Does pectoralis major flap harvesting induce upper extremity dysfunction?

Abstract

Objective

To evaluate the effect of pectoralis major myocutaneous (PMM) flap reconstruction on upper extremity dysfunction.

Methods

Patients undergoing PMM flap reconstruction following head and neck cancer resection were enrolled. The control group comprised age-, sex- and clinical characteristic-matched patients undergoing non-PMM flap reconstruction. All patients completed the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire preoperatively and >1 year postoperatively.

Results

There was no significant difference between pre- and postoperative DASH scores in the control group (n = 46; 2.38 ± 3.33 and 2.99 ± 4.21, respectively). In the PMM flap group (n = 46), the postoperative DASH score was significantly higher than the preoperative score (7.00 ± 9.13 and 2.44 ± 3.50, respectively). In the PMM flap group, flap size was significantly associated with postoperative DASH score.

Conclusion

PMM flap reconstruction has a small but significant negative effect on upper extremity dysfunction.

Keywords

Upper extremity dysfunction pectoralis major myocutaneous flap DASH questionnaire shoulder function

Introduction

The pectoralis major myocutaneous (PMM) flap has been a popular procedure for head and neck reconstructive surgery since its introduction in the 1970s.^1–3 This procedure covers an extensive area, can be performed in patients in generally poor health, and requires no microvascular anastomosis.^4,5 Donor site complications include postoperative shoulder dysfunction, but there are conflicting data regarding the effect of PMM flap harvesting. Studies have variously indicated that any loss in shoulder function is well tolerated,⁶ while others have presented patients who were unable to return to normal function after PMM flap surgery.⁷ The aim of the present study was to investigate the effect of PMM flap surgery on upper extremity function.

Patients and methods

Study population

The study recruited consecutive patients who underwent PMM flap reconstruction following head and neck cancer excision at the First Affiliated Hospital of China Medical University, Shenyang, China, between January 2007 and December 2012. The control group comprised patients who received a non-PMM flap reconstruction following head and neck cancer excision. Control patients were matched to PMM patients by sex, age (≥5 years), tumour stage (according to the International Union Against Cancer 2002 classification⁸), primary tumour site and type of neck dissection (selective vs modified radical). In all neck dissections, the spine accessory nerve was preserved and levels I, II and III were dissected.

The China Medical University institutional research committee approved the study. All participants provided written informed consent prior to enrolment.

DASH questionnaire

All patients completed the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire⁹ preoperatively and at >1 year postoperatively. This questionnaire evaluates symptoms and the ability to perform everyday activities, and reflects upper-extremity function regardless of which hand/arm is used. DASH comprises two components: disability/symptom questions (30 items, each scored 1–5); and optional high performance sport/music or work questions (four items, each scored 1–5). The final score ranges between 0 and 100, with higher scores indicating more severe disability.

Statistical analyses

Due to previous conflicting data it was not possible to calculate the actual incidence of postoperative complications and the required least sample size. However, taking the study’s prospective design into consideration, it was determined that a sample size consistent with that used in earlier studies would be reasonable.^6,7,10–18

Data were presented as mean ± SD (range) or n (%) and compared using the paired t-test. Pearson’s and Spearman’s correlation coefficients were used to determine associations between clinical and demographic factors, and postoperative DASH score. All statistical analyses were performed using SPSS® version 13.0 (SPSS Inc., Chicago, IL, USA) for Windows®. P-values < 0.05 were considered statistically significant.

Results

A total of 59 consecutive patients who underwent PMM flap reconstruction completed the preoperative DASH questionnaire, but 13 died in the first postoperative year. The study therefore included 46 patients (46 male/0 female; mean age 56.8 ± 10.8 years; age range 44–78 years). Of these, seven tumours were classified as stage T3, and the remaining 39 were stage T4. Mean PMM flap size was 66.5 ± 20.3 cm² (range 50–120 cm²). Partial necrosis developed in six patients; there were no cases of total necrosis. The control group comprised 46 patients matched for age, sex and clinical characteristics, who underwent anterolateral thigh flap (n = 33), submental island flap (n = 8), or platysma myocutaneous flap (n = 5). Demographic and clinical data for the study population are shown in Table 1.

