Thoracoacromial Vessels Research Articles

Thoraco-acromial artery perforator ‘propeller’ flap

Thoraco-acromial artery perforator ‘propeller’ flap

Hidradenitis Suppurativa Sternalis: Surgical Treatment of This “No-Touch Zone.” A 10-Year Follow-Up

Sir: Hidradenitis suppurativa is a chronic, socially debilitating disease of apocrine gland-bearing skin with a predilection for intertriginous areas. Our interest focused on hidradenitis suppurativa sternalis. The cause is still not completely known, but medical treatment with antibiotics, local wound care, and limited incisions gives only temporary relief.1 Although there exist many articles on hidradenitis, we could not find any report on surgical treatment of hidradenitis suppurativa sternalis in the available literature.2,3 Therefore, our interest focused on this “no-touch zone” because this region is especially debilitating for sufferers of hidradenitis suppurativa sternalis, both physically and psychologically, and often leads to social isolation, failed relationships, and/or depression. In therapy-resistant patients, our experience has shown that only radical debridement prevents recurrence. In three female patients suffering from hidradenitis suppurativa sternalis (Fig. 1), we used the myocutaneous pectoralis major paddle flap4–7 for tension-free defect closure to avoid hypertrophic scars. After wide excision, a defined ellipsoid paddle not wider than 9 to 10 cm and not longer than 18 cm was outlined. The rectus sheath with the fascia of the serratus muscle was elevated together with the skin paddle up to the origin of the abdominal part of the pectoralis mayor muscle. During flap elevation, it is possible to take the whole muscle with the skin-fascia paddle or only a part of it. In our cases, only parts of the muscle were used, especially the lower section of the sternocostal part and the abdominal part of the muscle together with the skin-fascia paddle. After careful identification of the thoracoacromial vessels, the muscle was removed at its insertion. By dissection as described, the contour of the anterior axillary fold can be preserved.Fig. 1.: A 27-year-old patient with hidradenitis suppurativa sternalis after mammaplasty 4 years previously.In all cases, there was no reoccurrence of hidradenitis suppurativa sternalis or partial or total flap loss. There was primarily wound healing in all patients. No further surgical treatment such as debulking of the flap was necessary (Fig. 2).Fig. 2.: Postoperative result 10 years after surgical intervention. The right breast is essentially unchanged.The pectoralis major paddle flap is well established in reconstructive surgery. Despite the increased use of microvascular flaps, this regional flap remains an excellent choice at this area because of the excellent color match, the anatomical shape of the reconstructed area, and the minimal donor-site morbidity. In our long-term experience with keloid scars, especially in this region, we obtained less hypertrophic scar formation when tension-free wound closure was possible. In addition, if bone is exposed, vascularized tissue for defect reconstruction should be the first choice. No reoccurrence of hidradenitis suppurativa was observed after a follow-up of 10 years. In all cases, a normal breast contour was preserved without any distortion of the nipple. In conclusion, we think that our treatment of this no-touch zone using the pectoralis major paddle flap is an easy and short surgical procedure that remains an excellent alternative in therapy-resistant patients suffering from hidradenitis suppurativa sternalis. Sabine Gruber, M.D. Christian Windhofer, M.D. Wolfgang Michlits, M.D. Christoph Papp, M.D. Department of Plastic and Reconstructive Surgery Hospital of the Barmherzigen Brüder Salzburg, Austria

The interpectoral fascia flap

Despite the great number of pedicled and free flaps that are available for defect and contour repair, the number of fascia flaps with an axial blood supply are sparse. Such flaps with their gliding function are mandatory, whenever coverage with very thin, well-vascularized tissue is necessary. To the currently established fascia flaps, (the temporoparietal fascia flap, the radial forearm fascia flap, the lateral arm fascia flap, and the serratus anterior fascia flap), we want to add a new fascia flap, the interpectoral fascia flap. We dissected the interpectoral fascia flap from 20 cadavers. In each of the 40 hemichests, the trunk of the thoracoacromial vessels was selectively injected with red polyurethane and the tissue containing the pectoral branches was separated from the overlying pectoralis major muscle and converted into an independent fascia flap. The maximum flap length was 13.5 cm and the maximum breadth was 10.3 cm. The length of the vascular pedicle before entering the flap was 3.9 cm +/- 1.4 cm with a range of 1.5-6.8 cm. Concerning the arc of rotation, all 40 flaps reached the posterior axillary fold, and 29 flaps (73%) reached the mandibular border. This new fascia flap has applications as pedicled and as free flap. The pedicled flap is used in the neck region, in the axillary region and as gliding tissue between the nipple-areola complex and the pectoralis major muscle. The usage of the fascia flap as a free flap has similar characteristics as the other fascia flaps.

