used in resource limited countries, effectively with acceptable morbidity and results.

Introduction: Reconstruction of the surgically created defects in the head and neck regions is a crucial step in the patients’ treatment plan. Regarding the involved tissues, various flaps and grafts have been introduced in the literature. The pectoralis major myocutaneous flap (PMMF) is one of the most versatile flaps with many variations for providing more advantages. Also, when bone tissue is needed, it can be reconstructed via an osteomyocutaneous flap including rib, sternum, or clavicle. Case Presentation: In this article, a case of oral squamous cell carcinoma with the extension to facial structures and, then, reconstructed with PMMF was presented, in which a medial half of clavicle bone was resected and employed as a free bone graft. Conclusions: Sectioning clavicle not only increases the arc of rotation and mobility of the PMMF but also provides a new source of bone graft in the vicinity. Besides, the survival of the graft and integration with the native bone is noteworthy.

The pectoralis major flap (PMF) is one of the most used pedicled flaps for reconstructive surgery in head and neck. Basing on previous studies observing that a vascular accident or pedicle ligation not always resulted in necrosis of free flaps, sometimes after a short critical period, we describe the possibility to perform the division of the PMF pedicle. The autonomization of PMF is based on the hypothesis that the flap, after a critical period, develops a neoangiogenesis at the free portion in the recipient site. It represents a possible choice in selected patients with relapse or second tumour of the oral floor and/or mobile tongue, who have been already treated with PMF reconstruction. We provide a step-by-step description of the autonomization and use of the modified PMF. Moreover, we reported advantages and pitfalls. The modified PMF represents a safe reconstructive choice for patients advised against a free flap or a second pedicled flap, with good surgical outcomes.

Background/Purpose: We analyzed complications and functional outcomes and aimed at identifying prognostic factors for functional outcomes and complications in patients who underwent salvage total laryngectomy (STL) for residual, recurrent, and second primary squamous cell carcinoma (SCC) of the larynx and hypopharynx after initial (chemo)radiation. Methods: Retrospective cohort study of patients who underwent STL in four major Belgian reference hospitals between 2002 and 2018. Prognostic factors for functional outcomes and complications were identified with uni- and multivariable analysis. Results: A total of 405 patients were included in the final analysis. STL was performed for residual tumor (40.2%), local recurrence (40.5%), or second primary laryngeal or hypopharyngeal SCC (19.4%). Early postoperative complications were experienced by 34.2% of patients: postoperative hemorrhage occurred in 5.4%, wound infection in 16.2%, and clinical pharyngocutaneous fistula (PCF) in 25.5% of patients. Early readmission proved necessary in 15.1% of cases, most often due to late PCF development (72.2%). Patients achieved total peroral intake in 94.2% of cases. However, subjective dysphagia was reported by 31.3% of patients during follow-up. Functional speech, defined as functional communication by speech without additional aids, was reported in 86.7% of cases and was most often achieved by tracheo-esophageal puncture (TEP) (94.1%). In a multivariable model, lower preoperative hemoglobin (

OBJECTIVES To describe American Head and Neck Society (AHNS) surgeon supraclavicular flap (SCF) practice patterns and to identify variables associated with SCF complications. METHODS The design is a cross-sectional study. An online survey was distributed to 782 AHNS surgeons between November 11, 2016, and December 31, 2016. The primary outcome was frequency of SCF complications. Independent variables included demographics, training, practice patterns, and SCF techniques. RESULTS Adequate survey responses were obtained from 221 AHNS surgeons. Among these, 54.3% (n = 120) performed supraclavicular flaps (SCFs). Most surgeons used the SCF for cutaneous (n = 85; 78.7%) or parotid-temporal bone (n = 59; 54.6%) defects. Nearly one-third (n = 31; 29.8%) of surgeons experienced more than a "few" SCF complications. Surgeons experienced fewer pectoralis major flap (P

Radical surgical management of tongue cancer results in sever speech and swallowing disruption, impaired airway protection and life-threatening aspiration. Surgical objective of total glossectomy defect management is an adequate restoration of lingual mass and affected tissues of the floor of the mouth. Range of flaps are known to provide the adequate outcome, i. e. pediculed pectoralis major flap, anterolateral free thigh flap, rectus abdominis flap, radial free forearm flap and latissimus dorsi flap. In the current report, we present a case of glossectomy defect reconstruction with pediculed latissimus dorsi flap. Postoperative assessment of the transplant was made according to clinical criteria and viability of the flap was assessed via laser Doppler flowmetry. Signs of microcirculation improved starting from day 5 postoperatively, and were almost equal with donor site microcirculation signs on day 14. A sufficiently large mass of the transplant allowed to create a thickening over the epiglottis, as well as to close the defect in the oral cavity. The latissimus dorsi flap in the tongue reconstruction has a high potential: its use provides a relatively good quality of articulation, recovery of deglutition.

