Pectoralis major myocutaneous island flap revisited: A sentinel vessel simplifying dissection

Surgical extirpation of advanced cancers of the head and neck almost always requires extensive resections that invariably necessitate some sort of large flap for reconstruction. In recent years immediate one-stage reconstruction of large defects in the area of the tonsillar fossa and the pharynx have been facilitated by the development of myocutaneous flaps, especially the pectoralis major myocutaneous flap. With this flap, immediate one-step reconstruction at the time of the initial operation is accomplished. Myocutaneous flaps, however, require more skill and concentration in their elevation than do skin flaps in order to preserve the axial feeder vessel running along the underside of the muscle and supplying the all-important perforating vessels to the overlying muscles and skin. We have noticed a constant perforating vessel, approximately 2-cm long, coming off the pectoral branch of the thoracoacromial artery medial to the cephalic vein and 2 cm below the border of the clavicle. This pierces the substance of the overlying pectoralis major muscle and runs anteriorly into the subcutaneous fatty hypodermal layer. This vessel accurately localizes the position of the proximal portion of the pectoral branch of the thoracoacromial artery before elevation of the pectoralis major muscle has been started. The imaginary line joining this vessel and the island skin flap allows simplicity in elevation of the muscle pedicle and obviates fear of transecting the arterial supply to the skin island during the dissection. We have found the vessel to be present in 26 consecutive cases over the last 12 months. We present our findings of a sentinel vessel localizing the pectoral branch of the thoracoacromial artery as a guide in liberating the muscular paddle and axial artery in elevation of pectoralis major myocutaneous island flaps.     

Closure of large orbital-maxillary defects with free latissimus dorsi myocutaneous flaps

The treatment of advanced cancer of the maxillary sinus often requires extensive ablation and orbital exenteration that results in large full-thickness defects of the upper cheek and orbital regions. Reconstruction of such defects with local flaps is usually difficult because of the need for a large flap. Several regional flaps such as the deltopectoral flap, the temporal flap, and the shoulder flap may be used, but these techniques frequently require surgery in stages and result in severe deformity of the donor site. The island pedicled, pectoralis major myocutaneous flap may be rotated up to the orbital region; however, the uncertain blood supply to the skin in the distal area of the pectoralis may cause unexpected marginal necrosis of the flap. Reconstruction of large orbital-maxillary defects can readily be accomplished in one stage using microsurgical free transfer of latissimus dorsi myocutaneous flaps. The thoracodorsal artery and vein that form the nutrient pedicle of the flap approaches 2 mm in external diameter and up to 10 cm in length, allowing greater versatility in head and neck reconstruction. The muscle may be used to fill the orbital and maxillary cavities and will accept a skin graft on its deep surface. The donor defect is closed primarily and the resulting scar is well concealed beneath the arm. If necessary, extremely large flaps may be transferred by harvesting the entire latissimus dorsi muscle and the overlying skin based on the thoracodorsal system.     

Reconstruction of complex thoracic defects with myocutaneous and muscle flaps. Applications of new flap refinements

This report describes reconstructions of complex thoracic defects with myocutaneous and muscle flaps that were modified by several recent refinements of flap design. These refinements comprise a second generation of myocutaneous and muscle flaps, which have substantially increased versatility and extended applications, as compared with the originally described flaps. These refinements include the following: (1) segmentally split latissimus dorsi and pectoralis major flaps, which transfer only one muscle segment as the flap and leave other segments of the same muscle in situ to preserve motor function; (2) pectoralis major fasciocutaneous flaps, which are extended by abdominal skin and fascia to provide longer, larger flaps; (3) reversed pectoralis major and latissimus dorsi flaps, which are supplied by secondary, distal vascular pedicles that permit flap use when the primary vascular supply is interrupted; and (4) island vascular pedicle muscle flaps, which allow intercostal passage for reconstruction of intrathoracic defects and cavities. The anatomic bases for these flap refinements are described, and the advantages provided are discussed.     

