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| CASE REPORT |
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| Year : 2018 | Volume
: 8
| Issue : 1 | Page : 27-29 |
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The Hairy Cheek: Two Cases of Intraoral Pectoralis Major Myocutaneous Flap Reconstruction
Geon Pauly, Roopashri Rajesh Kashyap, Raghavendra Kini, Prasanna Kumar Rao, Gowri P Bhandarkar, PT Surashmi
Department of Oral Medicine and Radiology, A. J. Institute of Dental Sciences, Mangaluru, Karnataka, India
| Date of Web Publication | 5-Mar-2018 |
Correspondence Address:
Geon Pauly
Department of Oral Medicine and Radiology, A. J. Institute of Dental Sciences, Kuntikana, NH-66, Mangaluru - 575 004, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jid.jid_24_17
 Abstract | | |
The presence of hairs in the oral cavity is an uncommon phenomenon, despite the frequent use of flaps for reconstruction. An intraoral hairy flap may result in constant discomfort affecting the quality of life of these patients. There are two lines of treatment available – One, by using laser to epilate hair, or second, an inexpensive mean of using scalpel to trim of the hair, which would result only in a temporary relief to the patient. Thus, it is apt to say that it is always preferable to prevent it in the first place than to cure it afterwards. Hereby, we like to highlight two such cases with intraoral hair growth and an alternative technique to negate it which needs to be incorporated in daily practice.
Keywords: Intraoral hair, myocutaneous flaps, myofascial flaps, pectoralis major
How to cite this article:
Pauly G, Kashyap RR, Kini R, Rao PK, Bhandarkar GP, Surashmi P T. The Hairy Cheek: Two Cases of Intraoral Pectoralis Major Myocutaneous Flap Reconstruction. J Interdiscip Dentistry 2018;8:27-9 |
How to cite this URL:
Pauly G, Kashyap RR, Kini R, Rao PK, Bhandarkar GP, Surashmi P T. The Hairy Cheek: Two Cases of Intraoral Pectoralis Major Myocutaneous Flap Reconstruction. J Interdiscip Dentistry [serial online] 2018 [cited 2023 Mar 27];8:27-9. Available from: https://www.jidonline.com/text.asp?2018/8/1/27/226636 |
| Clinical Relevance to Interdisciplinary Dentistry | |  |
Medical and dental treatment must always complement and gather inputs form each other. Even within dentistry, it is of utmost importance that different disciplines should keep their communications open in every case, for it will only aid in identification and easy rectification of the shortcomings and collectively we can work for a more effective treatment in the best interest of the patient, which would be a win-win situation on all the three fronts; medical, dental and the patient.
| Introduction | | |
Oral cavity cancers form the major bulk of the cancers seen in the head-and-neck region. Surgical excision remains the mainstay of the treatment followed by adjuvant radiotherapy and/or chemotherapy. Extensive resection defects cause functional, cosmetic, and psychological effects on the patients. Furthermore, a variety of functions such as speech, mastication, and deglutition may be affected that need to be managed with proper reconstructive options and rehabilitation. The goals of reconstruction are to achieve oral competence, cosmesis, and maintenance of dynamic function while allowing adequate access for oral hygiene. Various options are available in the reconstructive ladder ranging from primary closure, split skin graft, local rotation flaps, pedicled muscle flaps, and microvascular free flaps.[1] Pectoralis major myocutaneous (PMMC) flap is a sturdy flap that serves as a workhorse of major head-and-neck reconstructive defects with acceptable functional and cosmetic outcomes. Hereby, we present two cases of carcinoma-treated patients who reported with a PMMC flap placed on the right buccal mucosa.
| Case Reports | | |
Case 1
A 60-year-old male patient was referred to our department for dental evaluation. The patient complained of inadequate mouth opening and difficulty in consuming food. The patient was a known case of carcinoma of the buccal mucosa which was surgical treated 2 months prior followed by placement of a PMMC flap and was to undergo chemotherapy. Intraoral examination revealed a very limited mouth opening with nonclosure [Figure 1]a and continued hair growth on the buccal mucosa of the right side [Figure 1]b. The patient was aware of these hairs and felt uncomfortable about them. The patient had partially edentulous maxillary and mandibular arches. The teeth present had compromised periodontal health, although they exhibited no mobility. The patient was advised to have laser excision of these hairs done. The patient was referred back to the department of oncology for medical consent for the required dental treatment. | Figure 1: (a) Nonclosure of the pectoral flap. (b) Intraoral hair growth seen. (c) Intraoral hair growth seen. (d) Hair protruding out extraorally
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Case 2
A 57-year-old male patient was referred to our department for dental evaluation. The patient complained of inadequate mouth opening and missing teeth on one side of the face. The patient was a known case of carcinoma of the buccal mucosa which was surgical treated 3 years prior followed by placement of a PMMC flap. Intraoral examination revealed restricted mouth opening with continued hair growth on the buccal mucosa of the right side [Figure 1]c. In this case as well, the patient was aware of these hairs and felt irritated and extremely uncomfortable as they would often protrude outward [Figure 1]d. The patient had partially edentulous maxillary and mandibular arches. The patient was advised to have laser excision of these hairs, but he refused despite adequate explanations of the procedure. His refusal was related to his previous surgical experiences. The patient was referred to the department of prosthodontics for further treatment.
