The pectoral major myocutaneous flap, as described by Ariyan  in the late 70's, is the "working horse" of reconstructive surgery after radical tumor resection of the head and neck region. The large number of publications since then have concentrated mainly on the operation technique, indications and complications that might arise as a result of this flap surgery. In terms of the blood supply, the method seems to be relatively safe with reported complication rates varying between 8.5% to 35%, regarding the high morbidity of these patients. Several modifications of the technique have also been reported. One modification is called the pectoralis major myofascial (PMMF) flap which includes raising the muscle and muscle fascia but without the skin or breast parenchyma. The major advantage of this flap technique is seen in less bulge formation in the jaw region and a better shaping ability .
In terms of the blood supply, it also seems to have a higher safety [8, 9]. The complication rates of this procedure are largely made up of approximately 8.5% flap necrosis, of which 1.5% are complete necrosis and 18.5% wound healing problems mostly associated with the reported 13.5% orocutaneous fistulas . In subgroups of patients with preexistent chronic medicine disorders, the total complication rate has been reported to as high as 27% compared to patients without any preexisting disorders, showing complication rates of around 8.5%. In the largest published data enclosing 244 patients, the authors report a total complication rate of 35% which include all possible and also minor complications such as hematoma, infection, seroma, dehiscence, fistulas, partial or complete necrosis or other rare complications .
However, the theoretic and remote possibility of the development of breast cancer due to transplanted breast parenchyma has so far not been documented. The indication for a PMMC flap is usually seen only in surgery for recurrences or advanced primary carcinomas. Due to the relatively poor prognosis of these patients, the rare and late onset complication of a new primary tumor arising within the flap tissue is usually not of major concern. However, in patients with cured primary cancer the development of a breast carcinoma in such transplants has to be associated with a poor prognosis which mainly results from its difficult diagnosis.
Up to now there is no general consensus for breast cancer screening in patients undergoind PMMC flap; therefore these patients are not routinely screened. According to the literature, only 7 to 22% of all patients undergoing a PMMC flap reconstruction are female [4, 11, 12]. The average age at time of operation varied between 36 and 59 years. Most patients were operated due to an advanced primary oropharynx carcinoma or a tumor recurrence. The development of such a carcinoma in patients without risk factors as nicotine or alcohol as in our patient is rare and may generally reflect a predisposition towards tumor development. A molecular genetic hallmark of the squamous cell carcinomas of the oropharynx in female patients without any risk factors is the frequent finding of a p53 mutation and/or positive HPV test. Distinct from this group of patients, there are some patients with genetic germ line mutation of p53, also called the Li Fraumeni syndrome, with a familial predisposition to this type of carcinoma as well as to breast carcinoma.
It seems reasonable to perform mammography and additional breast ultrasound as a preoperative measure in female patients being considered for a PMMC flap. With these routine diagnostic tools it should be possible to gain information on the distribution of breast parenchyma including aberrant breast tissue and thus help to prevent early manifestation or transplantation of preneoplasia or non palpable breast cancer. In this case, the time course from flap surgery to diagnosis of breast cancer was approximately 4 years and therefore any screening at time of transplantation may have been unremarkable. The promotion of breast cancer due to short term recent topical estrogen-therapy because of senile kolpitis seems unlikely but can not be completely excluded. The use of an aromatase inhibitor as an adjuvant systemic endocrine therapy in this hormone receptor positive patient seems to be adequate. It also avoids the additional risk elevation for endometrial carcinoma under tamoxifen. After 9 years the patient is free of any relapses due to the cancer from the oropharynx and the breast. In case of future metastasis, it is pertinent to histologically confirm the origin of the metastatic tissue, before any therapy is initiated or changed.
Part of this work was already published in Oral Oncology EXTRA (2005) 41, 238-241