Table 1.

Demographic and clinical characteristics of patients with head and neck cancer undergoing pectoralis major myocutaneous (PMM) flap or alternative reconstructive surgery, included in a study investigating the effect of PMM flap reconstruction on upper extremity function.

Characteristic	PMM flap group n = 46	Non PMM flap group n = 46
Age, years	56.8 ± 10.8 (44–78)	57.3 ± 11.1 (42–77)
Sex, female/male	0/46	0/46
Tumour site
Tongue	22	22
Mouth floor	15	15
Gingiva	8	8
Buccal	1	1
Tumour stage^a
T3	7	7
T4	39	39
Neck dissection
Selective	37	37
Modified radical	9	9
Postoperative radiation	33	35
DASH score
Preoperative	2.44 ± 3.50 (0–9.12)	2.38 ± 3.33 (0–8.78)
Postoperative	7.00 ± 9.13 (3.04–44.20)***	2.99 ± 4.21 (0–10.00)

Data presented as mean ± SD (range) or n patients.

***

P = 0.001 vs preoperative score in same group; paired t-test.

UICC 2002 classification system.⁸

DASH, Disability of the Arm, Shoulder, and Hand (DASH) questionnaire.⁹

There was no significant difference between pre- and postoperative DASH scores in the control group. In the PMM flap group, the postoperative DASH score was significantly higher than the preoperative score (P < 0.001; Table 1).

Correlation analyses revealed that flap size was significantly associated with postoperative DASH score in the PMM flap group (r = 0.901, P < 0.001). Preoperative DASH score, age, sex, tumour site, tumour stage, and the occurrence of complications (flap necrosis) were not significantly associated with postoperative DASH score.

Discussion

The shoulder is an important component of the upper extremity, and any factor that negatively affects this joint may also have an impact on upper extremity function. The effect of neck dissection on shoulder function is well documented. Selective neck dissection has a better outcome than radical neck dissection, with the risk of injury (including neural injury, local devascularization and decompression injury) to the accessory nerve reduced if the level 5 nodes are not included. Patients undergoing level 2–4 dissection have less shoulder dysfunction that those undergoing level 2–5 dissection,¹⁰ and those who undergo modified radical neck dissection report more severe disability (“shoulder syndrome”) than other patients.¹¹ Although the current study found no significant increase in DASH score in the control group, neck dissection can inherently induce upper extremity dysfunction. It is therefore important that studies are designed to exclude these effects of neck dissection.

The few studies evaluating the association between PMM flap reconstruction and shoulder function did not take the effect of neck dissection into account. A retrospective study found that PMM flap reconstruction resulted in minimal or low shoulder morbidity.¹² Another study compared both shoulders in patients who underwent PMM flap surgery, and found significantly reduced flexion angle and strength, as well as higher disability scores, in the donor shoulder compared with the non-donor side.¹³

The effect of radiotherapy on upper extremity function is unclear. Postoperative radiotherapy in patients who undergo neck dissection has been shown to result in a 20% decrease in the range of shoulder motion compared with patients who undergo neck dissection but no radiotherapy.¹⁴ In addition, a tendency towards reduced shoulder function in patients undergoing postoperative radiotherapy has been reported.¹⁵ However, others have found no apparent negative effect of radiotherapy on shoulder function.^16,17 The current study did not examine the effect of radiotherapy, and this should be evaluated in future studies.

To our knowledge, the present study is the first to evaluate the effect of PMM flap reconstruction on upper extremity function as determined by DASH score. The DASH questionnaire is brief, self-administered and multifactorial, and has sufficient detail to identify subtle changes. It has high reliability and credibility in assessing upper extremity dysfunction.^18,19 PMM flap reconstruction resulted in significantly higher DASH scores (i.e., more extensive upper extremity disability) compared with preoperative values in the present study. However, it should be noted that all patients were evaluated ≥1 year after surgery, and early physical therapy is known to improve the recovery of shoulder function.²⁰ Furthermore, the mean postoperative DASH score after PMM flap surgery was 7.0 (of a possible maximum of 100), indicating that any damage caused was not severe.

