Microvascular salvage of a failing pectoralis major myocutaneous flap

Summary While being elevated prior to reconstruction of a left-sided neck defect, a pectoralis major myocutaneous island flap was rendered ischemic by the inadvertant transection of the pectoral branch of the thoracoacromial artery. In order to save the flap, a microvascular repair between the distal end of this vessel and the ascending branch of the transverse cervical artery was performed. The flap was successfully revascularized and the patient went on to uneventful healing with 100% flap viability. This technique could be used following similar technical error in the elevation of any axial pattern flap providing that suitable vessels for repair were present.     

Preservation of lateral thoracic artery to improve vascular supply of distal skin without compromising pedicle length in harvesting pectoralis major myocutaneous flap.

The pectoralis major myocutaneous (PM) flap is supplied by three arterial systems. The lower chest skin of the PM flap is mainly supplied by the branches of lateral thoracic artery and internal mammary artery. The conventional harvesting technique for head and neck reconstruction utilizes single arterial supply from the pectoral branch of thoracoacromial artery. The distal skin island of PM flap is therefore compromised and requires indirect blood supply by communicating vessels. In harvesting the PM flap, the pectoralis minor muscle is divided to preserve the lateral thoracic artery and its blood supply to the lateral distal skin island of PM flap without compromising the pedicle length for head and neck reconstruction. Six PM flaps were harvested for reconstruction of head and neck defects with preservation of both the pectoral artery and lateral thoracic artery. The focal pint of swing of all six flaps was at the same point just below the mid-point of clavicle for both pectoral artery and lateral thoracic artery. The flaps can reach the oral cavity, tonsil or hypopharynx without limitation and there is no flap necrosis. In conclusion, the lateral thoracic artery can be preserved without compromising the pedicle length of PM flap. It is a recommended technique to improve the blood supply to the distal skin of PM flap.     

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.     

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.     

Outcome of Pectoralis Major Myomammary Flap for Post-mastectomy Breast Reconstruction: Extended Experience

BACKGROUND: In the past decade there has been an enormously expanding interest among rural Egyptian patients, relatives, and treating oncologists in post-mastectomy reconstruction as an integral part of patient care. We introduced our technique of pectoralis major myomammary cutaneous flap for single-stage reconstruction of large breasts, nipple, and areola. METHODS: The new technique is based on performing modified radical mastectomy in the classic manner, and then using a pectoralis major myocutaneous pedicled flap from the other side in breast reconstruction. The flap is based on the pectoral branch of the thoracoacromial artery, and a sector from the medial part of the healthy breast with its overlying skin and a part of the nipple-areola complex is included with the flap. This technique was used in our center in one 118 patients, with very promising results. RESULTS: Major flap necrosis was not observed in patients treated with this technique, and there were no local recurrences observed during the follow-up period. Excellent cosmetic results were achieved in 49 of the 118 (41.5%) cases. CONCLUSION: We recommend this new technique as a single-stage, simple solution for reconstruction of large breasts after mastectomy.     

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.     

An assessment of the anatomical basis of the thoracoacromial artery perforator flap

BACKGROUND:

Musculocutaneous perforator flaps offer advantages over musculocutaneous flaps, including reduced donor site morbidity, more predictable reconstruction of soft tissue deformities, and a wider variety of flap options. Perforator flaps are becoming increasingly popular for many applications. In the present study, we set out to examine the various perforators of the thoracoacromial axis through the pectoralis major (PM) muscle with respect to their suitability for transfer to the head and neck region as a pedicled flap.

METHODS:

A series of 10 fresh cadavers were injected with lead oxide, gelatin and water (250 mL/kg) through the femoral vessels. The cadavers were cooled and the integument was removed. Perforating vessels from the underlying muscles were marked and the resulting angiograms of the integument and deep tissues were compared with the dissection notes describing the course, size and distribution of the perforating vessels.

RESULTS:

The perforators through the PM muscle to the overlying skin included three regional groups: perforators of the thoracoacromial axis; perforators of the medial intercostal vessels; and perforators of the lateral thoracic artery. The major group of perforators supplying the overlying skin was from the intercostal vessels. However, the thoracoacromial axis did consistently give rise to perforators in the upper portion of the PM muscle. In particular, there were reliable perforators from the clavicular and deltoid branches of the thoracoacromial artery.

DISCUSSION:

The present study illustrates the potential clinical applications of a series of perforator flaps based on the thoracoacromial axis, which may be useful in head and neck reconstructive surgery.     

