Modern Plastic Surgery, 2012, 2, 103-107
http://dx.doi.org/10.4236/mps.2012.24025 Published Online October 2012 (http://www.SciRP.org/journal/mps) 103
Indications and Outcomes for Pedicled Pectoralis Major
Myocutaneous Flaps at a Primary Microvascular
Head and Neck Reconstructive Center
Akira Saito1, Hidehiko Minakawa1, Noriko Saito2, Tatsumi Nagahashi3
1Division of Plastic and Reconstructive Surgery, Hokkaido Cancer Center, Sapporo, Japan; 2Department of Plastic and Reconstruc-
tive Surgery, Graduate School of Medicine, Hokkaido University, Sapporo, Japan; 3Division of Head and Neck Surgery, Hokkaido
Cancer Center, Sapporo, Japan.
Received July 14th, 2012; revised August 16th, 2012; accepted September 17th, 2012
ABSTRACT
The pectoralis major musculocutaneous (PMMC) flap has been a useful technique for head and neck reconstruction
since its first description by Ariyan in 1979. How ever, techniques in microvascular surgery have since evolved and re-
cently free tissue transfer has played an important role in head and neck reconstruction. Although we use free flaps as
the first choice for head and neck reconstruction, similar to many other institutions, some patients at our hospital have
undergone reconstruction with PMMC flaps. We retrospectively analyzed the indications and outcomes of this recon-
structive technique from our experience with 12 patients. The medical records of all patients who underwent PMMC
flaps at Hokkaido Cancer Center from 2001 to 2010 were reviewed. Data concerning diagnosis, main indication, site of
reconstruction, previous treatment, and postoperative complications were analyzed. Of the 12 PMMC flap surgeries
performed, 3 were carried out as primary reconstructive procedures, whereas 9 were done as “salvage” procedures.
Flap-related complications were observed in 6 cases. Partial flap loss developed in 4 patients, although there were no
cases of total flap loss. There were 3 recurrent fistulae following reconstruction with PMMC flaps. The preoperative
goals of performing PMMC flap surgery were met in 83% of our cases. The authors conclude that while free flap trans-
fer is usually the first choice for head and neck reconstruction, PMMC flaps can produce acceptable results in certain
situations.
Keywords: Pectoralis Major Myocutaneous Flap; Head and Neck Reconstruction; Pedicled Flap; Pedicled Pectoralis
Major Myocutaneous Flap; Reconstruction, Microsurgery
1. Introduction
Since its first description by Ariyan in 1979 [1], pector-
alis major musculocutaneous (PMMC) flap surgery has
been a useful technique for head and neck reconstruction
[2-5], the advantages of which include robust size, versa-
tility, and determinate blood supply [6]. However, since
the early 1980s, techniques of microvascular surgery
have evolved and free tissue transfer has played an im-
portant role in reconstructive surgery for advanced head
and neck cancers [7].
There have been studies comparing the differences
between free flaps and pedicled myocutaneous flaps for
head and neck reconstruction which suggest that free
flaps are superior with regard to postoperative results and
cost effectiveness [8,9]. Currently, free tissue transfer is
the first choice for head and neck reconstruction at many
institutes [10].
However, free flap transfer cannot be used for all pa-
tients at every institute since it requires special tech-
niques and equipment for microsurgery, and it takes a
longer time to perform than does the pedicled myocuta-
neous flap. Although we usually use free flaps as the first
choice for head and neck reconstruction, some patients at
our institution have undergone reconstruction using
PMMC flaps. We retrospectively analyzed the indica-
tions and outcomes for this technique from our experi-
ence with 12 patients.
2. Methods
The medical records of all patients who underwent
PMMC flap surgery at Hokkaido Cancer Center from
2001 to 2010 were reviewed. Thirteen patients were
identified as having undergone a PMMC flap for head
and neck reconstruction, but 1 patient was excluded due

Indications and Outcomes for Pedicled Pectoralis Major Myocutaneous Flaps at a
Primary Microvascular Head and Neck Reconstructive Center
104
to a lack of adequate information. The medical charts of
the 12 participating patients were retrospectively re-
viewed for data regarding diagnosis, main indication, site
of reconstruction, previous treatment, and postoperative
complications. Major complications were defined as
those requiring revision surg eries, while minor complica-
tions required conservative wound care alone. Statistical
analyses were performed by Fisher’s exact probability
tests. A value of p < 0.05 was considered statistically
significant.
