The functional pectoralis major musculocutaneous island flap in head and neck reconstruction

We describe our experience with the true island pectoralis major musculocutaneous flap in patients with high-volume defects for whom free-tissue transfer is unsuitable. Our operative technique is presented. We have modified the method of making a true island of the pectoralis major musculocutaneous flap on a muscle-free pedicle as first described by Wei et al. in 1984. This maintains maximal donor-site muscle function and facilitates closure of the donor-site defect. We present our results in 24 patients, in whom the flap has proved to be robust and reliable. The flap's advantages in terms of increased pedicle length, wider arc of rotation, decreased pedicle bulk, and improved cosmesis of the reconstruction are discussed.     

The nerve supply to the clavicular part of the pectoralis major muscle: an anatomical study and clinical application of the function-preserving pectoralis major island flap

The purpose of this study was to investigate the nerve supply to the clavicular part of the pectoralis major muscle so that the innervation to this part can be maintained in the muscle-preserving pectoralis major island-flap transfer. Although methods have been described that include a limited portion of the muscle while leaving the upper parts undisturbed with an intact motor innervation, reports on anatomical studies of this nerve supply are brief. The distal distribution of the nerves, the spatial relationship to the main vascular pedicle, and the ways to preserve them during surgical procedures remain unclear. Surgically relevant features of the clavicular part of the pectoralis major muscle were studied by dissection. The nerve supply to this part was examined on 11 sides of eight formalin-fixed cadavers. Two fresh cadavers were used for dissection, intraarterial polymer injection, and application of a nerve-preserving surgical technique. In all subjects, a separate nerve innervated the clavicular and upper medial sternocostal portions of the pectoralis major muscle. This nerve arises craniomedial to the main vascular pedicle of the flap and divides into several branches. These branches run in a fascia on the deep surface of the pectoralis major muscle, superficial to the origin and distal course of the vascular pedicle. Most branches to the clavicular part end medial to the coracoid process. The course of the branches to the upper sternocostal part is more medial. Based on their anatomical findings, the authors propose a surgical technique for transfer of the pectoralis major island flap to the head and neck area through a tunnel in the deltopectoral groove, lateral to the origin of the vascular pedicle. Head and neck reconstruction was performed using this technique. The presented method is a muscle-preserving procedure that maintains maximal donor-site function and morphology.     

Arterial and venous anatomical features of the pectoralis minor muscle flap pedicle

The pectoralis minor muscle has been used as an innervated, vascularized, free-muscle graft in the field of facial reanimation for 20 years. Throughout this period, several centers have demonstrated consistent success with functional muscle transfer; however, opinions regarding the arterial pedicle of the flap have varied. The lateral thoracic and thoracoacromial arteries have been proposed as the predominant arterial sources. It has been the experience of our unit that a vessel (not described in anatomy textbooks) arising directly from the axillary artery and entering the muscle from its dorsal surface provides the dominant supply to the flap and is capable of sustaining it for free-tissue transfer. The vascular pedicle encountered was recorded and photographed in 97 consecutive cases in which the pectoralis minor muscle flap was raised. The findings demonstrated that the dominant supply to the muscle was from a single artery in 77 percent of cases and took the form of an artery arising directly from the axillary vessel in 72 percent of cases. More than one major arterial source was noted in the remainder of the cases. The venous outflow was usually through single or multiple veins running directly from the muscle into the axillary vein.     

A retrospective analysis of 48 infected sternal wound closures: delayed closure decreases wound complications

Forty-eight patients who suffered sternal wound infections following coronary artery bypass grafting were retrospectively reviewed over a 5-year period. All patients in this study had clinical signs of major infection including redness, pain, and purulence at the time of mediastinal drainage and debridement. One patient died 11 days postoperatively because of heart failure, leaving 47 patients available for long-term follow-up. All muscle flaps (pectoralis and rectus abdominis) survived completely. All wound complications were related to chest wall skin flap dehiscence or continued infection. Seventeen of 22 patients (77 percent) undergoing flap closure 4 days or less after sternal debridement and irrigation suffered wound complications. Five of these 22 patients (23 percent) had major wound complications, meaning that the wound required more than 2 months of care before healing was complete. No major wound complications and only three minor complications (12 percent) occurred in 25 patients undergoing sternal flap closure 5 days or more after mediastinal debridement and irrigation. The frequency and severity of wound complications were significantly decreased in the group of patients undergoing sternal flap closure 5 or more days after sternal drainage and debridement (p < 0.00005). In the majority of cases [29 of 47 (62 percent)], secure sternal wound closure was obtained with a single, split, medially based, right pectoralis major muscle flap.     

