Comparison of the Rectus Abdominis Free Flap With the Pectoralis Major Myocutaneous Flap for Reconstructions in the Head and Neck Stephen S. Kroll, MD, Gregory P. Reece, MI), Michael J. Miller, MD, Mark A. Schusterman, MD, Houston, Texas
The peetoralis major myoeutaneous flap (PMMF) is often used in the reconstruction of large head and neck defects. Unfortunately, its use is associated with a high incidence of minor complications, can distort the contour of the neck, and may cause significant d o n o r site d e f o r m i t y , e s p e c i a l l y in w o m e n . This study compared 30 patients with major head and neck eaneer-related defects who u n d e r w e n t r e -
construction with a reetus abdominis free flap (RAFF) with 39 patients with similar defects who underwent reconstruction with the PMMF. The complication rate found in the RAFF group (13%) was signifieantly lower than that found in the PMMF group (44%; p = 0.0145). Flap necrosis was found in 10% of the PMMF group, whereas none was found in the RAFF group. The aesthetic outcome was also better in patients who had reconstructions with the RAFF. We conclude that, for most major head and neck defects, reconstruetion methods that utilize the RAFF and other free tissue transfer techniques are preferable when the requisite equipment and expertise are available.
From the Department of Reconstructive and Plastic Surgery (SSK, GPR, MJM, MAS), The University of Texas M. D. Anderson Cancer Center, and the Division of Plastic Surgery (SSK), Baylor College of Medicine, Houston, Texas. Requests for reprints should be addressed to Stephen Kroll, MD, Department of Reconstructiveand Plastic Surgery, Box 62, University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030. Presented at the Third International Conferenceon Head and Neck Cancer, San Francisco, California, July 26-30, 1992.
uring the past decade, the most widely used flap for the repair of large head and neck defects has unD doubtedly been the pectoralis major myocutaneous flap (PMMF) [I-9]. It is conveniently located and relatively simple to raise, and its use does not require specialized microsurgieal training. Although the PMMF is popular among nonplastic surgeons, it has not always been as highly regarded by reconstructive specialists. It has a bulky pedicle that can lead to an unsightly contour in the neck, has a limited arc of rotation, and is associated with a high incidence of minor wound complications [10-13]. In women, moreover, the donor site deformity can be significant. For these reasons, an alternative to this "workhorse" reconstructive technique is desirable. One such technique that we have been using with increasing frequency for the repair of soft-tissue head and neck defects is the rectus abdominis free flap (RAFF) [14,15]. Because the RAFF requires microvascular surgery, it was initially used only when the PMMF was not available, but, as our experience with this flap grew, we have begun using it frequently as a preferred alternative to the PMMF. To document whether our change in flap preference was reasonable, we reviewed our experience with both methods, comparing the complication rates, the incidence of flap failure, and the aesthetic results. PATIENTS AND METHODS The records of all patients who had undergone reconstruction for head and neck defects with RAFFs at the University of Texas M. D. Anderson Cancer Center between January 1, 1986, and December 31, 1991, were reviewed. For comparison, the records of all patients who had undergone reconstruction for head and neck defects with PMMFs during 1989 were also r~viewed. Although this was a retrospective review, almost all of the data had been accumulated prospectively and were believed to be accurate. Complications included hematomas, wound dehiseenees, the occurrence of partial flap necrosis, wound infections, fistulas, and abdominal bulges or hernias. Partial flap necrosis was defined as edge necrosis that did not require the patient to return to the operating room for treatment. Major flap necrosis required d6bridement in the operating room or replacement by another flap. Statistical significance was determined by X2 analysis, incorporating the Yates' correction for small sample size when appropriate, and by the t-test. RESULTS Thirty patients underwent reconstruction for large head and neck defects using the RAFF, and 39 underwent reconstruction with the PMMF (Table I). In the
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KROLL ET AL
TABLE I Complications Associated With the Use of the RAFF and the PMMF
Flap
No. of Complications
Major Necrosis
Minor Necrosis
Total Complications (%)
PMMF RAFF
39 30
2 0
2 0
17 (44) 4 (13)
RAFF = rectus abdominis free flap; PMMF = pectoralis major myocutaneous flap,
RAFF group, four patients (13%) had complications, but none had any degree of flap necrosis. In the PMMF group, 17 patients (44%) developed complications; there were 2 cases of major flap necrosis and 2 cases of partial flap necrosis, for a combined flap necrosis rate of 10%. The difference in total complication rates was statistically significant (p = 0.0145), but the difference in the inei. dence of flap necrosis was not significant (p = 0.1979), probably because of the relatively small sample size. Aesthetically, we believe that the results obtained with the RAFF have been better than those that have been achieved with the PMMF (Figures 1 and 2).
