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| CASE REPORT |
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| Year : 2022 | Volume
: 28
| Issue : 2 | Page : 198-201 |
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Feasibility of pectoralis major myocutaneous flap for primary reconstruction of near-total glossectomy defects: A report of 2 cases
Jency Mathews1, Shali Subash2, PM Prathiba3, Prince Seviar1
1 Department of Surgical Oncology, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
2 Department of Oral and Maxillofacial Surgery, Pushpagiri College of Dental Sciences, Tiruvalla, Kerala, India
3 Dental Hub Dental and Maxillofacial Center, Ernakulam, Kerala, India
| Date of Submission | 10-Oct-2022 |
| Date of Decision | 15-Nov-2022 |
| Date of Acceptance | 03-Dec-2022 |
| Date of Web Publication | 30-Jan-2023 |
Correspondence Address:
Dr. Jency Mathews
Department of Surgical Oncology, Pushpagiri Institute of Medical Sciences, Thiruvalla, Pathanamthitta - 689 101, Kerala
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ksj.ksj_32_22
The aim of tongue cancer surgery is to restore speech and swallowing. Smaller defects have a plethora of options, including local and distant flaps to restore volume and function may not be compromised. Large tumours of the tongue require extensive resection - near total or total glossectomy, which creates large volume defects. Free flaps using microvascular reconstruction techniques are the ideal method of reconstruction in such defects. Regional flaps like pectoralis major myocutaneous (PMMC) flaps are used only as salvage flaps when the free flaps fail and they are not used as the primary method of reconstruction. The disadvantage with free flaps is that it requires a team of surgeons with microvascular expertise, which may not be feasible in low-resource settings. Hence, the workhorse flap of head–neck reconstruction, the PMMC flap, has a lot to offer in the primary reconstruction of large tongue defects. There is always a risk of lifelong dependence on feeding tubes and tracheostomy tubes following these surgeries despite free flap reconstruction. The outcomes of the reconstruction methods are validated by the absence of dependence on these tubes. We report 2 cases of near glossectomy defects reconstructed primarily by PMMC flap and the functional outcomes of speech and swallowing and the absence of dependence on tubes for feeding and breathing.
Keywords: Near-total glossectomy defect, pectoralis major myocutaneous flap, primary reconstruction, squamous cell carcinoma tongue
How to cite this article:
Mathews J, Subash S, Prathiba P M, Seviar P. Feasibility of pectoralis major myocutaneous flap for primary reconstruction of near-total glossectomy defects: A report of 2 cases. Kerala Surg J 2022;28:198-201 |
How to cite this URL:
Mathews J, Subash S, Prathiba P M, Seviar P. Feasibility of pectoralis major myocutaneous flap for primary reconstruction of near-total glossectomy defects: A report of 2 cases. Kerala Surg J [serial online] 2022 [cited 2023 Mar 24];28:198-201. Available from: http://www.keralasurgj.com/text.asp?2022/28/2/198/368589 |
| Introduction | |  |
The aim of tongue cancer surgery is to restore speech and swallowing. Large tumours of the tongue require extensive resection-near total or total glossectomy, which creates large volume defects. Free flaps using microvascular reconstruction techniques are the ideal method of reconstruction in such defects. Regional flaps like pectoralis major myocutaneous (PMMC) flaps are used only as salvage flaps when the free flaps fail and they are not used as the primary method of reconstruction.