The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck.

A compound flap is described that utilizes skin from the anterior chest on a narrow segment of pectoralis major muscle, with its underlying axial neurovascular bundle. This flap has been used successfully to reconstruct large defects in 4 consecutive patients. Our experience with this flap suggests that it may be more versatile than the deltopectoral flap.     

改良带蒂胸大肌肌皮瓣修复口腔颌面肿瘤术后缺损的临床分析

目的:探讨只带血管蒂的改良胸大肌皮瓣转移修复口腔颌面部组织缺损的临床效果。方法:取胸大肌皮瓣时蒂部只保留血管,利用改良只带血管蒂的胸大肌皮瓣对6例不同口腔颌面部组织缺损进行修复,包括舌癌3例、舌咽癌1例、牙龈癌1例、颊癌1例。结果:术后皮瓣血供良好,完整成活,成活率100%;所有患者获得3~18个月随访,在随访期内均存活;重建的舌外形良好,虽然味觉功能无法恢复,运动功能随切除范围增加而降低,但均能满足发音、吞咽和咀嚼功能需要。结论:只带血管蒂的改良胸大肌皮瓣是修复口腔颌面部组织缺损有效而可靠的方法,为恶性肿瘤根治术后造成的缺损提供了有力修复保障。     

The extended pectoralis major myocutaneous flap: uses and indications

The vascular territory of the pectoralis major muscle and overlying skin was studied by selective intraarterial dye injections in fresh cadavers. The area of skin overlying the anterior chest and abdominal wall beyond the limits of the pectoralis major muscle that can be elevated as an extended myocutaneous flap was determined. The cadaver injections were evaluated to determine the size and shape of the skin island used to reconstruct defects of the head, neck, and upper trunk with an extended skin paddle off the pectoralis major muscle. Pectoralis muscle flaps with variously shaped skin paddles, some extending beyond the limits of the muscle, were used in 27 patients to cover large soft-tissue defects of the upper thorax, face, and floor of the mouth and as a skin tube to reconstruct the cervical esophagus. The size of the skin paddle ranged from 5 x 7 cm to 26 x 16 cm. All flaps survived completely, and there were no major donor-site complications.     

Breast reconstruction with an external oblique abdominis muscle turnover flap and a bipedicled abdominal skin flap

A new technique of breast reconstruction is demonstrated using a turnover flap of the external oblique abdominis muscle together with a sheath of the rectus muscle to enlarge the submuscular pectoralis major pocket for the implant. To overcome a tight skin, a bipedicled abdominal skin flap is transposed for breast reconstruction. In so doing, a natural-looking breast is formed by a simple operative technique with rare complications. The technique has been applied in 11 patients with good results.     

The lateral pectoral composite flap in one-stage reconstruction of the irradiated mandible

We present a composite flap based on the musculature of the anterolateral thorax that allows immediate reconstruction of the mandible through the interposition of vascularized bony fifth rib. While the vascular pedicle remains the pectoral branch of the thoracoacromial artery, the pectoralis major muscle can be spared largely intact. The lateral position of the composite rib segment ensures a purely bony composition, while the lateral skin island remains largely hairless. Despite the unfavorable conditions of massive tumor size and prior irradiation attending the clinical cases presented, the complication rate was acceptable, with only one flap loss, and this followed technical error.     

Successful treatment for exposure of a dacron aorta, with surrounding infection: case report.

The treatment of the patient with an exposed vascular implant should usually be in the hands of an expert vascular surgeon. In certain instances, such as when the exposed area is not close to a suture line and no fistulous tracts connect the exposed area to either suture line, plastic surgery can solve the problem. We present a case of an exposed aortic prosthesis which was successfully treated by removing devitalized tissue, turning a pectoralis major muscle flap over the implant, and closing the skin and subcutaneous tissue over the muscle flap.     

Shoulder reconstruction following disarticulation for ruptured mycotic aneurysm

A method of wound management following shoulder disarticulation is described. In this report, the primary lesion is a mycotic aneurysm of the axillary artery. The pectoralis major muscular flap provides satisfactory coverage and maintains shoulder contour. It can be performed in a single procedure. Preoperative arteriography is important to determine the extent of arterial damage as well as the vascular anatomy of the proposed flap.     

Complicated neck contracture treated with a pectoralis major myocutaneous flap.

