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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
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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.
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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)
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102
N. Vahidi et al.
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
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).
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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
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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.
t.me/Dr_Mouayyad_AlbtousH
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.
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106
N. Vahidi et al.
References
1. Ariyan S.The pectoralis major myocutaneous ap. A versatile ap for reconstruction in the
head and neck. Plast Reconstr Surg. 1979;63(1):73–81.
2. Erovic BM, Lercher P. Pectoralis major muscle ap. In: Manual of head and neck reconstruction using regional and free aps. Vienna: Springer; 2015. p. 129–42. https://doi.
org/10.1007/978- 3- 7091- 1172- 7_23.
3. Hueston JT, McConchie IH.A compound pectoral ap. Aust N Z J Surg. 1968;38(1):61–3.
4. Liu M, Liu W, Yang X, etal. Pectoralis major myocutaneous ap for head and neck defects in
the era of free aps: harvesting technique and indications. Sci Rep. 2017;7:46256. https://doi.
org/10.1038/srep46256.
5. Resto VA, McKenna MJ, Deschler DG.Pectoralis major ap in composite lateral skull base
defect reconstruction. Arch Otolaryngol Head Neck Surg. 2007;133(5):490–4. https://doi.
org/10.1001/archotol.133.5.490.
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Anterolateral Thigh Free Flap
AdrianA.Ong andFiyinSokoya
Introduction/History
The anterolateral thigh (ALT) ap was rst described by Song etal. and is based on
branches of the descending branch of the lateral circumex femoral artery (LCFA)
[1]. Its original description was that of a fasciocutaneous ap supplied by septocutaneous perforators; however, it has since been described as a ap with predominantly musculocutaneous perforator vessels through the vastus lateralis muscle. The
adoption of the ALT was initially slow due to concerns of unclear and unpredictable
anatomy of the vascular pedicle. However, with a better understanding of the anatomy, it is now known as a ap with a long, large-caliber vascular pedicle; and due
to the anatomic location, the ALT is amenable to a one- or two-team approach. The
ALT has gained popularity since its initial introduction and has become a workhorse
ap for the reconstruction of many types of head and neck defects, which can provide skin, fascia, muscle, or any combination of the above, with minimal donor site
morbidity. The ability to harvest a large skin paddle, and use multiple pedicles,
provides an additional advantage in reconstructing large skin defects of the face and
scalp [2].
7
A. A. Ong
Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, TX, USA
F. Sokoya (*)
Wellstar Health Systems, Atlanta, GA, USA
© 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_7
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107
108
Musculocutaneous
l
A. A. Ong and F. Sokoya
Anatomy
Arterial Anatomy
In the majority of cases, the ALT ap is supplied by the descending branch of the
LCFA, a branch of the profunda femoris artery, and travels between the rectus femoris and vastus lateralis muscles. Along its course, the descending branch of the
LCFA provides intramuscular branches to the rectus femoris muscle as well as
intramuscular branches to the vastus lateralis muscle, with one to three branches
(the “ABC system”) which then supply the skin in most cases. Figure7.1 shows a
cross-section of the thigh depicting the anatomy of the perforator vessels in the
ALT ap.
There are three types of cutaneous perforators to the ALT ap as described in the
literature [3]. In 90% of cases (type I), the cutaneous perforators originate from the
intramuscular branches of the descending branch of the LCFA.The most common
perforator (“perforator B”) is located near the midpoint between the anterior superior iliac spine and supralateral corner of the patella with the other two cutaneous
perforator vessels located approximately 5cm proximal (“perforator A”) and distal
(“perforator C”) to this point. In approximately 90% of cases, these are musculocutaneous perforators, with the remainder being septocutaneous perforators. In
approximately 5–10% of cases, the type II cutaneous perforators arise from the
transverse branch of the LCFA and have a long intramuscular course of up to 10cm.
Given the long intramuscular course, type II musculocutaneous perforators are
onerous to dissect. In the remaining 1–5% of cases, type III cutaneous perforators
Fig. 7.1 Location of septocutaneous and musculocutaneous perforators
Septocutaneous
perforator
perforator
M.vastus lateralis
LCFA
Deep femora
artery
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Type I Type II Type III
7 Anterolateral Thigh Free Flap
109
arise directly from the profunda femoris artery and travel through the rectus femoris
muscle before supplying the skin of the lateral thigh. The three types of vascular
supply to the ALT ap can be seen in Fig.7.2.
Depending on the perforator location, length of pedicle dissection, and location
of recipient vessels, the vascular pedicle averages approximately 12 cm (range
8–16cm) with a diameter of 2.1mm (range 2–2.25mm).
Venous Anatomy
Two venae comitantes typically accompany the descending branch of the LCFA
with an average diameter of 2.3mm (range 1.8–3.3mm). Due to the multiple H-type
connections between the venae comitantes, one or both venae comitantes may be
anastomosed to provide venous drainage.
Neural Anatomy
The lateral femoral cutaneous nerve (L2–L3) provides the cutaneous innervation of
the lateral thigh, and can be included with the ap for sensory reinnervation. This
nerve arises approximately 10cm below the inguinal ligament medial to the sensor
A
BB
C
Fig. 7.2 Three branching patterns of cutaneous perforators of the lateral circumference femoral artery
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B
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