Use of a prefabricated pectoralis major muscle flap and pedicled jejunal interposition graft for salvage esophageal reconstruction after failed gastric pull-up and colon interposition

Secondaryreconstruction after failedesophageal surgeryremains a challenging surgical problem. In circumstances when neither the stomach nor the small or large bowel is available or adequate as an esophageal replacement, skin or musculocutaneous flaps should be considered. We report a case of salvage esophageal reconstruction using a prefabricated muscle flap in combination with pedicled jejunum in a staged fashion that highlights some of the management issues in addressing this difficult clinical situation. Clinical Summary A 50-year-old man with a history of Barrett’s esophagus was found to have invasive adenocarcinoma in the distal third of his esophagus during surveillance endoscopy. He underwent en bloc esophagogastrectomy with 3-field lymph node dissection. On the fourth postoperative day ischemic necrosis of the gastric conduit developed, and the distal third of the conduit was resected. The left colic artery was sclerotic, so an isoperistaltic right colon interposition graft was used to connect the cervical esophagus to the gastric conduit remnant. Two weeks later, a right-sided empyema developed, and the colon interposition graft was found to be infarcted. The patient underwent decortication of the right lung and excision of the necrotic colon graft, and a cervical esophagostomy was created. Five months after the initial operation, the patient was referred to Massachusetts General Hospital/Harvard Medical School for an opinion on the options for esophageal reconstruction. Esophageal reconstruction was performed using a delayed, prelaminated, and tubularized pectoralis major muscle flap and pedicled jejunal interposition graft in a series of 3 staged procedures. Thefirst procedure was prelamination and delay of a right-sided pectoralis major muscle flap. A large fasciocutaneous flap was elevated to expose the entire pectoralis muscle. After the superior and lateral vascular bundles entering the pectoralis major were divided, a splitthickness skin graft from the right thigh was sutured over the entire muscle flap. The fasciocutaneous flap was then returned to the chest wall to cover the entire construct. One month later the pectoralis major flap was elevated, and the thoracoacromial vessels were divided, leaving the flap based on the internal thoracic artery perforators medially. The flap was tubularized by rolling it to create a skin-lined tube 22 cm in length. The proximal end of the tube was anastomosed to the distal cervical esophagus. The fasciocutaneous chest wall flap was advanced to cover the neoesophagus. At the distal end of the neoesophagus, the tube was sutured to the abdominal wall skin. This allowed salivary secretions to drain into an ostomy appliance affixed to the abdominal wall. Two months later a laparotomy was performed, and a Roux-en-Y jejunal segment was anastomosed to the distal end of the tubularized pectoralis major muscle flap (Figure 1). On postoperative day 7, the patient underwent a barium swallow that showed no anastomotic leaks with contrast flowing rapidly to the jejunum. The patient was able to discontinue enteral tube feedings and now is able to obtain 100% of his nutrition orally. Figure 2 shows the patient at the time of discharge from the hospital after the completed reconstruction.

Vessel‐depleted neck: Techniques for achieving microvascular reconstruction

In the neck, the recipient vessels most frequently used for microsurgical reconstruction are compromised by prior surgery and radiation. We conducted a retrospective chart review of all patients who underwent microvascular reconstruction between July 2001 and June 2005. Donor vessels, vein grafts, and flap survival were examined. Fourteen of 197 patients (7%) were identified with a vessel-depleted neck. All patients had undergone a prior neck dissection and radiation (100%) or chemoradiation (42%). Free flap revascularization was achieved using the transverse cervical artery with a vein graft and a cephalic vein (4 patients), thoracoacromial artery and cephalic vein (3 patients), internal mammary artery and vein (3 patients), and inferior thyroid artery and cephalic vein (1 case). In 3 patients, the reverse flow thoracodorsal artery and cephalic vein were used to vascularize the scapular flap. The cephalic vein, transverse cervical, internal mammary, and thoracoacromial vessels represent reliable alternatives in the vessel-depleted neck.

