Comparison of Clinical and Functional Outcomes Using Pectoralis Major and Cutaneous Free Flaps for Hypopharyngeal Squamous Cell Carcinoma

BACKGROUND: The purpose of this study was to compare postoperative morbidities and functional outcomes of pectoralis major myocutaneous (PMMC) flap and cutaneous free flap reconstruction approaches in hypopharyngeal squamous cell carcinoma patients. METHODS: We retrospectively reviewed records from 99 patients who underwent hypopharyngeal reconstruction with a cutaneous free flap (n=85) or PMMC flap (n=14) between 1995 and 2013. Morbidity was classified into hospitalization, medical, or flap-related complications. Functional outcomes were classified into oral re-alimentation and decannulation time. RESULTS: The overall flap-related complication rate was higher in the PMMC flap group (n=8, 57.1%; P=0.019), but the medical morbidity rate was higher in the cutaneous free flap group (n=68, 80%; P=0.006). The rate of pneumonia was higher in the cutaneous free flap group (n=48, 56.5%; P=0.020). Pulmonary premorbidity was the variable most significantly associated with pneumonia (odds ratio=3.012, P=0.012). There was no statistically significant difference in oral re-alimentation and decannulation time between the two groups. CONCLUSIONS: Although the functional superiority of free flaps has been reported in many studies, our results do not support this hypothesis. One limitation of our study is the relatively smaller flap size and fewer PMMC flap cases compared with the cutaneous free flap group. The low postoperative medical morbidity incidence rate in the PMMC flap group was clinically significant; however, the free flap group had more flap-related complications. Thus, PMMC flaps should be considered a viable option, especially for patients with pulmonary premorbidities.

Thinned Thoracodorsal Perforator-Based Cutaneous Free Flap

The latissimus dorsi has been used as an excellent donor site for free flap because of many advantages such as reliable anatomy, long pedicle with large-caliber vessels, easiness of dissection, and minimal functional deficit of the donor site. It is also one of the most versatile free flaps due to its carrying skin, muscle, and bone components. Nevertheless, bulkiness limits its use for resurfacing the defect in thin regions such as hand, foot, and anterior tibial area. To reduce its excessive volume when bulk is considered a disadvantage, surgical modifications were introduced: muscle sectioning, reduced musculocutaneous flap, muscle splitting, and thoracodorsal perforator-based cutaneous flap. Although the thoracodorsal perforator-based cutaneous flap excluding muscle component is thinner than others, it also needs secondary debulking procedures to resurface the thin regions. Thinning of the cutaneous flap was successfully performed in paraumbilical perforator-based flap and anterolateral thigh flap. These thinned flaps depend for their circulation on the subdermal plexus originating from their pedicled vessel. Based on their survival concept, we made the thoracodorsal perforator-based cutaneous flap thin and clinically applied it to 7 patients as a free flap. They were all survived and there was no need for secondary debulking procedures. This flap adds the advantage of little bulkiness to the conventional latissimus dorsi flap. However, it has some disadvantages such as technical difficulties in dissection of the perforator, anatomical variation in the location of the perforator, and nonsensory flap.