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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4479_Библиотеки_им_академика_М_И_Перельмана.pdf
96
N. Vahidi et al.
– The patient remains supine during harvesting, which allows a two-team approach
and increased efciency in the operating room.
– Depending on the ap design, the distal end of the ap can reach up to 2–3cm
above the level of the zygoma.
Disadvantages
– In women, the ap may include breast skin and underlying soft tissue which can
result in breast asymmetry and disgurement. Such deformity may require
staged breast reconstruction to further optimize cosmesis. As a result, it is best to
avoid using the pectoralis muscle ap if a skin component is required for young,
female patients. A more cosmetically acceptable donor site, such as a pedicled
latissimus ap, should be considered in this patient population.
– In men, the ap may have hair on the skin paddle which could be translocated
into unsightly areas in the head and neck region or within the oral cavity.
– Overweight patients may have excessive ap bulk which may be undesirable for
reconstruction. Additionally, the bulk of the ap may not be appropriate for small
defects.
– Translation of the pectoralis major muscle can result in diminution or loss of arm
abduction and/or rotation, which may require physical therapy to improve the
strength and function of the remaining pectoralis minor muscle.
– The limited pedicle length can prevent ap rotation into defects superior to the
zygomatic arch.
– Over time, it is common for patients to develop tethering of the neck associated
with head turning. This can be addressed by transecting the pectoralis muscle at
the level of the clavicle in a staged fashion, that is, at least 6months out from the
initial surgery, in order to give sufcient time for the skin ap to have sufcient
peripheral vascular ingrowth.
Preoperative Evaluation
Preoperative evaluation begins with a thorough history and physical examination, as
is the standard prior to any surgery. The chest should be examined for any notable
scars or defects that may interfere with ap harvest, and the presence and function
of the pectoralis muscle should be assessed by adducting the arm and palpating the
muscle. Congenital conditions such as Poland syndrome can result in the absence of
this particular muscle.
Considerations should also be made depending on the sex of the patient. Males
may have hairy chest walls which can obscure the surgical site and may require
shaving to adequately expose surgical landmarks. For females, the thickness of the
subcutaneous breast tissue or the presence of any breast implants should be noted.
If a breast implant is present on the ipsilateral side where the reconstruction is
required, the pectoralis major ap may be unreliable due to potentially compromised blood supply and also due to concern for damage to the breast implant. As
6 Pectoralis Major Flap
97
such, if a breast implant is present, it is generally best to avoid using the ipsilateral
pectoralis major ap.
The surgical site defect in the chest can result in postoperative chest pain and can
signicantly diminish forced vital capacity, which may negatively affect those
patients with cardiac or pulmonary medical conditions. Additionally, the large
donor site can present a challenge from a wound healing standpoint in those with
severe diabetes, vasculopathy, cardiopulmonary disease, or chronic tobacco use.
Flap Harvest
1. The patient is placed in a supine position, and the chest is prepared from the
midline to the clavicle superiorly and the costal margin inferiorly. Surgical
landmarks should be identied including the clavicle, ipsilateral sternum,
xiphoid process, and inferior costal margin. The surgical site should be marked
next. A line is drawn from the acromion to the xiphoid to mark the axis of the
ap. A second line is then drawn vertically from the mid-clavicle, which marks
the course of the vascular pedicle for planning purposes (Fig.6.2).
2. The skin ap is then designed along the course of the vascular pedicle and may
be designed as a curved ellipse to facilitate wound closure. The ap design can
also be placed closer to or further away from the arc of rotation, depending on
the length required to reach the tissue decit. The skin ap is typically designed
overlying the pectoralis major muscle while circumventing the nipple, though
various modications are possible (Fig.6.2).
(a) Medially Based—the placement of the skin ap medial to the nipple while
overlying the pectoralis major muscle.
(b) Laterally Based—the placement of the skin ap both superolateral and
inferolateral to the nipple (while leaving the nipple blood supply to enter
from its lateral aspect). This allows for a signicant increase in the size of
the skin ap that can be harvested. To preserve blood supply to the nipple
while maximizing the size of the ap, the soft tissue bridging the nipple
should be raised supercially to the underlying pectoralis major muscle fascia.
(c) Maximal Reach—by designing the skin ap more inferiorly along the cos-
tal margin (but not extending past it), one can increase the ap reach/size.