There was a positive correlation between flap size and DASH score in the present study. This may be due to the greater extent of muscle damage associated with a larger flap, since the pectoralis major has an important role in rotation, flexion and adduction of the shoulder. In a finding consistent with others, there was no association between postoperative DASH score and age.¹²

The present study had several limitations, primarily the lack of randomization. In addition, objective measurements would allow evaluation of the mechanism by which PMM flap reconstruction affects upper extremity function.

In conclusion, after taking into account the effect of neck dissection, PMM flap reconstruction has a small but significant negative effect on upper extremity dysfunction.

Footnotes

Declaration of conflicting interests

The authors declare that there are no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

References

Ariyan

. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1979; 63: 73–81.

Vartanian

Carvalho

. Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: experience with 437 cases at a single institution. Head Neck 2004; 26: 1018–1023.

Gadre

Sane

. Pectoralis major myocutaneous flap-still a workhorse for maxillofacial reconstruction in developing countries. J Oral Maxillofac Surg 2013; 71: 2005.e1–2005.e10.

Fang

Shi

Zhang

. Assessment of the quality of life of patients with oral cancer after pectoralis major myocutaneous flap reconstruction with a focus on speech. J Oral Maxillofac Surg 2013; 71: 2004.e1–2004.e5.

Hsing

Wong

Wang

. Comparison between free flap and pectoralis major pedicled flap for reconstruction in oral cavity cancer patients–a quality of life analysis. Oral Oncol 2011; 47: 522–527.

Urken

Biller

Pectoralis major. In: Urken

Cheney

Sullivan

Biller

(eds). Atlas of regional and free flaps for head and neck reconstruction, New York, NY: Raven Press, 1995, pp. 3–28.

de Azevedo

. Modified pectoralis major myocutaneous flap with partial preservation of the muscle: a study of 55 cases. Head Neck Surg 1986; 8: 327–331.

Sobin

Wittekind

. TNM classification of malignant tumors, 6th edn. New York, NY: John Wiley and Sons, 2002.

Hudak

Amadio

Bombardier

. Development of an upper extremity outcome measure: the DASH (Disabilities of the Arm, Shoulder, and Head). Am J Ind Med 1996; 29: 602–608.

10.

Cappiello

Piazza

Giudice

. Shoulder disability after different selective neck dissections (levels II-IV versus levels II-V): a comparative study. Laryngoscope 2005; 115: 259–263.

11.

Witt

Rejto

. Spinal accessory nerve monitoring in selective and modified neck dissection. Laryngoscope 2007; 117: 776–780.

12.

Merve

Mitra

Swindell

. Shoulder morbidity after pectoralis major flap reconstruction for head and neck cancer. Head Neck 2009; 31: 1470–1476.

13.

Moukarbel

Fung

Franklin

. Neck and shoulder disability following reconstruction with the pectoralis major pedicled flap. Laryngoscope 2010; 120: 1129–1134.

14.

Nowak

Parzuchowski

Jacobs

. Effects of combined modality therapy of head and neck carcinoma on shoulder and head mobility. J Surg Oncol 1989; 41: 143–147.

15.

Chepeha

Taylor

Chepeha

. Functional assessment using constant’s shoulder scale after modified radical and selective neck dissection. Head Neck 2002; 24: 432–436.

16.

Erisen

Basel

Irdesel

. Shoulder function after accessory nerve-sparing neck dissections. Head Neck 2004; 26: 967–971.

17.

Watkins

Williams

Mascioli

. Shoulder function in patients undergoing selective neck dissection with or without radiation and chemotherapy. Head Neck 2011; 33: 615–619.

18.

Fang

Shi

Zhang

. Upper extremity morbidity after radial forearm flap harvest: a prospective study. J Int Med Res 2014; 42: 231–235.

19.

Haldorsen

Svege

Roe

. Reliability and validity of the Norwegian version of the disabilities of the arm, shoulder and hand questionnaire in patients with shoulder impingement syndrome. BMC Musculoskelet Disord 2014; 15: 78–78.

20.

McGarvey AC, Hoffman GR, Osmotherly PG, et al. Maximizing shoulder function after accessory nerve injury and neck dissection surgery: a multicenter randomized controlled trial. Head Neck 2014. Epub ahead of print.