The average time required in the operating room for the combined ablative and reconstructive procedures was 8.7 hours when the RAFF was used and 8.3 hours when the PMMF was used. This difference was not significant. The mean length of hospital stay was 11.3 days when the RAFF was used and 21.2 days when the PMMF was used, a difference that was statistically significant (p --0.0O3). COMMENTS The PMMF has been widely used by head and neck surgeons for over a decade [1-9]. Its use is convenient and usually results in a successfully healed wound, and it can be rais~ quickly. When compared with older techniques like the deltopectoral flap, so widely used by head and neck surgeons prior to the development of myocutaneous flaps, the PMMF has been spectacularly successful. However, when the PMMF is compared with other reconstructive techniques used frequently by plastic surgeons, the former has had a high complication rate [12,13]. This is particularly true in women, in whom the intervening breast tissue can reduce perfusion of the overlying skin, which can result in a high incidence of partial flap necrosis [12]. Moreover, the results of using the PMMF are not always aesthetically pleasing. Unless a
Figure 1. Left, Right. A 35-year-old patient wi'd't melanoma 5 weeks after reconstnJction of a large defect of the left cheek and neck with a rectus abdominis free flap. Note the relatively normal contour of the neck and cheek.
616
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164 DECEMBER 1992
FLAP RECONSTRUCTIONS IN THE HEAD AND NECK
Figure 2. left. A 75-year-old man after repair of a large full-thickness defect of ~ left cheek, orbit, maxilla, and buceal mucosa with a rectus abdominis free flap. Note that the cervical contour is not disturbed. RlghL The intmocal defect was repaired with an extensionof the same f~o.
radical neck dissection has been performed (which is not usually the ease at our institution), the added bulk of the PMMF in the neck can cause a significant disturbance in the cervieal contour. Even after a radical neck dissection, excessive bulk in the lower portion of the face is common. Moreover, the limited arc of rotation can interfere with the surgeon's freedom to position the flap most advantageously. Finally, the donor site deformity can be objectionable, particularly in women. The RAFF, by contrast, has relatively few disadvantages. It has an excellent blood supply, so partial flap necrosis, wound dehiscence, and fistula formation are rare. Although the flap itself may be bulky in obese patients, the pedicle is thin and the rotation point is high in the neck, so disturbance of the cervical contour is unnecessary. The donor site scar is easily hidden and relatively undeforming. Of importance to women, the breasts are not violated, nor does breast tissue interfere with the successfulexecution of the flap. Our data, especially when combined with data reported in a previous comparison between the PMMF and the radial forearm free flap [13], suggest that the PMMF is not necessarily the best choice for repair of most head and neck defects. Both the radial forearm free flap and the RAFF have lower complication rates, better aesthetic
outcomes, less donor site morbidity, and the likelihood of a shorter hospital stay. In years to come, as microvascular surgery becomes more universally available, these flaps may well replace the PMMF and become the most cornmonly used method of reconstruction for large defects of the head and neck. REFERENCES 1. Ariyan S. The pectoralis major myocutancons flap: a versatile flap for reconstruction in the head and neck. Hast Reconstr Surg 1979; 63: 73-81. 2. Back S, BiUer HF, Kxcspi YP, Lawson W. The pectoralismajor myocutancous islandflapfor reconstructionof the head and neck. Head Neck Surg 1979; I: 293-300. 3. Back S, Lawson W, BilletHF. An analysisof 133 pectoralis major myecutancous flaps.Hast Reconstr Surg 1982; 69: 460-7. 4. Biller HF, Baek S, Lawson W, Krcspi YP, Blaugrund SM. Pectoralis major myecutaneous island flap in head and neck surgery: analysis of complications in 42 cases. Arch Otolaryngol Head Neck Surg 1981; 107: 23-6. 5. Magcr WP, McCraw JB, Horton CE, McInnis WD. Pectoralis "paddle" myocutancous flaps: the workhorse of head and neck reconstruction. Am J Surg 1980; 140: 507-13. 6. Ossof RH, Wurster CF, Berktold RE, Krcspi YP, Sisson GA. Complications after pectoralis major myocutaneous flap reconstruction of head and neck defects. Arch Otolaryngol Head Neck
THE AMERICAN JOURNAL OF SURGERY VOLUME 164 DECEMBER 1992 617
KROLL ET AL
Surg 1983; 109: 812-4. 7. Rees RS, Ivey GL, Shack RB, Franklin J-D,Lynch JB. Pectoralis major muscalocutaneous flaps: long-term follow-upof hypopharyngeel reconstruction. Hast Reconstr Surg 1986; 77: 586-90. 8. Wilson JSP, Yiacoumettis AM, O'Neill T. Some observations on 112 pectoralis major myecutaneous flaps. Am J Surg 1984; 147: 273-9. 9. Russell RC, Feller AM, Elliott LF, Kucan JO, Zook EG. The extended pectoralis major myocutaneous flap: uses and indications. Plast Reconstr Surg 1991; 88: 814-23. 10. Maisel RH, Liston SL, Adams GL. Complications of pectoralis myocutaneous flaps. Laryngoscope 1983; 93: 928-30. 11. Mehrhof AL Rosensteck A, Ncifeld JP, Merrit WH, Theogaraj SD, Cohen IK. The peetoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1983; 146: 478-82.
