Single-stage Restoration of a Full-thickness Buccal-Cheek Defect after Oral Squamous Cell Carcinoma Ablation using a Folded, Bipaddled Pectoralis Major Myocutaneous Flap: A Case Report

Advanced Squamous cell Carcinoma (SCC) of the buccal mucosa can invade through the cheek to involve skin and mandible, resulting in full-thickness defects requiring prompt and reliable restoration of the intra-oral lining and extra-oral cover. Single-stage reconstruction gains importance in the setting of limited options for free-flap reconstruction due to limitations of operative time, patient reserve or microvascular resources. A 40-year-old female with a history of kharra chewing presented with a 2-month history of rapidly progressive, non-healing, right cheek ulcer that evolved into an ulceroproliferative intra-oral lesion with extraoral fungation, pain, thick ropy saliva, progressive trismus (mouth opening of ~20 mm) and clinically palpable submandibular and submental lymph nodes. Incisional biopsy report suggestive of well differentiated squamous cell carcinoma with TNM staging of T4aN2bMx. The patient was planned for composite resection, modified radical neck dissection, and immediate reconstruction with a myocutaneous flap after complete clinical and radiological assessment and exclusion of distant metastasis by chest High-Resolution Computed Tomography (HRCT). The immediate postoperative course was uneventful with Intensive Care Unit (ICU) monitoring and supportive transfusions. Postoperative flap viability is assessed through regular clinical monitoring by the following four parameters, with particular attention to the flap's colour, temperature, capillary response to the pin-prick test, and turgor or consistency. Serial evaluation of these parameters allows early identification of vascular compromise and facilitates timely intervention to improve flap survival. These parameters should be monitored periodically in the first 24-72 hours postoperatively to detect early vascular compromise and assure flap survival. The final pathological TNM was pT4aN0Mx (stage IVA). Adjuvant radiotherapy was subsequently started based on the final histopathological diagnosis. On three months postoperatively the flap was well adapted, healing was satisfactory and with no evidence of local recurrence. Functionally, the patient had acceptable oral competence and speech. Mild limitation in mastication was noted. This case demonstrates the pragmatic single-stage reconstruction of a full-thickness buccal-cheek defect following oncologic ablation with a bipaddled Pectoralis Major Myocutaneous (PMMC) flap and highlights its continuing role as a robust, dependable option for complex oral cavity defects where rapid, reliable cover is required.