It is important to recognize that the distal portion of the skin ap will have
a more tenuous blood supply than the portion of the skin ap that is located
immediately supercial to the pectoralis major muscle. The deep tissue
plane along the inferior extension will be the plane contiguous from the
deep aspect of the pectoralis major muscle. This inferior extent can increase
reach to 2–3cm superior to the zygomatic arch.
(d) In women, the skin paddle should ideally be placed to include the inframa-
mmary crease, if possible, to hide the scar and optimize cosmesis (Fig.6.3).
3. Once the skin ap design has been nalized, the incision is made around the
skin paddle with the dissection carried deep until the fascia of the pectoralis
98
oral branch of
g
maximal si
N. Vahidi et al.
Pect
thoracoacromial
vessels
Lateral & medialy
based flap for
ze with
releasing incision
Fig. 6.2 Variations of pectoralis major ap design depiction. The left chest (blue incision) depicts
the surgical landmarks and course of the vascular pedicle. Also outlined are both the medial skin
ap (blue/left chest) and larger (yellow/right chest) skin ap designs. An important consideration
is that ap design can be placed closer or further away from the arc of rotation depending on the
reach and the ap size required for reconstruction. Another important consideration is nipple location and ensuring the vascular supply is not compromised with ap design. The nipple blood supply can be left intact laterally while harvesting the skin ap located medial to the nipple. Orange
line marks a releasing incision that is typically created to help with primary closure of the donor
site defect by raising skin ap from the axilla and the superior rectus region
Medially based
flap with releasin
incision
major muscle is identied. It is imperative to not violate the pectoralis major
muscle bers as the pedicle is located along the deep aspect of the muscle. Once
the supercial pectoralis major muscle fascia is identied and the skin incision
has been made circumferentially, the skin paddle can be secured to the underlying pectoralis major muscle with tacking sutures to minimize shearing injury to
the perforator vessels.
4. A releasing incision is typically created along the inferolateral aspect of the
skin ap to recruit axillary skin for the donor site closure as well as to improve
exposure during the harvesting process. Through the lateral releasing incision,
attention is turned to identifying the lateral border of the pectoralis major muscle.
5. Once the lateral border of the pectoralis major muscle is identied, a blunt dis-
section is performed to lift the pectoralis major muscle up while leaving the
pectoralis minor muscle down. In patients with a very thin or underdeveloped
pectoralis major muscle, the pectoralis minor muscle may be inadvertently
raised instead. In such a case, the progression of rib exposure indicates that an
incorrect plane has been employed. As the pectoralis major muscle is lifted, one
Pectoral branch of
6 Pectoralis Major Flap
Design around
inframammary
crease in females
with releasing
incision
99
thoracoacromial
vessels
Fig. 6.3 Flap design for female patients. The left chest demonstrates the vascular supply of the
pectoralis major ap. The right chest illustrates the location of the skin paddle incision which
should ideally be placed along the inframammary crease if possible to hide the scar and to optimize
cosmesis when possible. In young females, it is best to avoid doing a pectoralis major ap as it can
result in subjectively unacceptable breast deformity
can identify a brofatty tissue plane (appearing as “spider webs”) overlying the
pectoralis minor muscle.
In approaching the clavicle, blunt nger dissection and a long retractor can
assist in identifying a prominent vascular pedicle—the thoracoacromial vessels—running along the undersurface of the pectoralis major muscle.
6. Once the vascular pedicle has been identied, the pectoralis major muscle
should be divided with a 1–2cm cuff located both medial and lateral to the
vascular pedicle extending toward the clavicle. The pectoral branch of the thoracoacromial vessels, which runs the full length of the muscle, is preserved as
it provides the main blood supply for the ap. While the preservation of the
lateral thoracic artery allows for an additional vascular supply, it is often sacriced to optimize the rotation and reach of the ap.
100
N. Vahidi et al.
7. While dividing the pectoralis major muscle, one will encounter internal mammary perforators associated with the parasternal position of the ribs. These vessels should be clipped or tied to avoid a potential hemothorax that may occur if
the vessels retract into the chest. Sufcient release along the lateral attachment
of the pectoralis major to the humeral head is important to maximize ap reach
and minimize tension on the pedicle.