A case is presented which demonstrates the use of a pectoralis major myocutaneous flap for repair in a heavily radiated neck and chest, with neck contracture and a tracheocutaneous fistula.     

Use of pectoralis major muscle flaps to repair defects of anterior chest wall.

We closed defects of the anterior chest wall in 6 patients, using either unilateral or bilateral pectoralis major muscle flap transpositions. In 4 of these patients the defect was stabilized with autogenous rib grafts, and none of these had a flail chest. All of the transposed muscle flaps remained viable and innervated. The deformities and the functional disturbances resulting from the transpositions were minimal.     

Chest-wall reconstruction by contralateral latissimus dorsi musculocutaneous flap

Reconstruction of chest wall and axilla are performed in 11 patients using a contralateral latissimus dorsi musculocutaneous flap. The entire lattisimus dorsi muscle, including the fascial portion, safely carried an island of skin from the area of the lumbodorsal fascia to the contralateral axilla. The flap was transposed to the defect through a tunnel between the pectoralis major and minor muscles. Most patients who needed reconstruction of the chest wall and axilla had compromised ipsilateral vasculature that prohibited its use in a pedicled flap but had an intact contralateral chest wall, axilla, and thoracodorsal vessels. Therefore, this procedure was performed easily in comparison with a free flap or pedicled omental flap. This is a new, valuable application for the versatile latissimus dorsi musculocutaneous flap.     

Pectoralis major "trapdoor" flap for silicone breast implant medial knuckle deformities.

Loss of breast parenchyma through surgery and physiologic involution can lead to problems of subglandular silicone breast implant palpability and even contour irregularities. This can give rise to patient concern and detracts from the aesthetics of the breast augmentation, particularly when it occurs medially. We present a simple solution to this problem on the medial side of the breast in the form of a small segmental medially based pectoralis major "trapdoor" flap that augments the implant soft-tissue cover intracapsularly, at the site where it is deficient. The technique, which has been used with success in five patients over 3 years, is described.     

Use of the SpaceMaker balloon in sternal wound closure: comparison with other techniques.

Sternal wound infection is surgically treated by debridement of the infected sternum and closure of the defect with a muscular flap. These operations tend to be long, stressful, and time-consuming and to involve heavy blood loss. To facilitate wound closure, the SpaceMaker balloon was applied intraoperatively to expand the pectoralis major muscles and enable tensionless closure with musculocutaneous flaps. The aim of the present study was to compare the effectiveness and feasibility of this technique with a variety of others described in the literature. The study population consisted of 40 consecutive patients with sternal wound infection following median sternotomy who were treated with the advancement flap, turnover flap, transposition flap, or SpaceMaker balloon-assisted advancement flap technique (n = 10 each). The balloon-assisted technique was associated with a shorter length of operation and fewer blood transfusions than the other methods. Furthermore, there was no need for reoperation and there were no cases of skin necrosis. In conclusion, closure with the SpaceMaker balloon-assisted bilateral pectoralis major musculocutaneous flap may serve as an adjunctive measure in the treatment of sternal wound infection. This technique seems to have advantages over simple pectoralis major musculocutaneous advancement, particularly for midsternal wounds.     

Anterior shoulder reconstruction with pectoralis minor muscle flap

The pectoralis minor flap can be utilized by the reconstructive surgeon to cover defects of the shoulder, chest, and anterior neck without the morbidity or cosmetic deformity associated with the pectoralis major or latissimus dorsi flap.     

Immediate reconstruction of a composite mandibular defect with a regional osteomusculocutaneous flap

This is a report of an immediate reconstruction of a composite mandibular defect, using a pectoralis major osteomusculocutaneous flap incorporating a segment of the fifth rib. Viability of the transferred rib segment was established by tetracycline labeling at 2 weeks and technetium scanning at 3 months postoperatively. This clinical example supports the experimental observations of a vascular network interconnecting muscle, periosteum, and compact bone.     

Louis Ombredanne and the origin of muscle flap use for immediate breast mound reconstruction

The myocutaneous flaps that are being used for breast reconstruction have a long history, although the techniques of today are more sophisticated than those of the past. Louis Ombredanne was the first to describe the pectoralis muscle flap for immediate breast mound reconstruction in 1906. Mastectomy, as performed by Halstead, is described with some insight into the reasons why breast reconstruction was not encouraged in this country in the early part of this century. Lately, the advances in the myocutaneous flap have made breast reconstruction without a prosthesis possible. The tissue that was transferred to reconstruct a breast using a tubed pedicle flap in multiple stages can now be transferred in a single stage with a better result.