| Case Reports | | |
Case report 1
A 52-year-old female with no known comorbidities presented with a large ulceroproliferative growth in the anterior floor of the mouth involving the lingual surface of the arch mandible, extending to the dorsal surface of the oral tongue since 3 months, approximately 4 cm × 4 cm size [Figure 1]. No significant neck nodes were seen clinically biopsy showed moderately differentiated squamous cell carcinoma. Magnetic resonance imaging (MRI) showed a well-defined heterogeneously enhancing lesion involving the anterior one-third of the tongue with involvement of lingual septum with extension to the contralateral side with no significant neck node disease; clinical stage 3 (cT3N0M0). | Figure 1: Preoperative picture showing ulceroproliferative growth of the anterior tongueextending to floor of mouth and the lingual surface of mandible
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Surgical technique
Through a visor flap incision, bilateral neck dissection was performed. Arch marginal mandibulectomy was done transorally, and the tongue with marginal mandibulectomy (en bloc) was dropped into the neck [Figure 2] and [Figure 3]. Using the transcervical approach near-total glossectomy was done with en bloc marginal mandibulectomy. The right side Pectoralis major myocutaneous (PMMC) flap was harvested, and reconstruction of the defect was performed. The hyoid bone was suspended to the arch mandible using prolene sutures. Postoperative recovery was smooth with weaning of the tracheostomy by the post-operative day 5 and nasogastric tube removal by the post-operative day 12. Final pathology showed poorly differentiated squamous cell carcinoma (pT3N1) with perineural invasion and lymphovascular emboli. The patient received a full dose post-operative radiotherapy (50Gy in 25 Fractions). Post treatment, the patient achieved acceptable swallowing of liquid food and intelligible speech [Figure 4]. Five months after the surgery, she presented with local and distant metastases and, despite palliative chemotherapy, died 6 months later. | Figure 2: Intraoperative picture showing the trans cervical approach and dropping of the tongue with the arch mandibulectomy specimen into the neck
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 | Figure 3: Intraoperative image showing post glossectomy and arch mandibulectomy defect with preserved base of tongue preserved
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Case report 2
A 42-year-old male with a history of hypertension and diabetes mellitus and previous history of carcinoma of the lateral border of the left side of the tongue for which wide excision with selective neck dissection was done 2 years back, was detected with a 2 cm × 2 cm recurrence in the medial edge of the scar in the central portion of oral tongue [Figure 5]. | Figure 5: Preoperative picture of ulcerated lesion central anterior tongue
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Incisional biopsy of the lesion revealed well-differentiated squamous cell carcinoma. MRI showed [Figure 6] an ill-defined altered signal intensity involving the middle third of the tongue, approximately 3.2 cm × 3.3 cm. The lesion involved the intrinsic muscles and crossed the midline to the right side till the lateral aspect of the tongue, and inferiorly, the lesion involved the superior and anterior aspect of the genioglossus muscles on both sides [Figure 7]. No evidence of neck node metastases; clinical stage 3 - cT3N0M0. | Figure 6: Saggital and axial MRI views showing tumour in the central part of oral tongue
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 | Figure 7: Intraoperative picture showing trans cervical approach with harvested PMMC flap
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Surgical technique
Through a visor flap incision, bilateral comprehensive neck dissection was performed. The floor of the mouth was then opened, and the tongue dropped into the neck. Using the transcervical approach [Figure 6] near-total glossectomy was performed, preserving the base of the tongue. The left side PMMC flap was harvested, and the defect was reconstructed. The mandible with full dentition was preserved. The post-operative recovery was uneventful, with weaning of tracheostomy by the post-operative day 7. The nasogastric tube was removed on the post-operative day 10. The final pathology was well-differentiated squamous cell carcinoma with foci of perineural invasion - pT3N0. Adjuvant radiotherapy was given (50 Gy in 25 fractions), and the patient returned to daily activities, including resuming work as a transport driver. He has intelligible speech and tolerates a semisolid diet, is alive and well 24 months after surgery [Figure 8].
| Discussion | | |
Tongue defect reconstruction considers the size of the defect, involvement of the adjacent structures, dentition, mandibular invasion and availability of neck donor vessels.[1] Smaller defects have a plethora of options, including local and distant flaps to restore volume and function may not be compromised. However, the larger tumours require more extensive resection and functional restoration is challenging. Patients may never regain speech or swallowing following surgery and may become dependent on feeding tubes and tracheostomy.[2] The larger the glossectomy defect, the more difficult it is to restore swallowing and speech. Near-total glossectomy preserves the base tongue, which enables swallowing without aspiration when the larynx is preserved.[3] Reconstruction for these large defects by a free flap is ideal.[4] The goal of the reconstruction here is to use a flap which can adequately cover the floor of the mouth with adequate convexity for bolus swallowing. This avoids the pooling of secretions anteriorly, but the flap should not be bulky to impair breathing and speech.[5] The free flaps which provide adequate tissue volume are the anterolateral thigh (ALT) flap, rectus abdominis flap and radial free forearm flap. The key elements in such reconstruction are that the flap should be convex enough to touch the palate and the larynx should be suspended by fixing the hyoid to the mandible to prevent aspiration.[5] The convexity of the flaps is directly related to the swallowing outcomes, as described by Kimata et al.[6] Free flaps like ALT are the most preferred method of reconstruction,[7] as they provide bulk and do not shrink too much following post-operative radiotherapy.[4]
The disadvantage with free flaps is that it requires a team with microvascular expertise, and this may not be feasible in low-resource settings. Regional flaps are usually used when free flaps fail, and they are not the mainstay of reconstruction. In low-resource settings, regional flaps do play an important role in the reconstruction of larger defects. The advantages of regional flaps include stronger reliability, shorter operative time and the ability to harvest without an additional surgical team.