改良胸大肌肌皮瓣在晚期头颈肿瘤手术中的应用

目的探讨一种保留胸大肌功能的改良胸大肌肌皮瓣的制作方法。方法根据胸大肌肌皮瓣的解剖学特点设计皮岛，将胸大肌肌皮瓣的血管蒂完全解剖出来而不携带肌肉，使肌皮瓣成为名副其实的岛状瓣，从而完整保留了胸大肌的锁骨部分以及胸大肌外侧大部分肌纤维。结果2002至2005年采用该方法制做改良胸大肌肌皮瓣29例，其中20例修复口内缺损，4例修复颈部缺损。3例修复腮腺区缺损，2例修复下咽部缺损。术后皮瓣全部成活，随访6个月至2年，所有患者术后进食、吞咽功能良好，语言功能大多恢复良好。结论改良胸大肌肌皮瓣应用于头颈外科克服了传统的胸大肌肌皮瓣的缺点，提高了肌皮瓣血供的可靠性，最大程度地保留了胸大肌的功能和胸部的外形。     

Pectoralis major muscle: anatomical features of its arterial supply

Despite the extensive use of pectoralis major flaps in reconstructive surgery, certain pectoralis major musculocutaneous flaps may suffer from partial distal necrosis. The aim of the present study was to investigate the origin, length, and external diameter of its arterial pedicles to provide an anatomical basis for alternative techniques in reconstructive surgery. Thirty pectoral region specimens, pertaining to 14 fresh human adult cadavers and one stillbirth, were dissected, after retrograde injection of the brachial artery with red latex in pursuit of this aim. The thoracoacromial trunk (TAT) was the main nourishing vessel, arising from the first and the second parts of the axillary artery in 60% and 40%, respectively. The proximal segment was constantly supplied by the clavicular and the deltoid branches of the TAT, supplemented by its pectoral branch in 30% and the superior thoracic artery in 23.3%. The distal segment was constantly supplied by the lateral perforating branches of the anterior intercostal arteries and the perforating branches of the internal thoracic artery. The pectoral branch of both the TAT (P-TAT), and the axillary artery (PA) and the lateral thoracic artery participated in 90%, 66.7%, and 40%, respectively. Additionally, an arterial pedicle, from the arterial plexus inside the pectoralis minor muscle, was observed in 4/30 (13.3%). The clavicular and pectoral branches of the TAT are reliable pedicles for raising the proximal and distal segments of muscle flaps, respectively. The pectoral branch of axillary artery may be an alternative pedicle in the absence of P-TAT.     

Pectoralis major musculocutaneous flap with nipple-areola complex in head and neck reconstruction: preliminary results of a new modified method

Pectoralis major musculocutaneous flap remains the workhorse tool for head and neck reconstruction. Flap failure in head and neck reconstruction is a devastating complication with a high morbidity and mortality. Inclusion of nipple-areola complex on the skin paddle stabilizes the blood circulation in the skin island of the pectoralis major musculocutaneous flap. A modified use of pectoralis major musculocutaneous flap with nipple-areola complex on the skin island was performed in 11 male patients in head and neck reconstructions with success without partial or total skin island necrosis.We recommend the inclusion of nipple-areola complex on the skin island of the pectoralis major musculocutaneous flap in head and neck reconstructions to increase the blood supply of the skin paddle. We concluded that the skin island of the pectoralis major musculocutaneous flap might include the areola and nipple complex in patients with large defects of the head and neck, which stabilize the blood circulation in the skin island.     

The contralateral pectoralis muscle flap: a valuable alternative to cover chest wall tissue defects

The blood supply of the pectoralis major muscle is provided by the thoracoacromial artery and by segmental branches of the lateral thoracic artery and the internal thoracic artery. To close defects in the area of head, neck or chest, pectoralis flaps are commonly used pedicled on their major vessel. As the segmental medial vessels are capable of supplying the entire muscle, the pectoralis flap can be detached from its clavicular and acromial origin. Its main vessel is ligated and the flap can be transposed to the opposite side of the thorax to close tissue defects due to breast cancer, radiodermatitis and infectious or traumatic loss of tissue.     

以腓动脉远端穿支血管供血为蒂的小腿后外侧（复合）组织瓣的临床应用

目的探讨腓动脉穿支供血的小腿后外侧（复合）组织瓣在足踝部软组织缺损、骨感染修复中的临床效果。方法2007年3月至2010年9月,对23例足踝部软组织（跟腱）缺损及骨感染的患者,设计以腓动脉终末穿支为血管蒂,沿腓肠神经营养血管轴线切取皮瓣转位修复小腿下段及足踝部皮肤软组织缺损。采用腓动脉下段穿支供血携带腓肠神经逆行岛状（复合）皮瓣或肌皮瓣进行修复。皮瓣切取范围3cm×5cm～10cm×18cm。结果术后21例皮瓣完全成活,创面一期愈合,2例皮瓣边缘部分坏死,后经过二期扩创游离植皮后痊愈,平均住院时间21d。随访2～9个月,皮瓣质地优良,外观满意,无色素沉着、溃疡,皮瓣感觉恢复约S2,跟腱重建患者踝关节达功能位,恢复了劳动能力。结论以腓动脉远端穿支血管供血为蒂的小腿后外侧（复合）组织瓣血供可靠,变异率低,切取方便,供区隐蔽,可恢复部分感觉,且不牺牲肢体主要血管,是修复小腿中下部、踝关节周围及足部软组织缺损的一种良好方法。尤其对修复足踝部骨外露,骨髓炎,跟腱缺损,复合组织瓣（携带跟腱及肌肉）是一种较好的选择。     

