JSUR Journal

Discussion

Surgical resection is the principal treatment for malignant tumors that often outcome in large full-thickness defects. Flaps and grafts are commonly used to repair defects.5. Reconstruction depends on the size of the defect and the different techniques aim to achieve good aesthetic quality and acceptable sequalae at the donor site. After oncological resection,reconstruction of defects often requires various flaps, including random, pedicled and free flaps. It is determined by surgeons based on the defect size, complexity, and technical expertise,facilities available ,cost etc. [6].The technic of free flaps reconstruction surgeries requires longer operating time,advanced instruments and technical expertise, higher anaesthetic risk in patients with multiple comorbid conditions, intense postoperative monitoring and increased cost These are important factors to consider when planning free flaps or pedicled flaps. Reconstructive surgery are significantly increased along with the trend of using either free microvascular or pedicle flaps following ablative surgery [7]. The first pedicled flap was described by Susruta in 800 BC and consisted of a forehead flap [8]. The landmark innovation in reconstructive surgery by McGregor in1963 being the first ever reliable transposition flap [9]. McGregor’s temporalis muscle flap was significant because it demonstrated the reliable application of transposition flaps. In onco-reconstruction, locoregional flaps are an important tool in the hands of Plastic surgeon. Many onco-surgeons are trained in locoregional flaps, therefore plastic surgeons are not required in every case. Nowadays, microvascular free flaps done by plastic surgeons in the mainstay of onco-reconstruction in most centre in India.The flaps’ benefits are the preservation of vascular supply and the redistribution of tension lines around the defect [10]. Free flaps require the expertise of microvascular surgery and longer operative times, but they showmore versatility and robustness than PF for some defects [11]. Granzow JW et al,observed that pedicled flaps are accessible to both academic and community surgeons and considered more reliable in specific settings but are not suitable for every defect [12]. Pedicle flaps may have limitations in reconstructing very large defects. The choice between pedicled and free flaps depends on the size, location, and nature of the defect, as well as the patient’s overall health and available resources. The various technics for reconstructive surgery in oncological defect are available in pedicled flaps, such as the Pectoralis Major Myocutaneous flap (PMMC), delto-pectoral flap (DP flap), and forehead flap, and their many modifications [13,14].

Head and Neck

Although free flap reconstruction is undoubtedly the first choice of reconstruction .The Pectoralis Major Myocutaneous Flap (PMMF) ,became the flap of choice for head and neck reconstruction in many centers and was extensively studied.PMMC flap remains an important tool in head and neck reconstruction. Because of its versatility, it has become workhorse in head and neck reconstruction [15]. For reconstruction of head and neck defects,Mahieu R et al. in their study of 93 patients, found that pedicled flaps achieved results equivalent to those of free flaps [16]. A combined PMMC and DP flap for reconstruction were used by Pradhan et al. and noted without any loss of flap. Pradhan et al. in their study of 29 patients used combined PMMC and DP flap for reconstruction without any loss of flap [17]. It was done as first choice of flap in some cases whereas in some cases it was done after failure of a free flap. It remains the commonest performed pedicled flap in head and neck malignancy [18]. The subclavian artery’s preoperative angiography is not a standard procedure in the surgical planning of pedicled flap procedures in the head and neck area [19]. Pectoralis major muscle flap was used in 2 cases of carcinoma of tongue wherein hemiglossectomy was done. In one case of carcinoma of floor of mouth, pectoralis major muscle flap was done (Table 1,Figure 1). Reconstruction of eyelids can be challenging after tumour excisions. In 3 cases Mustarde flap was done for lower eyelid defects. Out of these 3 cases, 2 patients had total postresection lower eyelid loss and one had more than 50% loss. All 3 patients had no flap complications. M A Callahan et al published a series of 55 cases of mustarde flaps with no complications [20]. In 2 cases of more than 50% loss of lower lip post tumor resection, Gilles fan flap was done. Other flaps done by us were standard forehead flaps, median forehead flaps, scalp transposition flaps and deltopectoral flaps. To restore the function and aesthetic outcome is critically important. It has good cosmetic outcome with minimal patient morbidity. Pedicled flap is a versatile flap with good cosmetic outcome with minimal patient morbidity.The reconstruction of the lower eyelid and cheek defects is a challenging task for Plastic Surgeons.