The Expanded Supraclavicular Flap, Prefabricated with Thoracoacromial Vessels, for Reconstruction of Postburn Anterior Cervical Contractures

Mentosternal contractures are well-known complications after burns, scald injuries, and injuries with acid or lye. These contractures may cause severe deformities that are both functionally and aesthetically crippling. Reconstruction of the neck requires the transfer of large flaps of thin, pliable skin to optimally match the texture and color of the recipient region. With the introduction of free tissue transfer, the availability of flaps for reconstruction of large neck defects has greatly increased. Unfortunately, many of these flaps are bulky and are not well matched to the thin and pliable skin of the neck. This article introduces the expanded supraclavicular flap prefabricated with the thoracoacromial vessels for reconstruction of anterior cervical contractures. Their anatomic location, length, and arc of rotation make the thoracoacromial vessels an excellent choice for prefabricating the supraclavicular skin for its subsequent interpolation into the anterior neck. Skin expansion in the donor region not only allows coverage of the larger unit of the anterior neck but also modifies the morphologic characteristics of the transferred flap through capsule formation and fatty tissue atrophy, which is beneficial for obtaining an optimal neck reconstruction.

Thoracoacromial Vessels as the Recipients for Supercharged Muscle-Sparing Transverse Rectus Abdominis Myocutaneous Flaps

We describe the use of the thoracoacromial vessels in microvascular transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction in two cases. The thoracoacromial vessels, used as recipient vessels for supercharged TRAM flaps, offer several advantages. Their location high on the anterior chest wall is ideal for anastomotic repair under the microscope and lends itself to medial placement of the TRAM flap. The thoracoacromial vessels are relatively easily exposed and are suited for microsurgical anastomosis by virtue of their caliber and topology. The dissection of these vessels takes less time than either the internal mammary or thoracodorsal systems. The location of the thoracoacromial vessels allows the flexibility of using either the ipsilateral pedicle for supercharging (deep inferior epigastric vessels on the same side as the superior epigastric pedicle) or contralateral supercharging (deep inferior epigastric vessels on the opposite side of the superior epigastric pedicle). The thoracoacromial vessels make an excellent alternative recipient for microvascular anastomosis in breast reconstruction.

The thoracoacromial vessels as recipient vessels in microsurgery: An anatomic and sonographic study

The thoracoacromial vessels as recipient vessels in microsurgery: An anatomic and sonographic study

Pectoralis Major Musculocutaneous Flap in Oropharyngeal Reconstruction: Revisited

Free tissue transfer is now favored for head and neck reconstruction following cancer resection. Its success rate is rising with the obvious advances in microsurgery. The pectoralis major musculocutaneous flap, a former workhorse in head and neck reconstruction, has been overlooked and criticized because of its seemingly high rate of complications and cosmetic inferiority, but it is still being used by many surgeons and plays an important role in head and neck reconstruction. The authors reviewed 34 pectoralis major musculocutaneous flap cases and 18 free flap cases (12 radial forearm flaps, six rectus abdominis flaps) involving oropharyngeal reconstruction. Flap necrosis, fistula formation, and operative times were compared. The pectoralis major musculocutaneous flap was elevated in true island type with maximal skeletonization of the pectoral branch of the thoracoacromial vessels. In pectoralis major musculocutaneous cases, all defects were reconstructed successfully, with only two cases of partial necrosis that were managed conservatively. Among the free flaps, two resulted in total flap loss and were subsequently replaced with pectoralis major musculocutaneous flaps. Fistula formation did not occur in any case in either group. Mean operative time for pectoralis major musculocutaneous flap preparation was 76 +/- 7 minutes; that for free flap preparation was 145 +/- 11 minutes. Technical refinements and meticulous procedures minimized necrosis of the pectoralis major musculocutaneous flap and guaranteed the success of the reconstruction. The free flap is an excellent method for oropharyngeal reconstruction, but the refined pectoralis major musculocutaneous flap can also produce acceptable results with minimal complications. In some instances, the pectoralis major musculocutaneous flap is not only an alternative to the free flap but a better choice that presents less risk to the patient.