3. Results
Patient demographics and prior treatments are presented
in Table 1. There were 11 males and 1 female patient,
with a mean age of 66.3 years (range: 27 - 83 years).
The distribution of cases regarding site of reconstruc-
tion, indication for PMMC flaps, type of reconstruction,
and the requirement for skin grafts is shown in Table 2.
Of the 12 PMMC flaps, 3 were carried out as primary
reconstructive procedures, whereas 9 were done as “sal-
vage” procedures (5 for fistula, 2 for free flap failure, 1
for ablation of recurrent tumor after a free flap recon-
struction, and 1 for ablation of recurrent tumor after ra-
diation therapy). A titanium reconstruction plate was
used to restore mandibular con tinuity in conj unction with
Table 1. Patient and characteristics.
Characteristics n
Patients 12
Male 11
Female 1
Age, mean (range), years 66.3 (27 - 83)
Disease
Laryngeal cancer 4
Floor of mouth c a n ce r 3
Tongue cancer 2
Hypopharyngeal cancer 1
Esophageal cancer 1
Skin cancer 1
Prior treatment
Surgery only 3
Surgery + RT 4
Surgery + CCRT 2
CCRT 1
None 2
Table 2. Case distribution in relation to reconstructive sur-
gery.
Site of reconstruction n
Neck 6
Oral cavity 5
Cheek 1
Indication for PMMC flap
Repair of fistula 5
Pharyngocutaneous fistula 4
Gastric tube—skin fistula 1
Repair of defect following tumor ablation 5
Primary tumor 3
Recurrent tumor 2
Repair of total flap loss 2
Type of recon struction
PMMC flap 11
PMMC flap + reconstruction plate 1
Skin graft
Yes 4
Donor site 1
On the muscle 3
No 8
the PMMC flap.
Flap-related complications were observed in 6 cases
(50%) and are shown in Table 3. Major complications
were observed in 3 patients (25%) and minor complica-
tions were seen in 3 patients (25%). Partial flap loss de-
veloped in 4 patients, although there were no cases of
total flap loss. There were 3 recurrent fistulae following
reconstruction with PMMC flaps.
Data regarding comparisons between the occurrence of
complications and indications or previous treatments are
presented in Ta ble 4 . Among the 7 patients who received
prior radiotherapy, 5 (71%) developed complications,
whereas only 1 patient (20%) developed complications
among the 5 who did not receive pr i or radiot h erapy.
4. Discussion
Free flap transfers have become the first choice for head
and neck reconstruction surgeries at many institutions.
This procedure provides a one-stage restoration with sig-
nificantly lower morbidity and complication rate at donor
and recipient sites, and usually has better outcomes than

Indications and Outcomes for Pedicled Pectoralis Major Myocutaneous Flaps at a
Primary Microvascular Head and Neck Reconstructive Center 105
Table 3. Complications following reconstructive surgery
with PMMC flaps.
Complications n
Yes 6
Major complications 3
Minor complications 3
No 6
Detail of complications
Partial flap necrosis 4
Fistula 4
Wound dehiscence 1
Table 4. Comparisons between the presence of complication
and variables of interest.
Complication
Variables Yes No
Indication
Fistula 4 1
Others 2 5
Previous RT therapy
Yes 5 2
No 1 4
Previous surgery
Yes 5 4
No 1 2
alternative approaches [5,11]. At out institute, we also
use free flaps as the fi rst choice for head and ne ck recon-
struction, including free anterolateral thigh flaps, free
radial forearm flaps, free rectus abdominis flaps, and free
jejunum transfer. Nowadays, free flaps are more common
due to improved microsurgical techniques, while PMMC
flaps have lost much of their reputation for reconstruct-
tion of the head and neck region [12].