Background Major pharyngeal defects after total pharyngolaryngectomy for hypopharyngeal squamous cell carcinoma (SCC) frequently demand reconstruction strategies that include myocutaneous pedicled flaps, such as the pectoralis major flap. Methods We retrospectively reviewed the clinical charts of 24 patients with hypopharyngeal SCC treated with Bocca's hemipharyngo-total laryngectomy (HPTL) at our Institution. Results Eighteen patients (80%) experienced no disease recurrence after primary surgery and were alive with no evidence of disease after a mean follow-up of 43 months. The 2-year overall survival (OS) and disease-specific survival (DSS) rates in our sample were 69% and 82%, respectively. Conclusion Bocca's HPTL enables an immediate neopharyngeal reconstruction, and is indicated in selected patients with intermediate to advanced hypopharyngeal tumors.

Oral cavity squamous cell carcinoma (SCC) is a relatively common cancer, but with neglected symptoms and late diagnosis. The aim of this case report is to describe how aggressive this injury can be and demonstrate the extent of an aggressive treatment for healing of the locally advanced disease and local reconstruction. A black male patient, 42 years old, smoker, noticed a right submandibular tumor after falling from his own height. The examination showed a hard and fixed mass in the right mandibular region without cervical lymph node enlargement. The oroscopy presented a fissure on the right side of the mouth floor. Radiographic examination showed a trabecular bone with moth-eaten appearance. Histopathologic diagnosis of incisional biopsy showed SCC moderately differentiated. The treatment was performed by the combination of pelvis-glosso-mandibulectomy, reconstruction with titanium plate and myocutaneous flap of pectoralis major, modified radical bilateral cervical lymph node dissection, and protective tracheostomy.

INTRODUCTION The clavicular region is acknowledged as one of the most suitable donor sites for reconstruction of the face or neck. Recently, a free thoracoacromial artery (TAA) perforator (TAAP) flap was reported as a new option for reconstruction of the face. However, the TAAP flap has several drawbacks including tedious intramuscular dissection of the pedicle and loss of availability of a pectoralis major flap as a bailout option in case of cancer recurrence. We performed an anatomical study of the TAAP and developed a novel TAA "true-perforator" flap, in which we can preserve the main trunk of the TAA. PATIENTS AND METHODS Anatomical study of the TAAPs was performed in 6 patients while elevating a deltopectoral flap or a pedicled TAAP flap. Location and diameter of the perforators were recorded. Based on these anatomical findings, we developed a novel free TAA true-perforator flap, which we used for the reconstruction of a facial defect after cancer resection. RESULTS The most dominant TAAP was identified 4.8-cm (4 to 7-cm) caudally from the upper border of the deltopectoral triangle along the cephalic vein and 1.7-cm (0.5 to 2-cm) medially from the cephalic vein. The diameter of the TAAPs at the level of fascial penetration was 0.78-mm (0.6 to 1.0-mm). The pedicle could be elongated up to 3-cm with proximal dissection. Clinical case showed a satisfactory aesthetic result with minimal donor-site morbidity. CONCLUSIONS A free TAA true-perforator flap can be a new option for the reconstruction of the face with many advantages including reduced donor-site morbidity and satisfactory aesthetic outcome.

Primary squamous cell carcinoma of the sternum is very rare. Imaging features are not specific, and a biopsy specimen may help identify the pathology. Positron emission tomography scan helps rule out a primary focus elsewhere. The treatment will be surgical management, if operable. We encountered a patient with primary squamous cell carcinoma of the sternum with an unusual presentation. After the diagnostic workup, we managed the patient surgically with resection, followed by titanium mesh reconstruction and pectoralis major flap cover. We present the case in view of its rarity and to emphasize the key surgical points.

