Pectoralis Major Muscle Flap Research Articles

Surgical Treatment of Complications 45 Years After Extraperiosteal Pneumonolysis and Plombage Using Acrylic Resin Balls for Cavitary Pulmonary Tuberculosis

An infected axillary sinus tract discharged balls made of an acrylic resin consisting essentially of polymerized methyl methacrylate (Lucite) 45 years following performance of an extraperiosteal pneumonolysis and Lucite ball plombage for collapse therapy of right upper lobe cavitary tuberculosis. Surgical extraction of the balls was performed, followed by a partial decortication of the lung and intrathoracic transposition of a pectoralis major muscle flap to fill the residual pleural space. Primary healing was attained, and the patient is well 1 1/2 years after surgery.

Immediate Muscle Flap Coverage for Repair of Cardiac Rupture Associated with Mediastinitis

Sternal wound infection with mediastinitis is a dreaded complication of cardiac surgery. Even more devastating is perforation of the heart or great vessels secondary to advanced mediastinitis. The exsanguinating hemorrhage and presence of extensive infection usually lead to a poor salvage rate in these patients. Citations in the English literature of successful management of cardiac rupture associated with mediastinitis are, as expected, scare. Recently, the capability for immediate muscle flap coverage in the repair of associated rupture of the heart secondary to active mediastinal infection has been discussed in two reports. This article presents another report, in which bilateral pectoralis major muscle flaps were used successfully in salvage of a patient who sustained rupture of the right ventricle after debridement of an extensively purulent sternal wound and mediastinum.

Pectoralis major muscle flap with bone graft in intra-oral reconstruction

The use of the pectoralis major muscle only flap in conjunction with a free iliac crest bone graft for reconstruction of the mandible is described. These flaps were raised in 20 cadavers and found to be of consistently adequate length to be used as described.

Pectoralis Major Muscle-Musculocutaneous Flap for Chest-Wall Reconstruction

Pectoralis major muscle and musculocutaneous flaps are the most frequently selected for the ventral chest wall, sternum, and anterior mediastinum because of their proximity, reliability, and versatility. These advantages are derived from consistent anatomic features that allow knowledgeable surgeons to use a variety of flap designs tailored to defect needs. The flaps can be transferred on either thoracoacromial or internal mammary vascular pedicles and can be segmentally split to achieve defect closure while retaining portions of the muscle in situ to preserve donor motor function and surface form. The musculocutaneous paddles can be placed in a variety of locations and extended beyond the muscle borders to meet specific defect needs. This anatomic versatility gives pectoralis major muscle and musculocutaneous flaps a most useful role in the reconstruction of defects of the sternum and anterior mediastinum, defects of the ventral and lateral chest wall, and intrathoracic defects such as empyema cavities and bronchopleural fistula. A detailed knowledge of surgical anatomy is essential for optimal application of these flaps in the full spectrum of clinical needs.

What is the role of carotid arterial resection in the management of advanced cervical cancer?

From 1977 through 1988, 16 patients underwent carotid artery resection and reconstruction or simple ligation in the treatment of advanced cervical carcinomas. Three patients underwent carotid artery ligation, with postoperative transient ischemic attacks, which resolved, in one patient. In the remaining 13 patients, interposition saphenous vein grafts were used to reconstruct the resected carotid arteries. In one of these 13 patients, the previously unresected carotid artery ruptured and was treated by carotid artery resection with interposition vein grafting and coverage by a myocutaneous flap. There were two immediate postoperative strokes, with excellent neurologic recovery in one, and one late postoperative stroke (6 months). There was one postoperative death. Adjunctive intraoperative irradiation (1500 to 2000 rad) was employed in 15 patients to decrease the risk of recurrent disease. Since 1982, pectoralis major muscle flaps have been constructed in all patients to cover the vein grafts, with no subsequent carotid artery blowouts. Seven patients are free of cancer more than 1 year after surgery. In conclusion, carotid artery resection for the treatment of advanced cervical carcinomas may be accomplished with acceptable morbidity and mortality rates in carefully selected cases. Coverage of the vein graft by a myocutaneous flap appears to protect against carotid artery blowout. Intraoperative irradiation appears to decrease significantly the local recurrence rate of these aggressive tumors.

Clavicular division technique. A new approach for lengthening the pectoralis flap.

