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.     

Free fibula osteoseptocutaneous-pedicled pectoralis major myocutaneous flap combination in reconstruction of extensive composite mandibular defects

Lateral composite mandibular defects resulting from excision of advanced oral carcinoma often require mandible, intra-oral lining, external face, and soft-tissue bulk reconstruction. Ignorance of importance soft-tissue deficit in those patients may cause significant morbidity and functional loss. Such defects, therefore, can be reconstructed best with a double free flap technique. However, this procedure may not be feasible for every patient or surgeon. An alternative procedure is a free fibula osteoseptocutaneous flap combined with a pedicled pectoralis major myocutaneous flap. This combination was used in reconstruction of extensive composite mandibular defects in 14 patients with T3/T4 oral squamous cell carcinoma. All patients were men, and the average age was 54.3 years. The septocutaneous paddle of the fibula flap was used for the mucosal lining of the defects while the bony part established the rigid mandibular continuity. The pectoralis major flap then covered the external skin defect in the face and cheek, and the dead spaces left by the extirpated masticator muscles, buccal fat, and parotid gland. One free fibula flap failed totally, and one pectoralis major flap developed marginal necrosis. At the time of final evaluation, nine patients (64.3 percent) were alive, surviving an average of 25.7 months. All patients eventually regained their oral continence and an acceptable cosmetic appearance. In conclusion, the fibula osteoseptocutaneous flap plus regional myocutaneous flap choice is a successful and technically less demanding alternative to the double free flap procedures in reconstruction of extensive lateral mandibular defects.     

Pectoralis major myocutaneous flap for hypopharyngeal reconstruction

The reconstruction of total or subtotal defects after surgical treatment for hypopharyngeal cancer is a challenging problem in head and neck surgery. The authors discuss reconstructive surgery performed in 37 patients affected by advanced hypopharyngeal cancer using the pectoralis major myocutaneous flap. In 22 cases of total pharyngolaryngectomy, the reconstructive procedure originally proposed by the authors was based on the use of a pectoralis major myocutaneous flap directly sutured to the pharyngeal and esophageal stumps and the prevertebral fascia, which eventually represented the posterior wall of the neohypopharynx. In 15 cases of subtotal pharyngolaryngectomy, the posterior wall of the neohypopharynx consisted of a residual strip of pharyngeal mucosa. In each patient, removal of the tumor and reconstruction were performed during the same operation, with only a few complications. Neither flap necrosis nor strictures were encountered; five patients had pharyngeal fistula and one patient died because of massive pneumonia. Although the use of microvascular free flaps is a reliable procedure, the pectoralis major myocutaneous flap is still applicable for hypopharyngeal reconstruction, thanks to its feasibility and low complication rate. The other reconstructive options require surgical transgression of the abdomen and/or thorax in patients affected by malnutrition and other chronic systemic disorders.     

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 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.     

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 segmental pectoralis major muscle flap: a function-preserving procedure

A function-sparing pectoralis major muscle flap is presented. The flap is a medially based segmental transfer of a single intercostal portion of the pectoralis major muscle supplied by a single perforating branch of the internal thoracic artery. The segmental terminal nerve distribution of the medial and lateral pectoral nerves permits preservation of the remainder of the muscle in situ. Six cases of this procedure are presented with five successful outcomes. The single exception was in the loss of the distal tip when used to cover an irradiated carotid sheath to the base of the skull.     

改良胸大肌岛状肌皮瓣与传统皮瓣对舌癌术后修复影响的对比研究

目的：对比研究改良胸大肌岛状肌皮瓣与传统胸大肌岛状肌皮瓣在舌癌连续整块切除术后缺损修复中的的治疗效果。方法：选取2007年08月-2012年01月行舌癌连续整块切除术患者97例,其中49例采用改良胸大肌岛状肌皮瓣,48例采用传统胸大肌岛状肌皮瓣,分别命名为A组和B组,比较两组患者治疗效果和并发症发生情况。结果：A组治疗效果甲级、乙级、丙级分别为65．3％、28．6％、6．1％,B组治疗效果甲级、乙级、丙级分别为41．7％、33．3％、25．0％,A组治疗效果优于B组;A组术后并发症少于B组。结论：与传统胸大肌肌皮瓣相比,改良胸大肌岛状肌皮瓣治疗效果好,并发症少,能更好地实现舌癌连续整块切除术后缺损修复。     

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.     

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。     

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.     

Mammaplasty combining vertical and transverse approaches through a vertical incision

An adjustable vertical marking is described for vertical mammaplasty in mild and moderate hypertrophy or ptosis of the breast. A vertical rectangular flap with the pedicle supported at the inframammary fold provides fullness for the upper or the lower pole of the breast. It is fixed over the pectoralis aponeurosis along the upper pole to the base of the pedicle. Length, width, and thickness of the vertical rectangular flap change regarding the extent of breast ptosis and hypertrophy. Two transverse triangular flaps, dissected in the lower pole of the breast, are supported on the inferior half of the vertical pillars at the incision margins. The criss-crossing of the triangular flaps creates a transverse support sling, avoiding the downward displacement of the breast. The vertical flap is applied in conjunction with the triangular flap to attempt to achieve projection and support for the breast with long-term stabilization of the mammary cone. Resection of mammary tissue is performed transversely just above the pedicle of the vertical 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.     

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.     

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.     

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.     

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.     

Reconstruction of the mediastinal trachea with a tubed pectoralis major myocutaneous flap

A young patient with a massive postirradiation recurrence of thyroid cancer invading the larynx and mediastinal trachea had been treated by resecting the larynx and trachea to within three rings of the carina. A mediastinal tracheostomy was avoided by using a tubed pectoralis major myocutaneous flap to replace the ablated trachea. The flap, transferred into the mediastinum subclavicularly, was connected to the tracheal stump and exteriorized as a cervical tracheostomy. This resulted in direct closure of the donor site and primary healing. Four years after the operation, the patient remains free of disease and is tolerating the neotrachea without difficulty or complications. The technique described is offered as an alternative to conventional mediastinal tracheostomy methods, which have acknowledged shortcomings.     

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.