618
12. Kroll SS, Go~fert H, Jones M, Guillamondcgui O, Schusterman MA. Analysis of complications in 168 pectoralis major myocutaneous flaps used for heed and neck reconstruction. Ann Plast Surg 1990; 25: 93-7. 13. Sohusterman MA, Kroll SS, Weber RS, Byers RM, Guillamondegui O, Goepfert H. Intraoml soft tissue reconstruction after cancer ablation: a comparison of the pectoralis major flap and the free radial fore.arm flap. Am J Surg 1991; 162: 397-9. 14. Markowitz BL, Stterberg T, Caleeterra T, et al. The deep inferiorepigastricrectusabdominis muscle and myocutancous free tissuetransfer:furtherappfieetionsfor heed and neck reconstruction.Ann Plast Surg 1991; 27: 577-82. 15. Urken ML, Turk JB, Wcinberg H, Vickery C, Billet HF. The rectus abdominis free flap in heed and neck reconstruction. Arch Otolaryngol Heed Neck Surg 1991; 117: 857-66.
THE AMERICAN JOURNAL OF SURGERY VOLUME 164 DECEMBER 1992
The peetoralis major myoeutaneous flap (PMMF) is often used in the reconstruction of large head and neck defects. Unfortunately, its use is associated with a high incidence of minor complications, can distort the contour of the neck, and may cause significant d o n o r site d e f o r m i t y , e s p e c i a l l y in w o m e n . This study compared 30 patients with major head and neck eaneer-related defects who u n d e r w e n t r e -
construction with a reetus abdominis free flap (RAFF) with 39 patients with similar defects who underwent reconstruction with the PMMF. The complication rate found in the RAFF group (13%) was signifieantly lower than that found in the PMMF group (44%; p = 0.0145). Flap necrosis was found in 10% of the PMMF group, whereas none was found in the RAFF group. The aesthetic outcome was also better in patients who had reconstructions with the RAFF. We conclude that, for most major head and neck defects, reconstruetion methods that utilize the RAFF and other free tissue transfer techniques are preferable when the requisite equipment and expertise are available.
From the Department of Reconstructive and Plastic Surgery (SSK, GPR, MJM, MAS), The University of Texas M. D. Anderson Cancer Center, and the Division of Plastic Surgery (SSK), Baylor College of Medicine, Houston, Texas. Requests for reprints should be addressed to Stephen Kroll, MD, Department of Reconstructiveand Plastic Surgery, Box 62, University of Texas, M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030. Presented at the Third International Conferenceon Head and Neck Cancer, San Francisco, California, July 26-30, 1992.
