Distal positioning of the skin paddle of pectoralis major myocutaneous flap in head and neck reconstruction

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Abstract Background To assess outcomes of pectoralis major myocutaneous flap (PMF) wherein the skin paddle (SP) was positioned with its distal portion extending beyond the lower border of pectoralis major by ≥2 cm (PMF‐d). Methods Consecutive head and neck reconstructions with PMF‐d (n = 110). SP dimensions l2 (distal extent below the lower border of pectoralis major), l1 (proximal extent above lower border of pectoralis major), and b (breadth) were recorded. Endpoints were SP necrosis, recipient dehiscence, early fistula, and persistent fistula. Results Median values of l2, l1, and b were 3.0, 6.0, and 6.0 cm, respectively. When l2 = 2.0–3.0 cm, SP necrosis occurred in only one (1%) subject (with obesity). When l2 was ≥3.5 cm, necrosis occurred in four (16%) subjects, three of whom also had l1/l2 < 2.0 (proximal SP < 67% of entire SP). Statistically, increased l2 was the only risk factor for necrosis (p = 0.001). Overall, incidence of recipient dehiscence, early fistula, and persistent fistula were 32 (29%), 20 (20%), and 3 (3%), respectively. Persistent fistula occurred only in the setting of SP necrosis and/or re‐irradiation. Conclusion Careful patient selection, adequate proximal SP, and l2 = 2.0–3.0 cm is associated with a negligible risk of necrosis. The enhanced reach and laxity and additional skin surface area and soft tissue volume conferred with PMF‐d facilitate recipient wound healing.

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