However, PMMC flaps still have a place in head and
neck reconstruction. This technique can be used as a sal-
vage procedure after necrosis of free flaps and in cases
where there are contraindications to free flaps, such as
medical conditions that make the patient unable to toler-
ate long surgical procedures or inadequate recipient ves-
sels for microanastomosis in the necks of patients who
previously underwent high-dose radiotherapy [5]. PMMC
flaps can also be performed in combination with free
flaps, usually for covering large defects, to protect neck
vessels in patients that are at risk for rupture, and to pre-
vent possible complications of wounds that have a high
risk of breakdown [13].
Schneider et al. have previously described the indica-
tions for PMMC flap surgery at a primary microvascular
head and neck reconstructive center. In their series o f 53
patients, PMMC flaps were used: 1) to salvage free flap
complications (38%), 2) with simultaneous free flap re-
construction for additional soft tissue filler in extensive
resections, or for cervical skin reconstruction (33%), and
3) for primary reconstructions, most frequently involving
compromised host status with a need for cervical skin
reconstruction and great vessel coverage after radical
neck dissection (29%) [14]. In our series, primary recon-
struction with PMMC flaps was performed on 3 patients
(25%), while the other 9 patients (75%) underwent “sal-
vage” reconstructions (i.e., reconstruction after free flap
failure, fistulas, and recurrent tumor ablation). Since 2 of
them were elderly and another suffered from malnutrition,
the 3 patients who underwent primary reconstruction
with PMMC flaps were considered unable to tolerate
long, invasive surgeries.
Flap-related complications developed in 6 (50%) of
the patients, with 3 experiencing major complications.
Thus, the results of our series were comparable to previ-
ous reports, since overall complication rates of PMMC
flaps have been reported to be quite high, ranging from
16% to 63% [5].
One of the main advantages of PMMC flaps is survival.
Even if performed by an experienced microsurgeon, total
flap loss can occur in free flap reconstructions. On the
other hand, total loss of PMMC flaps is rare, although
partial flap loss can occur [13]. In the cu rrent series, par-
tial flap necrosis occurred in 4 patients (33%), although
all flaps survived. We suppose that it might occur since
the skin paddle was designed more inferiorly beyond
vascular territories for the flap in some cases. Two pa-
tients required revision surgery with other flaps because
they developed fistulas following reconstruction with
PMMC flaps. In all other patients, reconstructions with
primary PMMC flaps were successful, with the recon-
struction success rate being 83%. These results are
slightly lower than success rates of other studies, which
ranged from 87.5% to 100% [13,15-17].
Previous reports have described the risk factors asso-
ciated with the development of flap complications, such
as age, sex, tumor location, site of reconstruction, prior
radiotherapy, and comorbidities, large tumor resections,
cigarette packs smoked, and salvage procedures [3,15,18,
19]. However, results were not similar in all series with
some reports describing that complication rates were not
associated with age, sex, smoking, preoperative radio-
therapy, diabetes, o r obesity [2,4,5,12].

Indications and Outcomes for Pedicled Pectoralis Major Myocutaneous Flaps at a
Primary Microvascular Head and Neck Reconstructive Center
106
In our series, 5 out of the 6 patients (83%) who devel-
oped complications had a history of preoperative radio-
therapy, while only 1 of 6 patients (17%) who did not
develop complications had undergone preoperative ra-
diotherapy. However, this difference was not statistically
significant.
Three out of 5 patients with fistula had recurrences af-
ter the reconstructive procedures, with 2 of them devel-
oping fistula recurrence following partial flap loss. Since
many cases with fistula have a prior history of radiation,
which delays healing, when the primary indication of the
procedure is to repair a fistula, special care should be
taken to safely elevate the flap in order to minimize ne-
crosis.
In conclusion, of 12 PMMC flap surgeries performed
at our institution, 3 were carried out as primary recon-
structive procedures, whereas 9 were done as “salvage”
procedures. Major complications were observed in 3 pa-
tients (25%), and minor complications were seen in 3
patients (25%). Partial flap loss developed in 4 patients
(33%), although there were no cases of total flap loss.
The preoperative goals of the flaps were met in 83% of
our cases.
5. Conclusion
The authors conclude that although free flap transfer is
most often the first choice for head and neck reconstruct-
tion, PMMC flaps can produce acceptable results in cer-
tain situations.
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