Resumen Introducción y Objetivo La mama tuberosa es una anomalía congénita que se evidencia en la pubertad con un alto índice de presentación. Se caracteriza por alteraciones en la forma y estructura de la mama, con mayor afectación del polo inferior. Presentamos nuestra experiencia de 3 años en corrección de la mama tuberosa con la técnica de doble plano invertido con colgajo de pectoral mayor y evaluamos los resultados obtenidos. Material y Método Estudio prospectivo de 3 años sobre 12 pacientes intervenidas quirúrgicamente utilizando como alternativa de tratamiento un colgajo publicado por nosotros que utiliza el músculo pectoral mayor en su porción distal, irrigado por las perforantes internas (doble plano invertido), que proporciona mayor cobertura del implante en la zona problema. Resultados Obtuvimos un porcentaje de satisfacción del 83% de las pacientes intervenidas, evaluado mediante tabla de satisfacción a los 8 meses de postoperatorio. Conclusiones En nuestra experiencia, la técnica de doble plano invertido con colgajo de pectoral mayor para la plastia de mamas tuberosas otorga mayor cobertura en el polo inferior por utilizar cobertura muscular, con una anatomía constante, segura y conocida. Abstract Background and Objective The tuberous breast is a congenital anomaly that can be evidenced throughout puberty with a high rate of presentation. It is characterized by alterations in form and structure, the lower pole being the most usual condition. We present our 3 year experience using the double inverted plane technique in the correction of tuberous breast and evaluate our results. Methods Prospective 3 year study on 12 patients using as an alternative to the treatment an our authorship flap that uses the pectoralis major muscle in its distal portion, irrigated by the internal perforators (inverted dual plane), which provides greater coverage of the implant in the problem zone. Results A 83% percentage of patients´satisfaction was obtanined with the proposed technique; results were evaluated by means of a satisfaction table at 8 months postoperative period. Conclusions In our experience, the inverted double plane technique with pectoralis major flap for tuberous breast plasty, provides greater coverage in the lower pole by using muscle coverage, with a constant, safe and known anatomy.

The lower lip-splitting incision associated with different types of mandibulotomy, in order to obtain wide access to total or subtotal glossectomy, is described. In those cases, high rates of functional and aesthetic deficit and postoperative morbidity (more in cases of patients in which adjuvant radiotherapy has been performed) are described. We present our experience in the treatment of patients undergoing total or subtotal glossectomy and contemporary reconstruction with flaps, and without lip-splitting incision and mandibulotomy. Materials and Methods: Data about patients affected by malignant tumors requiring total or subtotal (posterior third of the tongue) resection that were treated at our department from January 2004 to December 2014 were retrospectively reviewed. Data evaluated included: T and N stage, resection margins, operation time, and post-operative complications, such as fistula and flap necrosis. Results: 41 patients were identified. In two cases microscopic infiltration of one margin was found (R1), in one case a close margin was identified. In 26 cases reconstruction was performed using free flaps, and in the remaining cases a pectoralis major flap was used. In three cases postoperative complications were observed. Discussion and conclusions: In theory, lip-splitting and mandible discontinuity could allow for increased access and tumor visualization, and could facilitate flap positioning. Nevertheless, in our experience, it is not necessary in the case of total or subtotal glossectomy.

Objectives The pectoralis major flap has been considered the workhorse flap for chest and sternoclavicular defect reconstruction. There have been many configurations of the pectoralis major flap reported in the literature for use in reconstruction sternoclavicular defects either involving bone, soft tissue elements, or both. This study reviews the different configurations of the pectoralis major flap for sternoclavicular defect reconstruction and provides the first ever classification for these techniques. We also provide an algorithm for the selection of these flap variants for sternoclavicular defect reconstruction. Methods EMBASE, Cochrane library, Ovid medicine and PubMed databases were searched from its inception to August of 2019. We included all studies describing surgical management of sternoclavicular defects. The studies were reviewed, and the different configurations of the pectoralis major flap used for sternoclavicular defect reconstruction were cataloged. We then proposed a new classification system for these procedures. Results The study included 6 articles published in the English language that provided a descriptive procedure for the use of pectoralis major flap in the reconstruction of sternoclavicular defects. The procedures were classified into three broad categories. In Type 1, the whole pectoris muscle is used. In Type 2, the pectoralis muscle is split and either advanced medially (type 2a) or rotated (type 2b) to fill the defect. In type 3, the clavicular portion of the pectoralis is islandized on a pedicle, either the thoracoacromial artery (type 3a) or the deltoid branch of the thoracoacromial artery (type 3b). Conclusion There are multiple configurations of the pectoralis flap reported in the English language literature for the reconstruction of sternoclavicular defects. Our classification system, the Opoku Classification will help surgeons select the appropriate configuration of the pectoralis major flap for sternoclavicular joint defect reconstruction based on size of defect, the status of the vascular anatomy, and acceptability of upper extremity disability. It will also help facilitate communication when describing the different configurations of the pectoralis major flap for reconstruction of sternoclavicular joint defects.