Complications associated with using the pectoralis major myocutaneous flap increase significantly when a portion of the paddle is randomized and/or the flap is closed under tension. The clavicular division technique was devised to increase the length of the flap to help alleviate this problem. Thirty pectoralis major muscle flaps were dissected in fresh cadavers, using the clavicular division technique. The length of the flap after transposition was measured and recorded before and after clavicular division. The distance from the sternal notch to the clavicular division point was also recorded. The average gain in length was found to be 2.9 cm, with a range of 0.5 cm to 6.5 cm. The clavicular division technique has been used since in five patients. The increase in length has allowed us to discard some or all of the random portion of the flap. We advocate the use of this procedure on any patient where the surgeon is concerned about the viability of the random portion of the flap and/or when it is felt that the tension on the suture line is excessive.

The pectoralis major muscle flap without skin in intra-oral reconstruction

There are many methods of reconstructing intra-oral defects following surgical treatment of cancer. A very reliable flap is the pectoralis major myocutaneous flap which has the added advantage of carotid artery protection when a radical neck dissection has also been necessary. However this flap is very bulky, may cause distortion of the female breast and there is also the problem of continued hair growth in male patients. A description of the use of the pectoralis major muscle-only flap without any overlying skin, fascia or breast tissue is given. The advantages of rapid epithelialisation within the mouth of the muscle flap together with the minimal changes to the breasts are emphasised.

Management of Postoperative Mediastinitis in Infants and Children by Muscle Flap Rotation

Between July 1, 1976, and June 30, 1986, at the Henrietta Egleston Hospital for Children, 2,242 infants and children underwent palliation or repair of a congenital heart defect. Twenty-one (0.94%) of these patients developed mediastinitis following a median sternotomy. Nineteen of these twenty-one patients had required cardiopulmonary bypass. All patients had positive mediastinal cultures. The first 8 patients were managed traditionally by debridement and irrigation. Three of these patients suffered serious metabolic complications related to the povidone-iodine irrigant, which resulted in 1 death. Another patient died from persistent sepsis following debridement. Subsequently, 13 patients were managed by early debridement and rotation of the pectoralis major or rectus abdominis muscle flaps, or both. Following muscle flap rotation and early wound closure, 2 patients had subsequent incisional complications. One patient had incisional dehiscence and 1 had a superficial skin separation. Two deaths in this group, 28 and 51 days, respectively, following muscle flap rotation, resulted from nonincisional problems in patients with healed median sternotomies. The group having muscle flap rotation required a significantly shorter duration of postoperative ventilatory support (3.2 versus 24 days, p < 0.05) and a significantly shorter confinement in the intensive care unit (6.2 versus 33 days, p < 0.01). Also, the physiological and physical trauma of continued wound care in the awake child was minimized in the group with muscle flap rotation.

Repair of salivary fistula after reconstruction of pharyngoesophagus.

We describe three surgical methods used to repair salivary fistulas in different situations that are seen after reconstruction of the pharyngoesophagus in patients with hypopharyngeal cancer. The principle of these methods is the same; a cervical skin flap next to the fistula is used as the internal lining and an anterior chest skin flap is rotated as an external lining to cover it. For the primary closure of heavily irradiated fistulas, this combination may not always be effective, and we emphasize that a combined use of a pedicled pectoralis major muscle flap with these two kinds of pedicled skin flap is extremely reliable.

Repair of Right Ventricular Free Wall Defect with a Pedicled Muscle Flap

A unique case of repair of a full-thickness cardiac defect and simultaneous reconstruction of an infected median sternotomy wound is presented. A right ventricular defect, 6 cm in diameter, was closed with a fascia lata graft and reinforced with a rectus abdominis muscle flap. The superior portion of the mediastinum was obliterated with a pectoralis major muscle flap. The patient tolerated the procedure well and remains free of cardiac symptoms seven months postoperatively, with no evidence of residual infection.

Pharyngocutaneous fistulas in advanced cancer: Closure with musculocutaneous or muscle flaps

Two hundred cases of head and neck cancer were reviewed and 16 pharyngocutaneous fistulas identified, for an incidence of 6 percent. The fistulas were closed with pectoralis major muscle flaps in four patients, pectoralis musculocutaneous flaps in seven patients, sternocleidomastoid muscle flaps in four patients, and latissimus dorsi flaps in two patients. Four types of fistulas were identified, and flap selection was determined by fistula location. Successful closure was obtained in 15 patients (88 percent), although one patient died from recurrence with a persistent fistula.

Pectoralis major muscle flaps for closure of sternal defects. (German)

Pectoralis major muscle flaps for closure of sternal defects. (German)

Reconstructive surgery in the treatment of hypopharyngeal cancer.

