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5 Reconstruction oftheLip
56. Jacobson L, Dedhia R, Kokot N, Chalian A.Scapular osteocutaneous free ap for total lower
lip and mandible reconstruction. Microsurgery. 2016;36:480–4.
57. Huang R, Blackwell KE.Microvascular reconstruction of composite defects of the mandible
and lip: aesthetic and functional considerations. Laryngoscope. 2000;110:1066–9.
58. Trignano E, Fallico N, Nitto A, Chen H-C.The treatment of composite defect of bone and soft
tissues with a combined latissimus dorsi and serratus anterior and rib free ap. Microsurgery.
2013;33:173–83.
59. Bali ZU, Ozkan B, Parspancı A, Kececi Y, Yoleri L.Reconstruction of lower lip defects with
free super-thin anterolateral thigh ap. Microsurgery. 2021;41:216–22.
60. Dougherty ME, Warden GD.A thirty-year review of oral appliances used to manage microstomia, 1972 to 2002. J Burn Care Rehabil. 2003;24:418–31; discussion 410.
61. Dougherty ME, Schwanholt CA. Thermoplastic mouth stretcher. J Burn Care Rehabil.
2001;22:S151.
62. Parsel SM, Winters RD. Commissuroplasty. Oper Tech Otolaryngol Head Neck Surg.
2020;31:33–7.
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Part II
Muscular and Musculocutaneous Flaps
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Pectoralis Major Flap
NimaVahidi, KevinQuinn, CherylYu, SeungLee,
andThomasS.Lee
Introduction
Reconstructive surgery with the pectoralis major myocutaneous ap was rst
described in 1968; however, it wasn’t until Ariyan in 1979 that its application in
head and neck reconstruction was well described [1–3]. It is now commonly used in
the reconstruction of soft tissue defects of the oral cavity, oropharynx, hypopharynx, as well as external skin defects of the face and neck. The pectoralis ap offers
both myocutaneous and myofascial ap options to support reconstruction needs.
Prior to wide-scale adoption of microvascular free tissue transfer in the 1980s,
the pectoralis myocutaneous ap was used extensively for head and neck reconstruction. It still remains a popular reconstructive option in developing nations with
a limited access to microvascular surgery and is now used selectively in developed
nations, particularly in the setting of salvage surgery or in patients without adequate
donor vessels for free ap reconstruction [4].
6
N. Vahidi · C. Yu · S. Lee · T. S. Lee (*)
Department of Otolaryngology, Virginia Commonwealth University Medical Center,
Richmond, VA, USA
e-mail: Nima.vahidi@vcuhealth.org; Cheryl.yu@vcuhealth.org; Seong.lee@vcu.edu;
Thomas.Lee@vcuhealth.org
K. Quinn
Department of Otolaryngology, Ohio State University Medical Center, Columbus, OH, USA
e-mail: Kevin.quinn@osumc.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
F. Sokoya, A. G. Vincent (eds.), Manual of Head and Neck Reconstruction,
https://doi.org/10.1007/978-3-031-65999-7_6
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N. Vahidi et al.
Anatomy
The pectoralis major muscle is situated in the upper chest and functions to rotate
and adduct the arm. It has four sites of origin which include the anterior surface of
the medial half of the clavicle, the anterior surface of the lateral half of the manubrium and sternum, the costal cartilage from the second to sixth ribs, and the aponeurosis of the external oblique muscle. From these points, the muscle bers
converge laterally toward their insertion on the humerus. The pectoralis minor muscle, which lies deep to the pectoralis major, originates from the anterior surface of
the third and fth ribs and inserts on the coracoid process of the scapula. It functions
to draw the scapula downward and forward. Typically, there is an avascular, fatty
tissue plane present between the pectoralis major and pectoralis minor within which
the motor nerve to the pectoralis major muscle is found. Deep to the pectoralis
muscles are the serratus anterior and intercostal muscles. Superolaterally, the pectoralis major muscle is bordered by the deltoid muscle.
Neurovascular Supply
The pectoralis major ap is an axial ap based on the pectoral branch of the thoracoacromial artery and vein (Fig.6.1). The thoracoacromial artery is a branch of the
axillary artery which is itself a continuation of the subclavian artery and can be
traced back to the aorta.
The thoracoacromial trunk arises from the second segment of the axillary artery
associated with the pectoralis minor muscle and has four distal branches including
the acromial, humeral, clavicular, and pectoral branches. The pectoral branch travels along the deep surface of the pectoralis major muscle (supercial to the pectoralis minor muscle) and provides the majority of its blood supply. The lateral thoracic
artery, which also arises from the second segment of the axillary artery, provides a
secondary blood supply but is often sacriced to maximize ap reach which can be
restricted by its lateral attachment. The pectoralis perforator vessels may also provide supplemental blood supply to the overlying skin.
The venous drainage of the pectoralis major mirrors the arterial supply, with
pectoral veins draining directly to the axillary vein. The cephalic vein which provides venous drainage for the upper extremities also supports the drainage of portions of the skin overlying the pectoralis muscle.
The pectoralis major muscle is innervated by the medial and lateral pectoral
nerves which arise from the brachial plexus. Additionally, the pectoralis major and
minor receive innervation from the seventh and eight cervical and rst thoracic
nerves. Of note, the motor nerve that innervates the pectoralis major muscle is often
sacriced during the harvesting process. It will appear as a nerve structure that
pierces the pectoralis minor muscle and enters the pectoralis major muscle from its
deep aspect. The denervated pectoralis major muscle will often lose signicant soft
tissue volume as a result of muscle atrophy, which can be advantageous in certain
scenarios where such loss of tissue bulk is desired. However, if this volume loss is
undesirable, such as if the ap is being used for near total glossectomy
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oral branch of
6 Pectoralis Major Flap
Clavicle
Pect
thoracoacromial
artery/vein
Pectoralis minor
muscle
Lateral thoracic
artery
Pectoralis major
muscle
Xyphoid
Fig. 6.1 Anatomical depiction of the left chest, highlighting surgical landmarks for the pectoralis
ap harvest. Halfway point along the clavicle marks the approximate location where the pectoral
branch of thoracoacromial artery and vein is located immediately deep to the pectoralis major
muscle. The pectoral branch of the thoracoacromial artery provides the primary blood supply for
the pectoralis major, while the lateral thoracic is a secondary blood vessel and is often sacriced
during ap harvest
95
reconstruction, the surgeon should consider providing additional muscle and soft
tissue bulk as in anticipation of these post-operative changes.
Advantages
– The pectoralis ap offers a single-stage reconstructive option.
– It is a relatively easy ap to harvest and offers an abundance of soft tissue volume
as well as a large skin ap for reconstruction.
– The vascular supply of the pectoralis ap is reliably identiable within a well-
established tissue plane located deep to the pectoralis major muscle.
– The tissue bulk and well-vascularized nature of the pectoralis major ap afford it
a superior ability to withstand contamination with saliva, tissue infection, or
radiation damage. It also typically lies outside the primary radiation elds for
head and neck cancer and can provide healthy, non-radiated tissues in the previ-
ously irradiated patient. Thus, it is ideal for intraoral, pharyngeal mucosal defects
in patients who are poor free ap candidates. Furthermore, it is the ap of choice
in situations where there is a potential for carotid artery injury or exposure in the
setting of a radical neck dissection with resection of sternocleidomastoid muscle.
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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
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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
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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
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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.
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