Pectoralis Major Myocutaneous Flap in Head and Neck Reconstruction: A Color Atlas Girish N Amlani, Jatin N Mody, Mudit Mittal
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1Pectoralis Major Myocutaneous Flap in Head and Neck Reconstruction: A Color Atlas2
3Pectoralis Major Myocutaneous Flap in Head and Neck Reconstruction: A Color Atlas
Girish N Amlani MS (General Surgery) MCh (Plastic Surgery) Honorary Head and Neck Reconstruction Surgeon Nathalal Parekh Cancer Hospital and Research Center Rajkot, Gujarat, India Jatin N Mody MS (ENT) DORL DLO (England) Honorary Head and Neck Surgeon Nathalal Parekh Cancer Hospital and Research Center Rajkot, Gujarat, India Recipient of “E-Merck Award” for Research on Cancer Base of Tongue Mudit Mittal MS (Otolaryngology) Head and Neck Surgeon Nathalal Parekh Cancer Hospital and Research Center Rajkot, Gujarat, India Fellow, Stanford University Hospital, Palo Alto, California, USA Recipient of “IVS-2011 Award” American Academy of Otolaryngology—Head and Neck Surgery Recipient of “FHNO Shireen Gazdar 2013 Award” Foreword Santosh Raibagkar
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Pectoralis Major Myocutaneous Flap in Head and Neck Reconstruction: A Color Atlas
First Edition: 2014
9789351521679
Printed at
5Dedicated to
Our parents, teachers, family and peers
6
7Foreword
I was delighted when I received a request from Dr Girish N Amlani, Dr Jatin N Mody and Dr Mudit Mittal to write a brief foreword for this book because, for many years, I have admired their incredible work. Dr Girish is a man with very strong vision and I appreciate the copious amount of effort he puts into anything that he works on. This team has done a very good job. Looking through this magnificent work Pectoralis Major Myocutaneous Flap in Head and Neck Reconstruction: A Color Atlas, I am happy to see what they have achieved in head and neck reconstruction. Their commitment to head and neck surgery and reconstruction is prodigious. I think it is not only a book of lovely illustrations but also a mine of information, demonstrating the technique in detail. It is a source of inspiration and information for those who work in this field of head and neck reconstruction.
In short, Pectoralis Major Myocutaneous Flap in Head and Neck Reconstruction: A Color Atlas is surely a book to treasure for anyone who is interested in reconstructive surgery.
I wish them a very good future.
Santosh Raibagkar ms mch (plastic surgery)
Professor and Head
Department of Plastic Surgery
Lallubhai Gordhanbhai Hospital
Ahmedabad, Gujarat, India
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9Preface
Writing is an exploration. You start from nothing and learn as you go.
EL Doctorow
In the modern world, visual pathways have outdistanced the other avenues for informational input; therefore, this is an attempt to render the material more accessible to students of medicine by making maximum use of images while keeping tedious theory to minimum. Pectoralis Major Myocutaneous Flap in Head and Neck Reconstruction: A Color Atlas is little more than 77 pages and only half of them are textual, so cannot be considered as a primary source information, but it does contain most of the basic principles and facts about pectoralis major myocutaneous flap.
It is very rare that surgery is entirely composed only of easy procedures. The great majority of intraoperative photographs in the atlas are taken during surgery performed in the operation room of Nathalal Parekh Cancer Hospital and Research Center, Rajkot, Gujarat, India. The procedure performed by expert surgeons often seems smooth, making each maneuver look easy, but can be misleading, especially for beginners. No expert can be created by simply reading the textbooks; however, it is our hope that this atlas will hasten the process.
The atlas is inevitably derivative, but many of the representations are new and we hope the innovative. The purpose of the atlas is to describe the general principles and techniques, it should be considered as an overview of introduction of subject and a concise review material. The tail section (Case Studies) has some pictures of cases to give an idea, how the flap can be designed in different situations and various ways to reconstruct particular head and neck defect.
The atlas is the product of our journey. We are sharing here our experience of over 2,000 pectoralis major myocutaneous flap reconstructions and hope that the atlas will prove to be a valuable tool for helping trainees better understand the topic, it will be a valuable reference for resident doctors and practicing surgeons.
Girish N Amlani
Jatin N Mody
Mudit Mittal
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11Acknowledgments
We gratefully express our indebtedness to Dr VK Gupta, Dr Heena Asher, Dr Deepak Patel, Dr Udyan Vayas, Dr Santosh Raibagkar, Dr PV Dhond, Dr Nirav Mody, Dr Rajesh Yadav, and Dr Neepa Vellimuttam and other staff of Nathalal Parekh Cancer Hospital and Research Center, Rajkot, Gujarat, India.
We thank Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing Director), Mr Tarun Duneja (Director-Pulishing) and Mr KK Raman (Production Manager) of M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India.
We also thank our patients, who have faced the threat of cancer and fought back.
15Introduction
Since the first description by Ariyan in the 1970s,1 the pectoralis major myocutaneous flap has been the most commonly used flap by head and neck surgeons. This is probably, due to their familiarity with the anterior chest, use of many deltopectoral skin flaps and the fact that the patients are in supine position and do not have to be repositioned during the procedure. Moreover, this flap supplies bulk and, probably, has the potential for the best survival rate of any distant flap. This flap is able to handle up to 90 percent of virtually all defects that require significant amount of soft tissue.4
The principle of oropharyngeal reconstruction is to obtain water-tight closure, maintain mobility, volume of resected tissue, and the oral competence, and prevent medically significant aspiration. Pectoralis major flap is very well suited for this type of reconstruction, especially when there is remaining functional tongue.
Today, microvascular reconstruction is changing the scenario in head and neck reconstruction; and free-tissue transfer is often preferred. Unfortunately, a specialized surgical team and costly instrumentation are required, and these are not available in many head and neck centers. Therefore, the pectoralis major myocutaneous flap still remains the mainstay reconstructive method in several centers worldwide.2,3 Also, the benefits of this flap should not be overlooked. This is a state-of-the-art method with many advantages which we will come across as we continue our journey of sailing through the atlas. Nonetheless, the surgical axiom of performing the simplest and least complicated procedure that will provide the desired result should be maintained.
Surgeons are very visual creatures and more use of original figures, graphs and diagrams to help with interpretation of the data would have been useful. The atlas is an attempt to fill a desperately large gap to give a clear and concise picture of pectoralis major myocutaneous flap and to discuss salient technical points. The atlas also calls attention to some simple modifications of procedure well known to head and neck surgeons. Although a variety of options and alternatives are available for soft-tissue oral reconstruction at the surgeon's disposal, the more likely, he is to select a procedure, but the technique chosen depends on the extent and functional characteristics of tissue involved, the health of patient, expectations and overall motivation. Imagination and dexterity are crucial but must be combined with the essential elements of a thorough knowledge of basic tenets of this reconstructive surgery.