The flap survival rate was 96% for the PMMC flap [21].

In Upper Limb

Pectoralis major myocutaneous flap has been used for coverage of defects in upper arm too. In one case of SCC over shoulder region, PMMC flap was used to cover the defect. In 2 cases of SCC in lower forearm, abdominal flap was used to cover exposed tendons, vessels and nerves. In 2 cases pedicled radial forearm flap was done.

In Lower Limb

Pedicled ALT (anterior lateral thigh) flap transfer represents a reliable option for soft tissue coverage. In the hands of experienced microsurgeons, this flap is a safe and swift option [22]. Pedicled ALT flap was done in 5 cases for reconstruction (Figure 2). Majority of these cases were soft tissue sarcomas.In 2 out of 5 cases, it was not islanded completely. In 2 cases of malignancy at lower thigh, fasciocutaneous flaps were done (Table 1, Figure 2,3). Anterolateral thigh flap was first described by Song in 1984 ,along with the anteromedial and posterior thigh flap [23]. and later popularized by Koshima et al. Fasciocutaneous flaps were done for postresection defects in leg [24].Another common flap done was reverse sural flap. Fasciocutaneous and muscular flaps are some options for coverage, such as the reverse-flow fasciocutaneous sural flap [25]. It was the choice of reconstruction for 2 cases in squamous cell carcinoma over medial malleolus (Figure 2). In one case reverse sural flap was done for reconstruction of defect over tendoachilles. Juan et al. in 2017 published their article of reverse sural flap for reconstruction of the mid and hind foot following melanoma excision. Out of the 4 patients in their case series, all flaps survived without any complications [26]. In ankle melanoma wide excision surgery to remove the tumor with reconstruction on the part of the heel by local flaps with sural graft with splitthickness skin grafting is required [27].In such malignancies tumor recurrence has to be looked properly at site which requires regular follow up.

In Trunk (Chest, Abdomen and Back)

In 2 cases, we did reconstruction by pedicled latissimus dorsi flap. Both these cases had postresection defect over scapular region fore which ipsilateral latissimus dorsi flap was done. One female had squamous cell carcinoma at posterior superior iliac spine. For her the postresection reconstruction was done by pedicled ALT flap (Figure 3). In one case the defect over sacral region was reconstructed by transverse back flap. One case had chest wall tumor on left side, the defect of which was closed by PMMC flap from opposite side. Bakri et al. published an article in 2011 describing latissimus dorsi, pectoralis major and rectus abdominis muscle flaps as the workhorse for chest wall reconstruction

Gynecological Malignancy

The Singapore flap, a pedicled fasciocutaneous flap from the thigh, can be used for vaginal reconstruction. It’s particularly useful in low-resource settings due to its ease of dissection and minimal need for additional supplies, We performed one case of vaginal reconstruction. It was a cae of squamous cell carcinama of lateral wall of vagina. Singapore flap was taken from right side. The flap involves raising a section of tissue, including skin and underlying tissue, from the thigh and moving it to the vaginal area. (Table 1, Figure 3). The flap is known for its reliability, safety, and relative ease of dissection. 29 Regarding post-operative complications, donor and recipient sites morbidity, as well as the impact of PF reconstruction techniques on patients’ quality of life to be considered in the future management plans. Plastic surgery is an important component of cancer reconstruction in complex surgeries, anatomically difficult and unfamiliar areas of tumors and in cases with flap failures or re-surgeries. Pedicled flap reconstruction still plays an essential role in cancer reconstruction surgery as an alternative to free grafts. PF is associated with minor complications which can be managed very easily.

Conclusions

Plastic surgeons and Onco-surgeons have a good knowledge about pedicled flaps and play an important role as far as onco surgical reconstruction is concerned. They have an important role to play in complex cases like difficult anatomical locations, second flap surgery after a flap failure or after any flap complications. Hence, plastic surgeons are crucial in any cancer reconstruction surgeries according to our study conducted in western India. The pedicled flap surgery typically has a shorter operative time, associated with lower hospital costs, are considered reliable in both academic and community settings compared to free flap surgery.

References

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