Tehran University of Medical Sciences Journal of Craniomaxillofacial Research 2345-5489 10 4 2024 03 02 167 171 Ata Garajei Department of Oral and Maxillofacial Surgery, School of Dentistry, Tehran University of Medical Sciences, Tehran, Iran; Department of Head and Neck Surgical Oncology and Reconstructive Surgery, The Cancer Institute, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Ali Arab Kheradmand Department of Head and Neck Surgical Oncology and Reconstructive Surgery, The Cancer Institute, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Azadeh Emami Department of Anesthesiology, Iran University of Medical Sciences, Tehran, Iran. 2024 02 07 2024 02 09 Introduction: The pectoralis major flap (PMF) is an important reconstructive tool for defects in the head and neck region but excessive bulk and a limited arc of rotation can be problematic. These problems can be addressed by passing the pedicle deep to the clavicle but some authors feel that this modification may compromise the vitality off the flap. In the current article, these problems have been addressed by using a modified method. Materials and Methods: During the past 15 years (2000 to 2014) 182 head and neck cancer patients were treated for primary reconstruction following tumor ablation. PMF was modified by passing the pedicle deeply to the clavicle. Following flap harvest, the pedicle was passed in the subclavicular plane for reconstruction. Results: It was possible to increase the average length of PMF to 2.5-3.5cm compared to the supraclavicular route by using this modification. Minor complications were observed in 9 of 182 cases (5%): Partial flap necrosis occurred in 6 cases and fistula formation was observed in 3 cases. Conclusion: The subclavicular route increases the length and arc of rotation without compromising vascular supply to a higher degree compared to the conventional supraclavicular route. Furthermore, this concept decreases the bulk of the flap pedicle which is functionally and cosmetically favourable. Keywords: Pectoralis major flap; Subclavicular route; Head and neck reconstruction; Pedicle flap. https://jcr.tums.ac.ir/index.php/jcr/article/view/488 https://jcr.tums.ac.ir/index.php/jcr/article/download/488/393