8. From the neck, a subplatysmal dissection is carried down to the clavicle. From
the chest, a subcutaneous tissue dissection immediately supercial to the pectoralis major muscle fascia is carried up to the clavicle. It is imperative to avoid
penetrating through the muscle bers while approaching the clavicle as the
pedicle will be located along their deep aspect. Once adequate superior and
inferior pockets are created, connect the two cavities while remaining supercial to the clavicle. The resulting tunnel should t at least four ngers.
9. Conrm that there is sufcient release of the pectoralis major muscle to the
level of the clavicle with the preservation of 1–2cm of muscle on either side of
the pedicle. Conrm adequate skin perfusion by pricking or cutting the distal
skin edges before passing the ap into the neck. Using an Allis clamp, gently
grasp the distal-most portion of the ap and pass it through the neck tunnel
without twisting. Do not turn the ap below the level of the clavicle but instead
ip it superiorly.
10. Once the ap is passed through the supraclavicular tunnel into the neck, start
gently reorienting the ap to allow for the skin paddle to sit in the correct location. This will minimize the risk of kinking the pedicle in the chest. Once the
ap is oriented appropriately, recheck its perfusion by pricking or cutting the
distal skin edges. If there is a decrease in perfusion following positioning of the
ap, ensure that the pedicle is not twisted and that the tunnel is adequately large
to avoid pedicle compression.
11. Proceed with Flap inset with attention to achieving watertight closure wherever
there is salivary exposure, as a salivary leak can lead to ap failure from infection. De-epithelialize any tissue that needs to be buried, as is commonly done
for oral cavity, pharyngeal, or esophageal reconstruction. One or two Jackson–
Pratt drains should be placed within the neck, with care taken to avoid pedicle
compression.
12. The previously created lateral incision along the inferolateral aspect of the skin
ap is used to recruit axillary skin, which will then be mobilized medially. The
axillary skin ap is raised within the subcutaneous tissue plane while remaining
supercial to underlying muscle fascia. An additional skin ap can also be
raised from the inferior skin edge along the costal margin extending inferiorly
and supercial to the rectus muscle.
13. The nipple is aligned to the contralateral nipple to optimize symmetry. Towel
clamps are used to mobilize the remaining superolateral chest skin toward the
medial incision. Simultaneously, the inferiorly located skin aps from the costal margin and the ipsilateral axillary skin aps are mobilized medially and
superiorly to close off the donor site defect. The vast majority of the time, primary closure is possible with the recruitment of these skin aps. If it is not
6 Pectoralis Major Flap
possible to achieve primary closure, one can consider the placement of a negative pressure dressing or other forms of delayed closure techniques along with
skin grafting. One or two Jackson–Pratt drains are placed along the inferior
aspect and the lateral (axillary region) aspect of the wound to minimize hematoma formation. The wound is then closed in two layers with absorbable buried
sutures, followed by skin closure with sutures or staples.
Important Considerations
– Generally, the superior most reach of a pectoralis major ap is the zygomatic
arch. However, by designing a skin ap that extends more inferiorly along the
costal margin and harvesting the skin ap within the same tissue plane as the
deep aspect of the pectoralis major muscle, one can increase ap reach to 2–3cm
superior to the zygomatic arch pectoralis major apzygomatic arch [5].
– When mobilizing the pectoralis major muscle from the chest to the neck, it is
imperative to avoid twisting the pedicle. The skin tunnel should be sufciently
wide to accommodate at least three to four ngers at the level of the clavicle.
More importantly, the senior author recommends ipping the pedicle vertically
over the clavicle into the neck without twisting it below the level of the clavicle.
Once the ap is in the neck (above the clavicle), create a gentle turn to the ap
pedicle to reach the desired site of reconstruction. It is best to conrm adequate
blood ow by pricking or supercially cutting the skin ap edges to ensure that
there is no obstructive kinking of the pedicle once the gentle twisting of the
pedicle has been introduced.
– It is important to consider soft tissue bulk shrinkage over time due to the dener-
vation of the muscle and resulting muscle atrophy that will follow 6 to 12months
after the reconstruction process. As such, it is important to overcompensate for
the skin ap size as well as the tissue bulk being used in reconstruction.