胸部多源血供皮瓣在颌颈部组织缺损或畸形修复中的应用

目的 探讨颌颈部组织缺损和畸形的适宜修复方法.方法 2006年1月-2008年11月,笔者采用胸部多源血供皮瓣(含预扩张皮瓣)对18例严重颌颈部组织缺损或畸形患者进行修复,分别选取颈横动脉前皮支、胸廓内动脉肋间前穿支、胸外侧动脉作为皮瓣的血管蒂.结果 除1例患者颈横动脉前皮支岛状皮瓣远端形成小范围表皮水疱,经短期换药愈合外,其余皮瓣完全成活;颌颈部组织缺损或畸形得到了较好的修复.随访6个月～2年,患者修复处外观及功能满意,无继发畸形.结论 胸部皮瓣血供来源多而恒定,在考虑患者的主观要求、全身情况、缺损部位和范围的前提下,选择以适宜血管为蒂的胸部岛状或窄蒂皮瓣可以达到良好的修复效果.     

Cutaneous vascular anatomy of the thoracic region of the dorsum and its role in flap design in the rat.

The cutaneous vascular anatomy of the proximal one-half of the dorsum (the thoracic region) and its role in flap design was studied in the rat. The investigation included anatomical dissection, ink injection into the axial artery, and flap harvesting in live animals. Anatomical dissection and india ink injection of the thoracic region revealed that the skin derives its principal blood supply from the lateral thoracic artery. The cutaneous vascular territory of the lateral thoracic artery was defined as follows: the medial border, along the midline of the back from the level of the inferior angle of the scapula to the lower border of the last rib; the lateral border, anterior axillary line corresponding with the length of the medial border; the cephalic border, a line joining the medial and lateral border at the level of the inferior angle of the scapula; and the caudal border, a line corresponding to the lower border of the last rib. Bilateral vascular pedicle island cutaneous flaps were harvested in living rats based on the vascular territory demarcated by India ink injection. All flaps survived; hence, this flap is reliable, with consistent vascularity, and is easy to harvest, and therefore, can be used as a vascular pedicle experimental model to study flap hemodynamics.     

A one-stage flap reconstruction following resection for stomal recurrence

The pectoralis major myocutaneous island flap has been used for a one-stage reconstruction following ablative surgery for stomal recurrence. The skin island of this flap is supplied by the perforating musculature vessels of the thoracicoacromial artery. The flap can be elevated primarily and is used in a one-stage reconstruction. The new stoma is created in the center of the skin island, and the great vessels are covered by the pectoralis major muscle pedicle. The surgical technique as performed in seven successful cases is presented.     

The vascular territory of the acromiothoracic axis

The precise vascular territory and the variations of the acromio-thoracic axis were investigated in a series of 60 fresh cadavers and 50 formalin fixed specimens using dissection, ink injection and barium radiographic studies. The sternocostal portion and the clavicular head of the pectoralis major were found to have virtually independent vascular and nerve supplies. The pectoral artery supplied the former, whereas the deltoid artery nourished the latter. The dominant supply from the pectoral artery to the rib cage was found to enter around the fourth rib in the mid clavicular line. This supply is associated with a previously undescribed origin of the pectoralis major muscle in this region. The supply to the sternum was determined as indirect via the captured territory of the internal mammary system. The dominant supply to the skin from the pectoral artery arose laterally along the free lower border of the muscle as fasciocutaneous branches. The deltoid artery supplies the skin over the shoulder by numerous small branches which emerge from the intramuscular septa of the deltoid muscle. In addition a large axial artery was noted. In most cases this arose from the deltoid artery or its acromial branch and coursed laterally. It is noteworthy that the majority of skin paddles of the pectoralis major myocutaneous flap currently used in clinical practice are designed medially and inferiorly around the perimeter of the muscle and onto the rectus sheath. In these situations such flaps are not supplied directly by the pectoral artery. In fact, they are supplied indirectly by cutaneous branches belonging to the internal mammary/superior epigastric system which are captured by arterial connections with the pectoral artery. These occur predominantly in the pectoralis major muscle. Suggestions, based on these anatomical studies, are offered to improve the versatility and safety of flaps designed in this area.     

