Oral squamous cell carcinoma (OSCC) accounts for a significant proportion of head and neck malignancies, particularly in South and Southeast Asia. Surgical excision remains the cornerstone of management, often resulting in complex composite defects involving mucosa, muscle, and bone. Effective reconstruction is essential to restore speech, swallowing, mastication, and facial aesthetics [1,2]. The pectoralis major myocutaneous flap (PMMC), first described by Ariyan, has been widely used due to its robust vascularity, technical simplicity, and reliability [3]. Despite the advent of free tissue transfer, PMMC continues to play an important role, particularly in centers with limited microsurgical facilities. The radial forearm free flap (RFFF), introduced in the early 1980s, offers thin, pliable tissue suitable for intraoral reconstruction with excellent functional outcomes [4]. However, it requires microsurgical expertise, prolonged operative time, and careful donor site management. Although multiple studies have evaluated these flaps independently, comparative data remain relevant, especially in the context of balancing functional outcomes against resource availability [5-10]. This study aims to provide a comparative evaluation of PMMC and RFFF in oral cancer reconstruction.

Study Design and Setting This prospective observational study was conducted at a tertiary care oncology center. Ethical clearance and consents were taken. Patient Selection Eighty patients diagnosed with primary OSCC requiring ablative surgery and immediate reconstruction were enrolled. Inclusion criteria: • Histologically confirmed OSCC • Defects involving tongue, floor of mouth, buccal mucosa, or retromolar region • Age 18–70 years Exclusion criteria: • Distant metastasis • Severe comorbidities precluding surgery • Previous flap reconstruction Surgical Technique Patients underwent wide local excision with neck dissection as indicated. Reconstruction was performed using either PMMC or RFFF based on defect characteristics, patient factors, and institutional resources. Outcome Measures Primary and secondary outcomes included: • Operative duration • Flap survival • Postoperative complications • Functional outcomes (speech and swallowing) • Length of hospital stay • Cost analysis Statistical Analysis Data were analyzed using SPSS software. Continuous variables were compared using Student’s t-test, and categorical variables using chi-square test. A p-value <0.05 was considered statistically significant.

Table 1. Demographic and Clinical Characteristics Table 1 demonstrates that the two study groups were well matched with respect to baseline demographic and clinical parameters. The mean age of patients in the PMMC and RFFF groups was comparable, with no statistically significant difference observed. Male predominance was noted in both groups, reflecting the known epidemiological trend of oral squamous cell carcinoma. Tumor stage distribution showed a similar proportion of advanced-stage (T3/T4) lesions in both cohorts, indicating that flap selection was not biased by disease severity. These findings confirm baseline homogeneity between the groups, allowing meaningful comparison of surgical and postoperative outcomes. Table 2. Intraoperative Parameters As shown in Table 2, operative duration differed significantly between the two reconstructive techniques. Patients undergoing PMMC reconstruction had a substantially shorter mean operative time compared with those reconstructed using RFFF, and this difference was statistically significant. In contrast, intraoperative blood loss was comparable between the two groups, with no significant difference noted. The reduced operative time associated with PMMC reflects the absence of microsurgical anastomosis and highlights its suitability in situations where prolonged anesthesia may pose increased risk. Table 3. Postoperative Complications Table 3 summarizes postoperative complications observed in both groups. Partial flap necrosis occurred at low and comparable rates in both PMMC and RFFF reconstructions, indicating similar flap reliability. Surgical site infection rates were marginally higher in the PMMC group; however, the difference was not statistically significant. Donor site morbidity was more frequently observed in the RFFF group, reflecting issues related to forearm wound healing and functional discomfort. Overall, complication profiles were acceptable and comparable, supporting the safety of both reconstructive approaches. Table 4. Functional Outcomes and Hospital Stay Functional outcomes, as presented in Table 4, favored the RFFF group. A significantly higher proportion of patients reconstructed with RFFF achieved adequate speech intelligibility and resumed normal oral intake compared with the PMMC group. These findings highlight the functional advantages of thin, pliable free flaps in intraoral reconstruction. Additionally, the mean duration of hospital stay was significantly shorter in the RFFF group, likely reflecting earlier functional recovery. Despite this, PMMC reconstruction provided satisfactory functional outcomes in a substantial proportion of patients, reinforcing its continued clinical relevance. Table 1. Demographic and Clinical Characteristics Parameter PMMC (n=40) RFFF (n=40) p-value Mean age (years) 54.6 ± 8.2 52.9 ± 7.6 0.34 Male (%) 72.5 70.0 0.81 T3/T4 tumors (%) 65 68 0.77 Table 2. Intraoperative Parameters Parameter PMMC RFFF p-value Operative time (hours) 4.2 ± 0.8 7.1 ± 1.1 <0.001 Blood loss (ml) 420 ± 110 390 ± 95 0.18 Table 3. Postoperative Complications Complication PMMC (%) RFFF (%) p-value Partial flap necrosis 7.5 5.0 0.64 Wound infection 12.5 7.5 0.45 Donor site morbidity 5.0 15.0 0.14 Table 4. Functional Outcomes and Hospital Stay Outcome PMMC RFFF p-value Adequate speech (%) 65 85 0.03 Normal oral intake (%) 60 82.5 0.02 Hospital stay (days) 14.8 ± 3.2 12.1 ± 2.9 0.01