Introduction: The pectoralis major flap is a reconstructive option to consider in the treatment of pharyngocutaneous fistula after a total laryngectomy. There are not large studies assessing variables related to pharyngocutaneous fistula recurrence after removal of the larynx. Our objectives were to review the results obtained with this type of treatment when pharyngocutaneous fistula appears in laryngectomized patients, and to evaluate variables related to the results. Methods: We retrospectively reviewed our results using either a myocutaneous or fasciomuscular pectoralis major flap to repair pharyngocutaneous fistula in 50 patients. Results: There were no cases of flap necrosis. Oral intake after fistula repair with a pectoralis major flap was restored in 94% of cases. Fistula recurrence occurred in 22 cases (44%), and it was associated with a lengthening of the hospital stay. Performing the flap as an emergency procedure was associated with a significantly higher risk of fistula recurrence. Hospital stay was significantly shorter when a salivary tube was placed. Conclusions: The pectoralis major flap is a useful approach to repair pharyngocutaneous fistula. Placing salivary tubes during fistula repair significantly reduces hospital stay and complication severity in case of pharyngocutaneous fistula recurrence. Resumo: Introdução: O retalho do músculo peitoral maior é uma opção a ser considerada no fechamento de fístula faringocutânea pós-laringectomia total. Não há grandes estudos que avaliem as variáveis relacionadas à recorrência da fístula faringocutânea após esse procedimento. Nossos objetivos foram avaliar os resultados obtidos com esse tipo de tratamento em pacientes laringectomizados com fístula faringocutânea e as variáveis relacionadas aos resultados. Método: Revisamos retrospectivamente os nossos resultados em 50 pacientes nos quais um retalho miocutâneo ou fasciomuscular do músculo peitoral maior foram utilizados para reparar a fístula faringocutânea. Resultados: Não houve casos de necrose de retalho. Após o reparo da fístula com um retalho do músculo peitoral maior, a ingestão oral foi restaurada em 94% dos casos. Houve recorrência da fístula em 22 casos (44%), a qual foi associada à duração da hospitalização. O uso do retalho como procedimento de emergência foi associado a um risco significativamente maior de recorrência da fístula. A permanência hospitalar foi significativamente menor quando utilizado um tubo de derivação salivar. Conclusões: O uso do retalho do músculo peitoral maior é uma abordagem útil para reparar a fístula faringocutânea. A colocação de tubos de derivação salivar durante o reparo da fístula reduz significativamente o tempo de hospitalização e a gravidade das complicações em caso de recorrência da fístula faringocutânea. Keywords: Total laryngectomy, Pharyngocutaneous fistula, Pectoralis major flap, Bypass salivary tube, Pharynx closure, Palavras-chave: Laringectomia total, Fístula faringocutânea, Retalho do músculo peitoral maior, Tubo de derivação salivar, Fechamento da faringe

Large and deep defects resulting from lateral skull base surgery represent a challenge to the head and neck surgeon. Different microvascular free flaps have specific advantages and disadvantages. While the pedicled pectoralis major flap is considered a “work horse,” it comes with a rather short pedicle. The aim of this study was to analyze the vascular anatomy of the pectoralis major flap and assess its suitability for microvascular transfer. Anatomical studies have been performed on 6 Thiel-fixed cadavers allowing a harvest of 12 flaps by the same surgeon. Measurements of the pedicle’s length and vessel diameters have been taken with a ruler and caliper. The mean pedicle length and mean diameters (Ø) of the thoracoacromial artery and concomitant vein were found to be 9.8 cm, Ø 4.2 mm, and Ø 4.9 mm, respectively. These results suggest the potential utility of a free pectoralis major flap with microvascular anastomosis.