| Discussion | | |
Intraoral hair is an uninvited complication of using a PMMC flap for intraoral postsurgical reconstruction. The primitive method followed was to trim the hair using a lancet, which reduced some of the discomfort pertaining to the patient. The demand for a noninvasive method for hair removal has led to the development of various light source technologies for the process. These include ruby, alexandrite, diode, and neodymium-doped yttrium aluminum garnet (Nd: YAG) lasers and intense pulsed light sources.[2] The pulsed Nd: YAG laser produces a light energy at a wavelength of 1064 nm and targets the chromophore of melanin in the hair follicle.[3]
PMMC flap, based on the thoracoacromial artery, whose first description is commonly attributed to Ariyan in 1979 who exhaustively described the technique and its anatomical basis, was however reported in 1977 by at least two authors.[4] Although it has proved to be a reliable flap, it has certain innate disadvantages which can often be attributed to the skin component of the flap. Countless disadvantages of this “old” pectoralis major flap have been listed over the years in various literatures.[5] To enlist a few common complications, this flap is very bulky and may cause distortion of the female breast, and there is also the problem of continued hair growth in male patients.[6] Other complications include partial or total necrosis of the flap, poor dental occlusion due to the traction of the flap, orocutaneous fistulas, suture line dehiscence, and those involving the donor site, such as chest wall hematoma and infections.[1],[4]
A pectoralis major myofascial flap (PMMF) is a simple variant of the PMMC and allows avoiding some of the disadvantages of Ariyan's technique while reducing well-known, overall complications.[7] Robertson and Robinson in 1985[8] and Shindo et al. in 1992[9] first reported the use of a pectoralis major flap without skin island in head-and-neck reconstruction.
To harvest the flap, outline the course of thoracoacromial artery and the size and configuration of skin paddle and muscle required to cover the defect. If deltopectoral flap is additionally required, it has to be elevated first from its distal portion on the medial aspect of the thoracoacromial artery.[10] Lateral thoracic artery can be preserved by dividing the humeral head of pectoralis major muscle. The initial incision for the flap is along the lateral border of the outlined skin for the pectoralis major flap, and it is carried down up to the muscle. After identification of the vascular pedicle, the elevation is done deep to the fascia above the pectoralis minor muscle. The required subcutaneous tissue is incised and sutured with the superficial fibers of the underlying muscle. The rest of the skin and the subcutaneous tissue are dissected free from the muscle with hemostasis as required.[11]
Various studies suggest that the PMMF is a valid procedure for head-and-neck reconstruction associated with low morbidity, overcoming the disadvantages of the PMMC flap and offering comparable results with fasciocutaneous free flaps.[1],[7] In comparison with PMMC, the absence of the skin paddle makes PMMF thinner and more stretchable. Furthermore, the absence of the cutaneous island, the most “high-risk” zone for vascular supply in the flap, decreases the risk of necrosis and fistula, avoids hair growth, and provides a better cosmetic result at the donor site.[7]
| Conclusion | | |
The surgical treatment of malignant neoplasms involving the head and neck continues to be a daunting task for the head-and-neck surgeons. Pectoralis major is still the “workhorse” for head-and-neck reconstruction in developing countries mainly owing to its ease of harvest and minimal requirements in terms of instrumentation. Although the PMMC flap serves the purpose, the side effects, in turn, can disrupt normal life for the patient. Newer methods such as a PMMF should be largely considered as it minimizes the shortcomings and is a “win–win” situation for both the surgeon and the patient.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Lekawale H, Patil B. Pectoralis major myocutaneous flap for oral cavity cancer reconstruction – Our experience with 30 cases. Indian J Appl Res 2011;2:159-61.  |
| 2. | Haedersdal M, Wulf HC. Evidence-based review of hair removal using lasers and light sources. J Eur Acad Dermatol Venereol 2006;20:9-20. |
| 3. | Lepselter J, Elman M. Biological and clinical aspects in laser hair removal. J Dermatolog Treat 2004;15:72-83. |
| 4. | Bussu F, Gallus R, Navach V, Bruschini R, Tagliabue M, Almadori G, et al. Contemporary role of pectoralis major regional flaps in head and neck surgery. Acta Otorhinolaryngol Ital 2014;34:327-41. |
| 5. | Johnson MA, Langdon JD. Is skin necessary for intraoral reconstruction with myocutaneous flaps? Br J Oral Maxillofac Surg 1990;28:299-301. |
| 6. | Phillips JG, Postlethwaite K, Peckitt N. The pectoralis major muscle flap without skin in intra-oral reconstruction. Br J Oral Maxillofac Surg 1988;26:479-85. |
| 7. | Montemari G, Rocco A, Galla S, Damiani V, Bellocchi G. Hypopharynx reconstruction with pectoralis major myofascial flap: Our experience in 45 cases. Acta Otorhinolaryngol Ital 2012;32:93-7. |
| 8. | Robertson MS, Robinson JM. Pharyngoesophageal reconstruction. Is a skin-lined pharynx necessary? Arch Otolaryngol 1985;111:375-6. |
| 9. | Shindo ML, Costantino PD, Friedman CD, Pelzer HJ, Sisson GA Sr., Bressler FJ, et al. The pectoralis major myofascial flap for intraoral and pharyngeal reconstruction. Arch Otolaryngol Head Neck Surg 1992;118:707-11. |
| 10. | Howard D. Rob & Smith's operative surgery: Head and neck – 2. 4 th ed. CRC Press. 1998. p. 381-2. |
| 11. | Watkinson JC, Gilbert RW. Stell & Maran's textbook of head and neck surgery and oncology. 5th ed. CRC Press. 2012. p. 939-48. |
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