The Thoracoacromial Vessels as Recipient Vessels in Microsurgery and Supermicrosurgery: An Anatomical and Sonographic Study

Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, Saitama, Japan Correspondence to Dr. Harashina, Department of Plastic and Reconstructive Surgery, Saitama Medical Center, Saitama Medical School, Kamoda, Kawagoe, Saitama, Japan 350-8550, [email protected], [email protected]

Medial and lateral pectoral nerves: Course and branches

During modified radical mastectomy or cosmetic surgery, denervation of the lower part of the pectoralis major frequently occurs and may reduce muscle spasm, with consequent better reconstruction of the breast. The aim of this study was to determine the relationship between the pectoral nerves and the pectoral muscles. Eight unembalmed female cadavers were dissected and vascular and radiologic studies performed. The lateral pectoral nerves showed a constant course, parallel to the thoraco-acromial vessels. They coursed for 55 +/- 7 mm inferomedially on the deep surface of pectoralis major, under its fascia. The medial pectoral nerves showed two main patterns of branching, which correlated with the extent of the costal attachments of the pectoralis minor muscles. In pattern A (56%), associated with costal attachments narrower than 6.0 cm, the nerve pierced the deep aspect of the pectoralis minor as a single trunk, ramified in the muscle, and gave some branches that appeared on the superficial aspect to enter the pectoralis major. In pattern B (44%), associated with costal attachments wider than 6.6 cm, the nerve divided before entering pectoralis minor and its branches passed through the muscle or round its lower border to reach pectoralis major. The most medial branch of the medial pectoral nerve directed to the pectoralis major muscle emerged from pectoralis minor at the third intercostal space in the midclavicular line, a mean of 10.3 cm lateral to the margin of the sternum. Knowledge of the relationship between the extent of the costal attachment of pectoralis minor and the two patterns of branching of the medial pectoral nerve may be useful when performing elective denervation of the major pectoralis muscle.

Alternative Bi-Pectoral Muscle Flaps for Postoperative Sternotomy Mediastinitis

Suppuration, mediastinitis, and disruption of median sternotomy are all rare, but nevertheless severe complications. We propose a simple mobilization of the two pectoralis major muscles for use as flaps to fill the sternal defect without the need for humeral detachment or a second cutaneous incision. These will be supplied from both the thoracoacromial vessels and the perforating arteries of the nongrafted internal mammary artery (IMA). Our technique is quick and easy, giving excellent results. Furthermore, by maintaining the perforating branches, we also preserve the nongrafted IMA.

The Thoracoacromial Vessels as Recipient Vessels in Microsurgery and Supermicrosurgery: An Anatomical and Sonographic Study

The purpose of this study was to investigate the presence and the precise course of the pectoral branch of the thoracoacromial vessels on the underside of the pectoralis major muscle by anatomical dissection and by color Doppler ultrasound. A further goal was to determine whether these vessels were suitable as recipient vessels in microsurgery and supermicrosurgery for breast reconstruction. In 18 cadavers, the pectoral branch of the thoracoacromial vessels was followed caudally until the diameter of the artery diminished to 1 mm. The same examination was carried out in 40 young female volunteers by tracing the vessel course with color Doppler ultrasound. The 1-mm cutoff point of the artery was measured with reference to the manubrium, the midsternal line, the clavicle, and the upper border of the closest rib. In addition, in the cadavers, the 2-mm cutoff point was determined. At both cutoff points, the diameter of the accompanying vein was measured. The pectoral branch of the thoracoacromial vessels with the artery and concomitant veins could be detected on all 100 undersides of the pectoralis major muscle, anatomically and sonographically. In their course from the acromial region downward, the arteries reached a diameter of 1 mm at an average of 9.9 cm from the manubrium, horizontally 9.4 cm from the midsternal line, and vertically 4.0 cm from the lower border of the clavicle. The 1-mm reference point was situated on the upper border of the third rib in 85 percent of cases. The average distance between the 1-mm and the 2-mm cutoff points was 3.5 cm. At the 1-mm cutoff point, the diameter of the vein was 0.9 mm, and at the 2-mm cutoff point, it was 1.7 mm. Because of their central position at the anterior hemithorax, these vessels are easily accessible from mastectomy incisions, even in skin-sparing mastectomies; the donor-site morbidity is negligible; and as the diameters of the vessels gradually decrease along their caudal course, the recipient site can be chosen precisely according to the length and the diameter of the donor vessels and major mismatch can be avoided. Thus, the pectoral branches of the thoracoacromial vessels are well suited as recipient vessels for (super)microsurgery and are a very promising addendum to the thoracodorsal and internal mammary vessels.