Head and neck reconstruction using lateral thigh free flap: flap design

Eleven lateral thigh free flaps were used in head and neck reconstruction, transferred on the basis of the second perforator as well as the third perforator of the profunda femoris artery. The lateral thigh free flap was useful and reliable in head and neck reconstruction and was versatile in flap design. Due to the wide cutaneous territory of the lateral thigh flap, the skin island could be designed freely in the lateral thigh region. Careful patient selection is mandatory for good results. The pinch test and an understanding of the variety of subcutaneous thicknesses in the lateral thigh region are helpful in designing a skin island of adequate thickness. Other considerations in flap design are discussed.     

腓肠肌远端岛状肌瓣修复膝和小腿上2/3软组织缺损

目的 探讨应用腓肠肌远端岛状肌瓣修复膝关节周围和小腿上2/3软组织缺损的临床效果.方法 2003年5月至2009年5月,应用腓肠肌远端岛状肌瓣修复18例膝关节周围和小腿上2/3软组织缺损,其中腓肠肌内侧头远端岛状肌瓣12例,腓肠肌外侧头6例.肌瓣表面以中厚网状皮片修复,供区直接缝合.结果 18例患者的肌瓣和其上所植皮片均成活,仅有2例术后创缘表浅感染,但经换药后逐渐愈合.术后随访8个月至4.8年,平均3.5年,供区愈合良好,仅有一纵行手术切口痕迹.患肢膝关节屈、伸与小腿内、外旋,以及足的跖屈与站立时上提足跟的肌力强度与功能,与健肢相比无明显差异,未见明显的功能障碍.受区肌瓣质地、厚薄及颜色均较好.结论 腓肠肌远端岛状肌瓣血供丰富,血管解剖恒定,血管蒂长,肌瓣较薄,适宜修复膝关节周围和小腿上2/3软组织缺损.     

Reconstruction of distal phalanx defect with microsurgical fascia latae flaps combined with rib and skin graft]

OBJECTIVE: To evaluate the clinical application of microsurgical fascia latae flaps combined with rib and skin graft for reconstruction of the distal phalanx defect. METHODS: The phalanx wounds were sutured together like syndactyly. The autologeous rib was revised to repair the bone defect of distal phalanx. The fascia latae flap was used to cover the bone exposure with microvascular anastomoses and resurfaced by a meshed split-thickness skin graft. RESULTS: 5 cases were treated successfully. The fascia latae flaps were all survived with only skin graft necrosis at the distal end in one case. It was healed spontaneously. CONCLUSIONS: The fascia latae flap is nourished by the desending branch of the lateral circumflex femoral artery. The flaps has a good blood supply and can be easily obtained with a long vascular pedicle. The flap is ideal for the reconstruction of distal phalanx defect when combined with autologeous rib implant and skin graft.     

Pectoralis Major Musculocutaneous Flap in Head and Neck Cancer Reconstruction

Described initially by Ariyan in the 1970s, the pectoralis major flap has broad acceptance for its versatility in head and neck cancer reconstructions. It is supplied by the thoracoacromial artery, with an additional circulation provided by the lateral thoracic artery. It can be safely used even in patients who have undergone postoperative radiation. The objective of this work is to analyze retrospectively the indications and results of this reconstruction technique in 17 patients with head and neck cancer. We have selected the pectoralis major flap for reconstruction of floor of the mouth and tongue (7 patients); pharyngoesophageal transit after pharyngolaryngectomy (7 patients); facial tissue repair after parotid cancer excision and reconstruction of the soft part of cervical area after skin excision during cervical dissection. Total necrosis of the flap for pharyngoesophageal reconstruction was observed in one patient. Partial loss of the skin flap with partial dehiscence occurred in four patients underwent tongue and floor of the mouth repair, but without fistulae and infection. There was donor site seroma in one patient. The flap was functionally adequate both in the reconstruction of the neopharynx and for repair of great surgical defects. So it is a versatile method with good functional results.     

A clinical experience of the supraclavicular flap used to reconstruct head and neck defects in late-stage cancer patients

The supraclavicular island flap has been widely used in head and neck reconstruction, providing an alternative to the traditional techniques like regional or free flaps, mainly because of its thin skin island tissue and reliable vascularity. Head and neck patients who require large reconstructions usually present poor clinical and healing conditions. An early experience using this flap for late-stage head and neck tumour treatment is reported. Forty-seven supraclavicular artery flaps were used to treat head and neck oncologic defects after cutaneous, intraoral and pharyngeal tumour resections. Dissection time, complications, donor and reconstructed area outcomes were assessed. The mean time for harvesting the flaps was 50?min by the senior author. All donor sites were closed primarily. Three cases of laryngopharyngectomy reconstruction developed a small controlled (salivary) leak that was resolved with conservative measures. Small or no strictures were detected on radiologic swallowing examinations and all patients regained normal swallowing function. Five patients developed donor site dehiscence. These wounds were treated with regular dressing until healing was complete. There were four distal flap necroses in this series. These necroses were debrided and closed primarily. The supraclavicular flap is pliable for head and neck oncologic reconstruction in late-stage patients. High-risk patients and modified radical neck dissection are not contraindications for its use. The absence of the need to isolate the pedicle offers quick and reliable harvesting. The arc of rotation on the base of the neck provides adequate length for pharyngeal, oral lining and to reconstruct the middle and superior third of the face.     