uring the past decade, the most widely used flap for the repair of large head and neck defects has unD doubtedly been the pectoralis major myocutaneous flap (PMMF) [I-9]. It is conveniently located and relatively simple to raise, and its use does not require specialized microsurgieal training. Although the PMMF is popular among nonplastic surgeons, it has not always been as highly regarded by reconstructive specialists. It has a bulky pedicle that can lead to an unsightly contour in the neck, has a limited arc of rotation, and is associated with a high incidence of minor wound complications [10-13]. In women, moreover, the donor site deformity can be significant. For these reasons, an alternative to this "workhorse" reconstructive technique is desirable. One such technique that we have been using with increasing frequency for the repair of soft-tissue head and neck defects is the rectus abdominis free flap (RAFF) [14,15]. Because the RAFF requires microvascular surgery, it was initially used only when the PMMF was not available, but, as our experience with this flap grew, we have begun using it frequently as a preferred alternative to the PMMF. To document whether our change in flap preference was reasonable, we reviewed our experience with both methods, comparing the complication rates, the incidence of flap failure, and the aesthetic results. PATIENTS AND METHODS The records of all patients who had undergone reconstruction for head and neck defects with RAFFs at the University of Texas M. D. Anderson Cancer Center between January 1, 1986, and December 31, 1991, were reviewed. For comparison, the records of all patients who had undergone reconstruction for head and neck defects with PMMFs during 1989 were also r~viewed. Although this was a retrospective review, almost all of the data had been accumulated prospectively and were believed to be accurate. Complications included hematomas, wound dehiseenees, the occurrence of partial flap necrosis, wound infections, fistulas, and abdominal bulges or hernias. Partial flap necrosis was defined as edge necrosis that did not require the patient to return to the operating room for treatment. Major flap necrosis required d6bridement in the operating room or replacement by another flap. Statistical significance was determined by X2 analysis, incorporating the Yates' correction for small sample size when appropriate, and by the t-test. RESULTS Thirty patients underwent reconstruction for large head and neck defects using the RAFF, and 39 underwent reconstruction with the PMMF (Table I). In the
THE AMERICAN JOURNAL OF SURGERY VOLUME 164 DECEMBER 1992 615
KROLL ET AL
TABLE I Complications Associated With the Use of the RAFF and the PMMF
Flap
No. of Complications
Major Necrosis
Minor Necrosis
Total Complications (%)
PMMF RAFF
39 30
2 0
2 0
17 (44) 4 (13)
RAFF = rectus abdominis free flap; PMMF = pectoralis major myocutaneous flap,
RAFF group, four patients (13%) had complications, but none had any degree of flap necrosis. In the PMMF group, 17 patients (44%) developed complications; there were 2 cases of major flap necrosis and 2 cases of partial flap necrosis, for a combined flap necrosis rate of 10%. The difference in total complication rates was statistically significant (p = 0.0145), but the difference in the inei. dence of flap necrosis was not significant (p = 0.1979), probably because of the relatively small sample size. Aesthetically, we believe that the results obtained with the RAFF have been better than those that have been achieved with the PMMF (Figures 1 and 2).
The average time required in the operating room for the combined ablative and reconstructive procedures was 8.7 hours when the RAFF was used and 8.3 hours when the PMMF was used. This difference was not significant. The mean length of hospital stay was 11.3 days when the RAFF was used and 21.2 days when the PMMF was used, a difference that was statistically significant (p --0.0O3). COMMENTS The PMMF has been widely used by head and neck surgeons for over a decade [1-9]. Its use is convenient and usually results in a successfully healed wound, and it can be rais~ quickly. When compared with older techniques like the deltopectoral flap, so widely used by head and neck surgeons prior to the development of myocutaneous flaps, the PMMF has been spectacularly successful. However, when the PMMF is compared with other reconstructive techniques used frequently by plastic surgeons, the former has had a high complication rate [12,13]. This is particularly true in women, in whom the intervening breast tissue can reduce perfusion of the overlying skin, which can result in a high incidence of partial flap necrosis [12]. Moreover, the results of using the PMMF are not always aesthetically pleasing. Unless a
Figure 1. Left, Right. A 35-year-old patient wi'd't melanoma 5 weeks after reconstnJction of a large defect of the left cheek and neck with a rectus abdominis free flap. Note the relatively normal contour of the neck and cheek.
616
THE AMERICAN JOURNAL OF SURGERY
VOLUME 164 DECEMBER 1992
FLAP RECONSTRUCTIONS IN THE HEAD AND NECK
Figure 2. left. A 75-year-old man after repair of a large full-thickness defect of ~ left cheek, orbit, maxilla, and buceal mucosa with a rectus abdominis free flap. Note that the cervical contour is not disturbed. RlghL The intmocal defect was repaired with an extensionof the same f~o.