Thoracodorsal vessels as recipient vessels for the free TRAM flap in delayed breast reconstruction.

The internal mammary vessels have been recommended as the first choice recipient vessels for delayed breast reconstruction with the free TRAM flap. This approach has avoided surgery in the previously operated axilla, has required a shorter pedicle length, and has allowed for more medial placement of the TRAM tissue. Frequency of nonusable axillary vessels has been reported at 11 percent, with a 6 percent incidence of flap loss in the delayed reconstructive setting. We reviewed our experience with the thoracodorsal vessels as recipient vessels in delayed free TRAM breast reconstruction to assess more accurately the adequacy of these potential recipient vessels. All patients undergoing delayed TRAM reconstruction were reviewed. Forty-seven of 300 consecutive TRAM procedures were for planned delayed free reconstruction. In seven of the patients (15 percent), the thoracodorsal vessels were found to be inadequate for free reconstruction. A supercharged pedicled TRAM was used for reconstruction in each of these seven patients. Average operating room time was 7 hours. Mean follow-up time was 38 months. Nineteen percent of all patients developed at least one complication. Twelve percent of free TRAM patients developed a complication, whereas 57 percent of supercharged patients developed a postoperative complication. The difference in complication rates was statistically significant. The thoracodorsal vessels have provided an adequate recipient vessel in 85 percent of delayed free TRAM reconstructions, comparable to previous reports. Pedicling and supercharging the flap, in those situations in which the thoracodorsal vessels were inadequate, were associated with an increased incidence of postoperative complications. This suggests that in the delayed reconstructive setting, higher-risk patients benefit from free reconstruction over supercharged reconstructions. A second recipient vessel should be used when the thoracodorsal vessels are inadequate for planned free TRAM reconstruction. In these circumstances, we would recommend the use of the internal mammary vessels followed by the thoracoacromial vessels as reliable alternative recipient sites for delayed free TRAM reconstruction.

Placement of an Axillary Catheter in the Subpectoral Space

To the Editor: The axillary approach for continuous brachial plexus anesthesia allows the clinican to provide prolonged neural blockade. However, the appropriate catheter length that should be threaded into the sheath has not been determined. We present a case that may advise against the practice of inserting catheters far along the axillary sheath. A 30-yr-old man suffering from reflex sympathetic dystrophy of the left hand was admitted to the hospital for intermittent axillary blockade to facilitate physical therapy. After locating the pulse just distal to the axillary crease, an 18-gauge Tuohy needle was advanced over the course of the artery. The penetration of the sheath was felt as a sudden loss of resistance, 10 mL of mepivacaine 1% was injected through the needle, and a multi-orifice epidural catheter was threaded 10 cm. Paresthesias and motor weakness of the extremity developed within a few minutes. The following day, when the catheter was injected for the first time, the patient reported shooting pain over the upper chest. A neurologic examination revealed dense sensory block in the musculocutaneous and median nerve dermatomes. A computed tomographic scan with contrast at the level of the coracoid process showed the catheter entering the subpectoral space (Figure 1). Another at the level of the second rib showed the contrast between the pectoralis major and minor muscles (Figure 2). The catheter was removed without further complication.Figure 1: Computed tomography of the thorax, which illustrates the catheter entering the subpectoral space. The long arrows are pointing to the catheter (big arrowhead) and the neurovascular bundle (small arrowhead). The short arrows outline the pectoralis major (big arrows) and the serratus anterior (small arrows). * = iodine contrast, R = second rib, C = coracoid process, A = acromion.Figure 2: This image shows how the iodine contrast (*) diffuses between both pectoral muscles. The short arrows outline the pectoralis major (big arrows) and the pectoralis minor (small arrows). The long arrow is pointing to the neurovascular bundle.The subpectoral space is separated from the axilla by the clavipectoral fascia, which extends from the clavicle to the inferior axilla. This fascia is pierced solely at its superior portion, the costocoracoid membrane, by the thoracoacromial vessels and the lateral pectoral nerve. We propose that the catheter followed that route to reach the subpectoral space, consistent with the paresthesia the patient felt (stimulation of the lateral pectoral nerve) and the close proximity of the musculocutaneous and median nerves to the thoracoacromial trunk. Furthermore, Figure 1 shows the area just above the subscapularis and pectoralis minor insertions, which is consistent with the costocoracoid foramen. We emphasize that this complication could be prevented by avoiding the insertion of extreme lengths of catheters. Jose Luis de Cordoba, MD* Josep Balsells, MD* Jose Angel de Marcos, MD** Jose Bernal, MD* Departments of *Anesthesiology and **Radiology; Hospital Mutua de Terrassa; University of Barcelona; Barcelona, Spain 08030