Sternoclavicular joint infection is very rare. Osteomyelitis is a known complication of septic sternoclavicular joint. Once this condition is diagnosed, aggressive management including antibiotic and surgical debridement is warranted. Patients are often left with sizeable sternoclavicular defects that may need surgical reconstruction. In this report, we describe the use of a completely detached pectoralis major flap for the reconstruction of a large sternoclavicular defect after resection for osteomyelitis. Briefly, after the debridement of the infected sternoclavicular joint, the pectoralis major was detached from its sternoclavicular attachments and further detached from the humeral attachments rendering it completely detached on a vascular pedicle. The muscle was advanced to cover the defect and secured. Patient recovered well without any surgery related complication. She retained good use of the ipsilateral upper extremity. The pectoralis major can be completely detached to provide ample coverage for sternoclavicular joint reconstruction if needed.

The introduction of well-vascularized flaps for infected sternotomy wound reconstruction has improved mortality rates dramatically. Multiple variations of the pectoralis major flap have been described in this context. However, unresolved limitations of this flap include poor cosmesis and problematic coverage of the inferior third of the sternotomy wound. We describe an approach to address these issues. The humeral attachments are preserved and bilateral muscles are advanced in a limited fashion. The left sternocostal head is advanced medially and rotated anticlockwise, using this portion to fill the upper half of the sternum while the caudal portion of the right pectoralis muscle is used as a turnover flap at the lower half of the wound. In all 25 patients, the anterior axillary fold was preserved bilaterally and the infection completely resolved. Complications included 3 cases of hematoma, 2 cases of coagulopathy, and 1 late bone sequestrum (aseptic). Although the study had a limited sample size, we had a high rate of success and few complications. With the preservation of bilateral axillary folds, good cosmesis, and adequate wound coverage, we recommend this modification of the pectoralis major flap in even complicated cases of mediastinitis.

Highlights • Undifferentiated pleomorphic sarcoma is extremely rare in the neck region. • Despite the availability of imaging modalities that suggest otherwise, clinical examination remains crucial in identifying malignancy in the neck. • A multidisciplinary approach is needed to obtain clear surgical margins due to the proximity of neurovascular structures., Undifferentiated pleomorphic sarcoma very rarely affect the neck. We report a case of a 62 year old man who presented with a right sided skin lump which he noticed after sustaining a neck contusion in a road traffic accident about one year ago. The initial CT and ultrasound scans of the lump were suggestive of a thrombosed varix. Clinical examination showed a hard skin nodule with signs of tethering. He underwent a wide excision of the skin nodule and the histology showed undifferentiated pleomorphic sarcoma with margins involved. He subsequently underwent another re-excision of margins and pectoralis major flap reconstruction. Following surgery, he was also prescribed adjuvant radiotherapy and he remains well about 12 months after follow up. The surgical management of undifferentiated pleomorphic sarcoma in the neck is challenging due to the proximity of critical neck structures and the need to obtain clear margins. Thus, adjuvant radiotherapy is often used to improve disease control.

Patient: Male, 51-year-old Final Diagnosis: Pharyngeal cutaneous fistula Symptoms: Fistula • infection Medication: — Clinical Procedure: — Specialty: Oncology • Plastic Surgery • Surgery Objective: Unusual or unexpected effect of treatment Background: Pharyngocutaneous fistulas are often difficult to treat because pharyngeal contents tend to leak into the cervical layer causing wound infections or abscesses. If reconstruction with free flaps is difficult, pedicled pectoralis major flaps are an option. Case Report: A 51-year-old male patient who had undergone radiation and chemotherapy for laryngeal cancer was scheduled for total laryngectomy with combined skin resection for local tumor recurrence. Reconstruction with a left deltopectoral (DP) flap was performed. However, a pharyngocutaneous fistula constructed due to cervical soft-tissue infection required reconstruction using a right bi-paddled pectoralis major muscle. The anterior pharyngeal wall was reconstructed with the medial skin island, and the lateral skin island was folded back to reconstruct the soft tissues. Since this was the patient’s third recurrence, the possibility of subsequent local recurrences, and hence of the need for radiation therapy, were high. In such cases, the pedicle of the pectoralis major muscle flap is normally closed using a DP flap. However, in the present case, the DP flap had already been used on both sides. We therefore utilized a right bi-paddled pectoralis major flap for cervical reconstruction. Conclusions: We successfully reconstructed the cervical skin and soft tissue thickly, and primarily-closed the donor site, by creating a second skin island from surplus areas of the existing skin island. This method is particularly useful for the reconstruction of cervical skin and soft tissues due to the possible need for future radiation therapy, when the use of free flaps and DP flap is unfeasible.