足部大面积皮肤软组织缺损的皮瓣修复临床分析

目的:比较足部大面积皮肤软组织缺损应用不同类型皮瓣(小腿主干血管逆行皮瓣、皮神经营养血管逆行皮瓣和游离皮瓣)修复的临床效果。方法:57例足部大面积皮肤软组织缺损的患者清创后,应用不同类型的皮瓣进行修复,并比较其成活面积、观察其疗效。其中,小腿主干血管逆行皮瓣14例,面积:7～9cm×11～20cm,平均:8cm×16cm,采用胫后动脉逆行皮瓣3例,腓动脉逆行皮瓣11例;皮神经营养血管逆行皮瓣26例,面积:7～9cm×9～15cm,平均:8cm×11cm,采用腓肠神经营养血管逆行岛状皮瓣23例,隐神经营养血管逆行岛状皮瓣3例;游离皮瓣17例,面积:9.5～15cm×12～28cm,平均:12cm×25cm,采用股前外侧皮瓣13例,隐动脉皮瓣3例,胸背动脉皮瓣1例。结果:57例皮瓣中,完全坏死2例,部分坏死7例,其余全部成活。坏死者全部涉及前足皮肤缺损,其中,主干血管逆行皮瓣完全坏死1例,部分坏死2例;皮神经营养血管逆行皮瓣远端部分坏死5例;游离皮瓣完全坏死1例。统计学分析:皮瓣面积按类型比较(ANOVA),P=0.000,差异有非常显著性意义;皮瓣成活率按类型比较(Kruskal-Wallis Test),P=0.455,差异无显著性意义。经3～18个月随访,所有成活皮瓣血运、外形、质地、功能均满意。结论:大部分足部大面积皮肤软组织缺损可选用皮神经营养血管逆行皮瓣进行修复,但如果涉及前足,特别是缺损较大时,选择游离皮瓣更为适宜。     

Reconstruction of elbow flexion in arthrogryposis multiplex congenita type I. Part I: surgical anatomy and vascular and nerve supply of the pectoralis major muscle as a basis for muscle transfer

Purpose  The anatomy and neurovascular supply of the pectoralis major muscle was studied in order to establish the safe and functional muscle transfer for the reconstruction of elbow flexion in patients with arthrogryposis multiplex congenita (AMC). Methods  Twenty pectoralis major muscles were dissected in 11 adult cadavers. The distribution of the motor end plates was studied in five pectoralis major muscles in foetuses by the detection of esterases. Results  The pectoralis major muscle consists of clavicular, manubrial, sternocostal, costal and abdominal parts. Each part has a distinct vascular and nerve supply. The motor nerves arise from the medial and lateral pectoral nerves. The motor end plates are localised in one zone in the clavicular and manubrial parts and in two oblique zones in the distal parts of the muscle. In 15 cases, each of the muscle parts were supplied by one nerve branch. In four cases, six nerves were distinguished and the clavicular part was supplied by two nerves. In one case, four nerves were found, with the clavicular and manubrial parts supplied by one common nerve. Three branches (13 cases) or two arterial branches (seven cases) supplied the muscle, arising from thoracoacromial and lateral thoracic arteries, respectively. The superior branch supplied the clavicular and manubrial parts, whereas the dominant pectoral branch supplied the manubrial, sternocostal and costal parts of the muscle. The inferior branch of the lateral thoracic artery supplied the abdominal part in 13 cases. In seven cases, the inferior branch failed and the abdominal part was supplied from the dominant branch. Conclusion  This study presents guidelines for the transfer of the distal parts of the pectoralis major muscle for the reconstruction of elbow flexion. The sternocostal, costal and abdominal parts of the muscle can be released as a unit from the chest wall after dissection between the second and third rib and be transferred to the brachium. They are sufficiently supplied from the dominant pectoral branch of the thoracoacromial artery in all cases and inconstantly from the inferior branch of the lateral thoracic artery and from three motor nerves.