We report our experiences with 283 reconstructions of pharyngoesophageal defects after adequate extirpation of hypopharyngeal cancer that have been accomplished in the past 17 years through 1970 to 1986 using various kinds of pedicled flaps such as Bakamjian's DP skin flap, slit technique of DP skin flap, pectoralis major and latissimus dorsi myocutaneous flaps, skin-grafted pectoralis major muscle flap and gastric or colic pull-ups. We conclude that each flap has its own merits and demerits and any one of these flaps cannot totally replace the others and that we must be familiar with characteristics of these flap techniques including free flap transfer to be able to indicate the best selection of reconstructive technique for every patient with different situations and, then, to obtain optimal result.

The pectoralis major muscle in head and neck reconstruction.

From June 1980 to June 1985 51 pectoralis major muscle flaps have been used for one-stage reconstruction of extensive defects in the head and neck following cancer surgery. The pectoralis major muscle was used as a myocutaneous flap on 28 occasions, as a muscle covered with split thickness skin on 17 occasions, and as a muscle-only flap six times. The muscle, in its various forms, was used for reconstruction of the pharyngooesophageal segment, the tongue, floor of the mouth and oropharynx, to replace the skin of the face and neck, and to provide a well vascularized recipient bed for a split-rib graft, used to replace a defect of the anterior arch of the mandible. Many of the problems associated with the use of a pectoralis major myocutaneous flap can be avoided by the judicious use of a muscle flap on its own or covered by a split thickness skin graft.

Pectoralis major muscle flaps for closure of sternal defects

A reliable and simple technique involving the use of pectoralis major muscle flaps is described for the closure of sternal and costal cartilage defects caused by debridement for chronic osteomyelitis following median sternotomy. No bone grafts, omentum flaps or skin grafts have been needed in more than 20 patients.

Costochondritis

The management of costochondritis of the chest wall is reviewed and four illustrative cases presented. Adequate debridement is the single most important factor to ensure eradication of this disease. Well-vascularized tissue coverage reduces ischemic factors, resists secondary infection by contamination, and promotes rapid healing. The pectoralis major, latissimus dorsi, and rectus abdominis muscle flaps are the primary choices for pedicle-flap coverage. Antibiotic coverage was not extended beyond 3 weeks in these cases, and no recurrences have been noted over a 1- to 3-year follow-up.

Use of the pectoralis major muscle flap for repair of a tracheoesophageal fistula

A case of tracheal rupture after a Lewis-Tanner esophagectomy in a patient with carcinoma of the esophagus was complicated by the formation of a tracheoesophageal fistula after initial direct repair. The fistula was successfully treated with a pectoralis major muscle flap moved into the superior mediastinum by a sternotomy and excision of the upper part of the sternum and adjacent costal cartilages.

Immediate pharyngoesophageal reconstruction. Use of a quilted skin-grafted pectoralis major muscle flap.

Pharyngoesophageal reconstruction continues to be a problem in the management of cancer involving the hypopharynx. In our experience, the use of deltopectoral and pectoralis major myocutaneous flaps for total reconstruction has been disappointing. We report four cases of immediate near-total reconstruction using a quilted , skin-grafted pectoralis major muscle flap. All cases had received full dosage preoperative irradiation. A thin-walled pharynx was created that has allowed early development of a good esophageal voice. There has been no stricture formation. All patients have experienced no difficulty in establishing a good oral intake.

Reconstruction of the zygoma, temporo-mandibular joint and mandible using a compound pectoralis major osteo-muscular flap

A method of reconstruction of the zygoma, temporo-mandibular joint and hemi-mandible utilising a segment of the outer table of the sternum, sterno-costal joint and rib vascularised by an ipsilateral pectoralis major muscle flap is described. The mobility of an isolated sterno-costal joint is compared with movements of the temporo-mandibular joint.

Esophageal reconstruction with a skin-grafted pectoralis major muscle flap.

Reconstruction of the cervical esophagus is a problem in the surgical treatment of hypopharyngeal cancer. The conventional deltopectoral skin flap and the pectoralis major myocutaneous flap both have shortcomings. We developed a new technique for the immediate reconstruction of the entire cervical esophagus that utilizes the pectoralis major muscle with skin grafted directly onto it. This is especially useful in female patients who are buxom or have thick subcutaneous adipose tissue, because the anterior chest skin is not used as the skin island and, therefore, the flap is not too bulky and cosmetic problems are minimal. The breast is left unaffected with the nipple in its normal position. We report the technical details and the results in four female patients with hypopharyngeal cancer.