– The lower size limit of a skin island is considered to be 5 × 7 cm. However,
depending on the body habitus and fatty tissue thickness, the minimal skin ap
as well as the maximal skin ap size will vary greatly between patients.
101
Muscle Dimensions
– Length: 15cm (12–22cm)
– Width: 24cm (21–26cm)
– Thickness: 1cm (0.8–1.4cm)
Skin Island Dimensions
– Length: 12cm (7–30cm) [maximum size to close primarily 8 cm]
– Width: 8cm (5–20cm) [maximum size to close primarily 10 cm]
– Thickness: 1.4cm (0.6–2.5cm)
102
Blood Supply:
• Thoracoacromial Artery
– Clavicular branch: length~1cm, diameter~2mm
– Pectoral branch: length~4.5cm, diameter~2mm
• Venae Comitantes
– Primary venae comitantes accompanying artery: length ~4.5 cm,
diameter~2.1mm
N. Vahidi et al.
Flap Usage
The pectoralis myocutaneous ap or muscle can be used to reconstruct defects of
the head and neck as well as the chest in its pedicled form. The pectoralis major ap
can also be harvested as a free ap or a pedicled ap with costal cartilage, although
these reconstructive options are rarely used. The pectoralis pedicle ap described
above can reach externally to the level of the zygomatic arch and internally to the
level of the soft palate.
– Reconstruction of intraoral defects (partial glossectomy, oor of mouth or buccal
mucosa resections)
– Reconstruction of partial pharyngeal or cervical esophageal defects or pharyngo-
cutaneous stula
– Coverage of facial or neck cutaneous defects
– Coverage of major vessels in the neck following extensive ablative surgery with
missing sternocleidomastoid muscle with concern for great vessel exposure
– Providing skin and soft tissue coverage (without bone) in patients without ade-
quate donor vessels for free ap reconstruction
Case Examples
This patient had a left-sided squamous cell carcinoma of the ear with gross invasion
into the surrounding temporal scalp and external auditory canal (Fig. 6.4). He
required wide local excision of the temporal scalp, total auriculectomy with surrounding cheek and superior neck skin, supercial parotidectomy with facial nerve
dissection, and a modied radical neck dissection (Fig.6.5). This led to a large skin
defect that was closed with a pectoralis myocutaneous ap modied to reach the
superior margin of the defect, 3–4cm superior to the level of the zygomatic arch
(Figs.6.6 and 6.7).
6 Pectoralis Major Flap
Fig. 6.4 Patient case
example: This patient had
a left-sided squamous cell
carcinoma of the ear with
gross invasion into the
surrounding temporal scalp
and external auditory canal
Fig. 6.5 Patient required
wide local excision of the
temporal scalp, total
auriculectomy with
surrounding cheek and
superior neck skin,
supercial parotidectomy
with facial nerve
dissection, and a modied
radical neck dissection
103
104
Fig. 6.6 Large pectoralis
myocutaneous ap with
modication to reach
above the zygomatic arch
is obtained by raising the
distal skin ap beyond the
pectoralis major muscle by
raising the skin ap deep
to the pectoralis major
muscle
N. Vahidi et al.
6 Pectoralis Major Flap
Fig. 6.7 The pectoralis
myocutaneous ap is
rotated and inset to reach
the superior margin of the
defect, 3–4cm superior to
the level of the
zygomatic arch
105
Complications
The incidence of complete ap failure for pedicle pectoralis major ap is relatively
low at 1–2%. The most common reason for failure is the occlusion of the pedicle,
typically from inadvertent twisting during tunneling. In these instances, the pedicle
should be untwisted or repositioned if the ap is salvageable. If the ap is not salvageable, it should be removed or aggressively debrided until bright red bleeding
edges are encountered. A new ap will need to be placed to reconstruct the defect.
Occasionally, a partial necrosis of the skin paddle may occur, particularly in
intraoral reconstructions from salivary exposure. As such, it is imperative to achieve
watertight closure whenever the tissue is being placed within the oral cavity or pharynx in areas where salivary exposure is possible.
Donor-site complications are generally limited and can include scarring, keloid
formation, diminished shoulder function, or hematoma occurrence. To minimize the
risk of hematoma formation, the placement of two drains along the inferior most
and lateral (axillary region) is recommended.