radical neck dissection has been performed (which is not usually the ease at our institution), the added bulk of the PMMF in the neck can cause a significant disturbance in the cervieal contour. Even after a radical neck dissection, excessive bulk in the lower portion of the face is common. Moreover, the limited arc of rotation can interfere with the surgeon's freedom to position the flap most advantageously. Finally, the donor site deformity can be objectionable, particularly in women. The RAFF, by contrast, has relatively few disadvantages. It has an excellent blood supply, so partial flap necrosis, wound dehiscence, and fistula formation are rare. Although the flap itself may be bulky in obese patients, the pedicle is thin and the rotation point is high in the neck, so disturbance of the cervical contour is unnecessary. The donor site scar is easily hidden and relatively undeforming. Of importance to women, the breasts are not violated, nor does breast tissue interfere with the successfulexecution of the flap. Our data, especially when combined with data reported in a previous comparison between the PMMF and the radial forearm free flap [13], suggest that the PMMF is not necessarily the best choice for repair of most head and neck defects. Both the radial forearm free flap and the RAFF have lower complication rates, better aesthetic
outcomes, less donor site morbidity, and the likelihood of a shorter hospital stay. In years to come, as microvascular surgery becomes more universally available, these flaps may well replace the PMMF and become the most cornmonly used method of reconstruction for large defects of the head and neck. REFERENCES 1. Ariyan S. The pectoralis major myocutancons flap: a versatile flap for reconstruction in the head and neck. Hast Reconstr Surg 1979; 63: 73-81. 2. Back S, BiUer HF, Kxcspi YP, Lawson W. The pectoralismajor myocutancous islandflapfor reconstructionof the head and neck. Head Neck Surg 1979; I: 293-300. 3. Back S, Lawson W, BilletHF. An analysisof 133 pectoralis major myecutancous flaps.Hast Reconstr Surg 1982; 69: 460-7. 4. Biller HF, Baek S, Lawson W, Krcspi YP, Blaugrund SM. Pectoralis major myecutaneous island flap in head and neck surgery: analysis of complications in 42 cases. Arch Otolaryngol Head Neck Surg 1981; 107: 23-6. 5. Magcr WP, McCraw JB, Horton CE, McInnis WD. Pectoralis "paddle" myocutancous flaps: the workhorse of head and neck reconstruction. Am J Surg 1980; 140: 507-13. 6. Ossof RH, Wurster CF, Berktold RE, Krcspi YP, Sisson GA. Complications after pectoralis major myocutaneous flap reconstruction of head and neck defects. Arch Otolaryngol Head Neck
THE AMERICAN JOURNAL OF SURGERY VOLUME 164 DECEMBER 1992 617
KROLL ET AL
Surg 1983; 109: 812-4. 7. Rees RS, Ivey GL, Shack RB, Franklin J-D,Lynch JB. Pectoralis major muscalocutaneous flaps: long-term follow-upof hypopharyngeel reconstruction. Hast Reconstr Surg 1986; 77: 586-90. 8. Wilson JSP, Yiacoumettis AM, O'Neill T. Some observations on 112 pectoralis major myecutaneous flaps. Am J Surg 1984; 147: 273-9. 9. Russell RC, Feller AM, Elliott LF, Kucan JO, Zook EG. The extended pectoralis major myocutaneous flap: uses and indications. Plast Reconstr Surg 1991; 88: 814-23. 10. Maisel RH, Liston SL, Adams GL. Complications of pectoralis myocutaneous flaps. Laryngoscope 1983; 93: 928-30. 11. Mehrhof AL Rosensteck A, Ncifeld JP, Merrit WH, Theogaraj SD, Cohen IK. The peetoralis major myocutaneous flap in head and neck reconstruction. Am J Surg 1983; 146: 478-82.
618
12. Kroll SS, Go~fert H, Jones M, Guillamondcgui O, Schusterman MA. Analysis of complications in 168 pectoralis major myocutaneous flaps used for heed and neck reconstruction. Ann Plast Surg 1990; 25: 93-7. 13. Sohusterman MA, Kroll SS, Weber RS, Byers RM, Guillamondegui O, Goepfert H. Intraoml soft tissue reconstruction after cancer ablation: a comparison of the pectoralis major flap and the free radial fore.arm flap. Am J Surg 1991; 162: 397-9. 14. Markowitz BL, Stterberg T, Caleeterra T, et al. The deep inferiorepigastricrectusabdominis muscle and myocutancous free tissuetransfer:furtherappfieetionsfor heed and neck reconstruction.Ann Plast Surg 1991; 27: 577-82. 15. Urken ML, Turk JB, Wcinberg H, Vickery C, Billet HF. The rectus abdominis free flap in heed and neck reconstruction. Arch Otolaryngol Heed Neck Surg 1991; 117: 857-66.
THE AMERICAN JOURNAL OF SURGERY VOLUME 164 DECEMBER 1992
