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Moreno-Sánchez et al. Double-paddled PMMF for complex orocervical defects

INTRODUCTION a tracheostomy was performed. A total laryngectomy
and partial glossectomy extending to the right base
Reconstruction of large oral cavity defects following of the tongue were performed by a “pull-through”
resection for advanced cancer is a challenge for approach exposing the entire tongue, oropharynx
reconstructive surgeons. In the microsurgical and suprahyoid space. A bilateral modified type III
era, microvascular free flaps constitute the main radical neck dissection was performed. The intraoral
reconstructive option for achieving excellent aesthetic and primary cervical defects were reconstructed
and functional results. However, in cases of flap with a microsurgical anterolateral thigh flap. In the
failure or inability to harvest a free flap, pedicled flaps postoperative period, the remainder of the tongue
provide a reliable alternative with predictable results. underwent total necrosis with subsequent distal flap
The pectoralis major myocutaneous flap (PMMF), dehiscence, cervical fistulae and a large defect in the
considered the workhorse in head and neck surgery, floor of the mouth [Figure 1]. In an attempt to solve
represents one such pedicled flap. In the event of major these complications by providing sufficient tissue for
defects requiring a large area volume for cutaneous reconstruction of the floor of the mouth while closing
coverage and mucosal lining, a modification of the the orocervical fistulae, a PMMF with two skin islands
standard technique is required. [1-3] was designed. This flap consisted of two vertically

separated skin islands over the area of the pectoralis
CASE REPORT major myocutaneous vascular territory: one skin island
was medial to the nipple-areolar complex and the
The authors describe a surgical technique for repair other was lateral. The skin paddles were designed
of a complex orocervical defect following failure of horizontally. The skin and the subcutaneous fat were
microsurgical reconstruction with use of a double- closed using vicryl sutures to avoid shearing of perforator
paddle PMMF. A 36-year-old man was diagnosed with vessels vascularizing the skin. The flap was raised using
T4 squamous cell carcinoma of the base of tongue with standard surgical technique leaving its proximal paddle
laryngeal involvement. Under general anaesthesia,
pedicled to the arterial plane [Figure 2]. The proximal
skin paddle was used to close the cervical skin and
the peri-tracheostomy defect [Figure 3A]. The distal
paddle was adapted to floor of the mouth and sutured

A

Figure 1: Distal flap dehiscence, cervical fistulae and large
defect in the floor of the mouth following failure of a microsurgical
anterolateral thigh flap
B

Figure 2: A pectoralis major myocutaneous flap design with two Figure 3: (A) The first skin paddle was used to close the cervical
skin islands: one skin island was designed for the floor of the mouth skin and the peri-tracheostomy defect; (B) the second skin paddle
defect with the other skin island for the cervical skin defect was adapted to floor of the mouth
Plastic and Aesthetic Research ¦ Volume 4 ¦ May 26, 2017 83