Segmentally Split Pectoral Girdle Muscle Flaps for Chest-Wall and Intrathoracic Reconstruction

The latissimus dorsi, pectoralis major, and serratus anterior provide the principal flaps for major chest-wall and intrathoracic reconstructions. Each of these muscles shows a philogenetically preserved internal metamerism that is expressed by a segmental morphology and neurovascular supply. This segmental anatomy creates multiple independent subunits in each muscle that can be surgically split and independently used. Surgically splitting these muscles permits flap refinements such as creating two flaps from one donor muscle and leaving independent subunits in situ to preserve donor motor function after flap transfer. The latissimus dorsi has a consistent proximal bifurcation of its neurovascular supply into a medial and lateral branch that permits dividing the muscle or skin-muscle unit into two independent flaps. The pectoralis major has three segmental neurovascular subunits, the clavicular, the sternocostal, and the external. These can be surgically split and independently transferred on vascular pedicles from the thoracoacromial, internal mammary, and lateral thoracic vessels. This provides a substantial degree of donor motor preservation, as shown by the pectoralis V-Y myoplasty for mediastinal reconstruction. The serratus arterial has a highly segmental morphology with multiple subunits corresponding to each of the first nine costovertebral units; it also can be surgically split. The resultant upper and lower groups can be further subdivided if needed. These flaps provide useful intrathoracic reconstruction with a substantial degree of donor motor preservation. Such technical refinements substantially increase each flap's versatility and lessens the donor cost for thoracic reconstruction.

Anatomy of the pectoral nerves and their preservation in modified mastectomy

The upper part of the pectoralis major muscle is innervated by the medial pectoral nerve, whereas the lateral pectoral nerve supplies approximately the lower third of the muscle. The lateral pectoral nerve is closely associated with the pectoralis minor muscle, with its branches passing through or around the lateral margin of the muscle, or both. As a result, the nerve may be compromised during division, retraction or removal of the pectoralis minor muscle and during resection of the central and anterior lymph nodes. The medial pectoral nerve distributes with the thoracoacromial vessel branches, and both should be avoided during removal of the lymph nodes at the apex of the axillary space. Injury to the lateral pectoral nerve by accidental division or by evulsion produces variable postoperative atrophy, fibrosis and shortening of the lower third of the pectoralis major muscle, with limitation of shoulder motion and change in the cosmetic contour of the pectoral region of the chest. Routine removal of the pectoralis minor muscle and the lateral pectoral nerve as described by Patey and Handley during their modified mastectomy is not recommended because of the loss of innervation of the lower part of the pectoralis major muscle. The medial and lateral pectoral nerves described herein were named according to their anatomic position in the pectoral area. Furthermore, it is suggested that the use of the terms medial and lateral as applied to these pectoral nerves should denote their actual course, location and distribution and not perpetuate the confusing traditional practice of reversing the names of these nerves on the basis of their origin.