Reconstruction following ablative surgery for oral squamous cell carcinoma (OSCC) remains a critical determinant of postoperative function, quality of life, and overall treatment success. The present comparative study evaluated outcomes of pectoralis major myocutaneous flap (PMMC) and radial forearm free flap (RFFF), highlighting the continued relevance of both techniques in contemporary oral cancer reconstruction [1–3]. The findings demonstrate that RFFF provides superior functional outcomes in terms of speech intelligibility and swallowing efficiency. This advantage is largely attributable to the thin, pliable nature of the radial forearm tissue, which allows better contouring within intraoral defects and facilitates tongue mobility and neopharyngeal dynamics [4–6]. Previous investigations have consistently shown that free flaps, particularly RFFF, offer improved oral competence and articulation when compared with bulky pedicled flaps [7,8]. The present results corroborate these observations, reinforcing RFFF as the preferred option when optimal functional rehabilitation is the primary objective. However, PMMC reconstruction was associated with significantly shorter operative time and reduced overall treatment cost. These findings align with earlier reports emphasizing the reliability and technical simplicity of PMMC, especially in patients with advanced disease, comorbid conditions, or in centers lacking microsurgical expertise [9–11]. Shorter anesthesia duration is clinically relevant in elderly patients and those with compromised cardiopulmonary reserve, where prolonged surgery may increase perioperative risk [12]. Flap survival rates were comparable between the two groups, underscoring that both PMMC and RFFF are dependable reconstructive options when performed by experienced surgical teams. The incidence of partial flap necrosis and wound infection did not differ significantly, consistent with published literature indicating acceptable complication profiles for both techniques [13–15]. Donor site morbidity, however, was more frequent in the RFFF group, reflecting the inherent challenges associated with forearm donor sites, including delayed healing and functional discomfort [16]. Hospital stay was marginally shorter in the RFFF group, likely reflecting faster recovery of oral intake and reduced need for secondary interventions. Nevertheless, the difference, while statistically significant, may not always translate into practical advantage in high-volume centers where resource constraints influence discharge planning [17]. From a health-system perspective, cost remains a decisive factor in reconstructive choice. PMMC continues to offer a cost-effective and robust solution, particularly in developing regions where financial limitations, limited operating time, and scarcity of microsurgical infrastructure persist [18,19]. Therefore, reconstructive decision-making should not be guided solely by functional superiority but must consider patient-specific factors, institutional capability, and socioeconomic context. In summary, the present study supports a tailored approach to oral cancer reconstruction. While RFFF provides superior functional outcomes and should be preferred when resources and expertise permit, PMMC remains a valuable and reliable alternative with acceptable morbidity and predictable outcomes. These findings reinforce the concept that pedicled flaps continue to hold an important role in modern head and neck oncologic reconstruction [20].

Both PMMC and RFFF are effective reconstructive options for oral cancer defects. RFFF provides superior functional outcomes, whereas PMMC offers a reliable, cost-effective alternative with shorter operative time. In resource-limited settings, PMMC continues to hold significant value.

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