Regional flaps like the PMMC have been historically used for salvage post-free flap failure or in post-radiation neck with a lack of donor's vessels. However, various studies have criticised the use of PMMC flap due to its bulkiness, high rate of fistula formation and high potential for marginal flap necrosis.[8] However, modification of the PMMC flap can be used for reconstruction of the near-total or total glossectomy defect, as shown in the series by Gangiti et al.[9] The modification includes harvesting a larger flap to increase bulk but de-epithelialising the edges to cover the floor of the mouth and vallecula.[9] Other modifications when using the PMMC flap include tunnelling the flap below the subclavian vessels.[10]
The two patients reported here had preservation of the base tongue, which enabled swallowing. There was no flap loss in the first patient and mild edge necrosis in the second patient. The shrinkage of the flap in the male patient was more than in the female patient, but the male patient was able to consume a semi-solid diet 6 months after the surgery. Studies have found that post-operative radiotherapy has worse long-term swallow outcomes because of tissue shrinkage and increased risk of aspiration pneumonitis.[2],[3],[5] The absence of dependence on tubes, either feeding or breathing, validates the success of this procedure. Both patients had adequate swallowing and speech despite post-operative radiotherapy and shrinkage of the flap. The female patient's tumour necessitated marginal mandibulectomy for margins. The male patients' dentition could be completely preserved as the floor of mouth and ventral surface of the tongue was completely uninvolved by tumour. Preserving the dentition ensures better cosmesis and speech and better quality of life.[11] However, this can be done only if the floor of the mouth is uninvolved by tumour and the dentition itself is healthy.
| Conclusion | | |
Primary reconstruction of the near-total glossectomy defects is feasible with a modified PMMC flap and it allows acceptable speech, swallowing and quality-of-life outcomes without lifelong dependence on feeding or breathing tubes. The modification includes harvesting a large flap with de-epithelialisation of skin edges to allow for a convex floor of the mouth. Preserving the dentition when feasible improves cosmesis.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Vincent A, Kohlert S, Lee TS, Inman J, Ducic Y. Free-Flap Reconstruction of the Tongue. Semin Plast Surg 2019;33:38-45.  |
| 2. | Miyamoto S, Sakuraba M, Nagamatsu S, Kayano S, Kamizono K, Hayashi R. Risk factors for gastric-tube dependence following tongue reconstruction. Ann Surg Oncol 2012;19:2320-6. |
| 3. | Pradhan SA, Rajpal RM. Total glossectomy sans laryngectomy – Are we justified? Laryngoscope 1983;93:813-5. |
| 4. | Ozkan O, Ozkan O, Derin AT, Bektas G, Cinpolat A, Duymaz A, et al. True functional reconstruction of total or subtotal glossectomy defects using a chimeric anterolateral thigh flap with both sensorial and motor innervation. Ann Plast Surg 2015;74:557-64. |
| 5. | |
| 6. | Kimata Y, Sakuraba M, Hishinuma S, Ebihara S, Hayashi R, Asakage T, et al. Analysis of the relations between the shape of the reconstructed tongue and postoperative functions after subtotal or total glossectomy. Laryngoscope 2003;113:905-9. |
| 7. | Sakuraba M, Asano T, Miyamoto S, Hayashi R, Yamazaki M, Miyazaki M, et al. A new flap design for tongue reconstruction after total or subtotal glossectomy in thin patients. J Plast Reconstr Aesthet Surg 2009;62:795-9. |
| 8. | Jena A, Patnayak R, Sharan R, Reddy SK, Manilal B, Rao LM. Outcomes of pectoralis major myocutaneous flap in female patients for oral cavity defect reconstruction. J Oral Maxillofac Surg 2014;72:222-31. |
| 9. | Gangiti KK, Gondi JT, Nemade H, Sampathirao LM, Raju KV, Rao TS. Modified pectoralis major myocutaneous flap for the total glossectomy defects: Effect on quality of life. J Surg Oncol 2016;114:32-5. |
| 10. | Kanno T, Nariai Y, Tatsumi H, Karino M, Yoshino A, Sekine J. A modified pectoralis major myocutaneous flap technique with improved vascular supply and an extended rotation arc for oral defects: A case report. Oncol Lett 2015;10:2739-42. |
| 11. | Aramany MA, Downs JA, Beery QC, Aslan Y. Prosthodontic rehabilitation for glossectomy patients. J Prosthet Dent 1982;48:78-81. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
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