(375) Pedicled Osteomyocutaneous Pectoralis Major-Rib Flap for Salvage Mandibular Reconstruction

Monday, October 2, 2023

2:45 PM – 3:45 PM East Coast USA Time

Presenting Author(s)

Ryan T. Judd, MD

Resident
Ohio State University Hospital Program
Columbus, Ohio, United States

Co-Author(s)

Hilary C. McCrary, MD

Assistant Professor of Otolaryngology - Head and Neck Surgery
University of Utah
Columbus, Ohio, United States
Janice L. Farlow, MD PhD

Assistant Professor
Indiana University
Indianapolis, Indiana, United States
JG

Jeremy Godsell, MD

The Ohio State University, USA
PK

Peter Kneuertz, MD

Associate Professor
The Ohio State University
Columbus, Ohio, United States

Senior Author(s)

EO

Enver Ozer, MD

Associate Professor
The Ohio State University
Columbus, Ohio, USA

Disclosure(s):

Ryan T. Judd, MD: No relevant relationships to disclose.

Hilary C. McCrary, MD: No relevant relationships to disclose.

Janice L. Farlow, MD PhD: No relevant relationships to disclose.

Peter Kneuertz, MD: No relevant relationships to disclose.

Introduction: In the modern era of free flap reconstruction, mandibular defects are almost exclusively reconstructed with osseous free flaps. In cases of flap failure, options for non-free flap bony reconstruction of the mandible are limited, and technical descriptions are lacking in the literature.

Methods: A 69-year-old male with T4aN0 squamous cell carcinoma of the right mandible underwent initial composite resection with fibula free flap of a 7cm parasymphyseal to angle defect. Despite early recognition of flap compromise and two microvascular revisions for venous congestion, the free flap was ultimately explanted. He declined additional free flap reconstruction. He elected to undergo salvage reconstruction with a pedicled osteomyocutaneous pectoralis major flap with osseous rib.

Results: A skin paddle was designed over the 5th and 6th rib. After raising an ipsilateral pectoralis myocutaneous flap, we dissected along the muscle-rib attachment and chose the 6th rib, which provided the strongest muscle-rib attachment and longest pedicle length. We dissected along the inferior and superior rib borders, ligating the intercostal vessels. The rib was separated from the pleura using periosteal elevators. We harvested a relatively straight 9cm rib segment just lateral to the sternocostal junction with a 5 cm skin paddle. The flap was tunneled to the neck. The rib was inverted with the pleural surface directed laterally to place the skin paddle intraorally and minimize tension on the pedicle. The rib was well-perfused evidenced by bleeding periosteum. The rib was secured to the pre-existing mandibular reconstruction plate with bicortical locking screws. The bony chest defect was closed with a biologic extracellular matrix mesh to avoid lung herniation. A chest tube was placed and removed prior to discharge. He was discharged home without apparent complication.

Conclusions: The pedicled osteomyocutaneous pectoralis major flap with osseous rib harvest, not described in the literature in over 25 years, remains a viable option for bony reconstruction in those who are poor candidates for or decline free flap reconstruction.