Re-evaluating the role of pedicled pectoralis major flap in subtotal hypopharyngeal reconstruction.

PURPOSE: Without requiring microvascular anastomosis, could the pedicled pectoralis major myocutaneous flap (PPMMF) represent a simpler, safer, and more efficient alternative to the free anterolateral thigh fasciocutaneous flap (FALTFF) in subtotal hypopharyngeal defect reconstruction? METHODS: This retrospective study analyzed 58 patients with hypopharyngeal cancer who underwent subtotal defect reconstruction using either a pedicled pectoralis major myocutaneous flap (PPMMF, n = 21) or a free anterolateral thigh fasciocutaneous flap (FALTFF, n = 37) between January 2011 and December 2024. Evaluated outcomes included postoperative complications, dietary function at 1 and 3 years, and 5-year survival. A restricted diet was defined as dependence on enterostomy feeding or the need for pharyngoesophageal dilation. RESULTS: FALTFF procedures were associated with longer operative times (14.79 vs. 10.94 h, p = 0.0001), longer ICU stays (4.92 vs. 2.62 days, p < 0.001), and slightly higher total costs (390,110 vs. 373,900 NTD, p = 0.0484). Despite these factors, FALTFF showed superior safety, with lower flap salvage rates (13.51% vs. 38.10%, p = 0.0487) and no cases of pharyngocutaneous fistula (0% vs. 14.29%, p = 0.0431). Dietary outcomes favored FALTFF, though not reaching statistical significance (regular diet at 1 year: 91.89% vs. 71.43%, p = 0.0593; at 3 years: 80.95% vs. 60.00%, p = 0.2600), indicating a consistent 20% reduction in dietary restriction. Five-year survival rates were similar between the two groups. CONCLUSION: FALTFF demonstrated superior safety with fewer complications and reoperations, and no fistulas, outweighing its slightly longer surgery and higher initial costs.