Distal positioning of the skin paddle of pectoralis major myocutaneous flap in head and neck reconstruction.

Background: To assess outcomes of pectoralis major myocutaneous flap (PMF) wherein the skin paddle (SP) was positioned with its distal portion extending beyond the lower border of pectoralis major by ≥2 cm (PMF-d).
Methods: Consecutive head and neck reconstructions with PMF-d (n = 110). SP dimensions l ₂ (distal extent below the lower border of pectoralis major), l ₁ (proximal extent above lower border of pectoralis major), and b (breadth) were recorded. Endpoints were SP necrosis, recipient dehiscence, early fistula, and persistent fistula.
Results: Median values of l ₂ , l ₁ , and b were 3.0, 6.0, and 6.0 cm, respectively. When l ₂  = 2.0-3.0 cm, SP necrosis occurred in only one (1%) subject (with obesity). When l ₂ was ≥3.5 cm, necrosis occurred in four (16%) subjects, three of whom also had l ₁ /l ₂  < 2.0 (proximal SP < 67% of entire SP). Statistically, increased l ₂ was the only risk factor for necrosis (p = 0.001). Overall, incidence of recipient dehiscence, early fistula, and persistent fistula were 32 (29%), 20 (20%), and 3 (3%), respectively. Persistent fistula occurred only in the setting of SP necrosis and/or re-irradiation.
Conclusion: Careful patient selection, adequate proximal SP, and l ₂  = 2.0-3.0 cm is associated with a negligible risk of necrosis. The enhanced reach and laxity and additional skin surface area and soft tissue volume conferred with PMF-d facilitate recipient wound healing.
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