胸大肌肌皮瓣脂肪液化的相关危险因素探讨

目的探讨胸大肌肌皮瓣术后发生脂肪液化的相关危险因素。方法对1998年5月至2005年12月采用胸大肌肌皮瓣修复口腔癌术后组织缺损的82例中10例术后发生不同程度脂肪液化的病例,进行Logistic回归分析。结果Logistic单因素回归分析结果表明：肥胖、电刀切开皮下组织、皮岛设计低于第7肋、吸烟等因素与胸大肌肌皮瓣术后发生脂肪液化有关;Logistic多因素回归分析结果表明：胸大肌肌皮瓣术后发生脂肪液化与肥胖、电刀切开皮下组织、皮岛设计低于第7肋等因素有关,而与吸烟无关。结论肥胖、电刀切开皮下组织、皮岛设计低于第7肋等因素是胸大肌肌皮瓣术后发生脂肪液化的危险因素。     

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。     

多种区域组织瓣在口腔颌面部缺损修复中的应用分析

目的:寻找口腔颌面部缺损的理想修复方法。方法:对97例口腔颌面部缺损,根据缺损部位、性质、范围,分别采用鼻唇沟皮瓣(6例),邻位滑行皮瓣(13例),Abbe瓣(4例),胸大肌肌皮瓣(17例),颈阔肌肌皮瓣(14例),下斜方肌肌皮瓣(4例),前臂皮瓣(13例),额瓣(6例),颞肌筋膜瓣修复(6例),舌瓣(11例),腓骨肌皮瓣(3例),观察修复效果。结果:97例区域组织瓣中,胸大肌肌皮瓣坏死1例,下斜方肌肌皮瓣尖端坏死1例,另1例胸大肌皮瓣术后放疗后坏死(术后4月),其余皮瓣存活,外形基本满意。所有患者均能进食,97%能正常饮食(食饭),其余可流质饮食。舌、腭、咽、口底肿物T3以上,术后语音轻度影响。结论:采用以上多种区域组织瓣修复口腔颌面部缺损,建议应尽可能采用邻近带蒂皮瓣;对于较大缺损修复主要是修复组织缺损,采用不同组织修复缺损,对进食、语音影响似区别不大,日后尚需作深入研究。     

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.     

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.     

应用胸大肌岛状肌皮瓣重建全舌体、口底的初步报告

目的 探讨累及双侧的舌癌根治术后全舌体、口底重建的有效方法及临床评价。方法 对2000年10月至2002年12月问我科收治的7例累及双侧的舌癌患者实施根治性手术，造成全舌体、口底的大面积缺损，采用一侧胸大肌岛状肌皮瓣转移即时重建全舌体和双侧口底。结果 6例转移肌皮瓣完全成活，口腔和颈、胸部创面均一期愈合。1例肌皮瓣远端部分皮肤坏死，但无口底颌下瘘和感染等并发症发生。术后随访2～16个月，重建舌体、口底形态基本满意，语言功能大部分恢复，吞咽功能恢复良好。1例在术后9个月死于肿瘤肺转移，其余6例目前均继在。结论 胸大肌岛状肌皮瓣组织量大，血供丰富，是全舌体、口底重建的理想选择。     

Microvascular transfer of the rectus abdominis muscle and myocutaneous flap in rats

A rat microvascular free rectus myocutaneous flap model with a superior epigastric vessel pedicle is presented. The rectus muscle has a predictable ?flow-through”? axial vascular system consisting of superior and inferior epigastric vessels anastomosing under the fascial sheath, and six to seven musculocutaneous perforating branches to the skin. The superior epigastric artery and vein, averaging 0.45 mm and 0.5 mm in diameter, can be used as the vascular pedicle in muscle or myocutaneous flap transplantation. Eight muscle and 15 myocutaneous flaps were transplanted to the groin. The myocutaneous flaps averaged 3.5 cm by 1.2 cm in size; the pedicle length averaged 11 mm. The 5 day survival was 100% for muscle flaps and 67% for myocutaneous flaps. The rectus myocutaneous flap is believed to be the first true myocutaneous model in the rat. © 1993 Wiley-Liss Inc.     

带胸大肌蒂锁骨膜瓣转位治疗锁骨骨折不愈合的解剖学研究

目的为带胸大肌蒂锁骨膜瓣转位治疗锁骨骨折不愈合提供解剖学基础。方法观测10例成人上肢标本胸大肌锁骨部解剖学形态,设计带胸大肌蒂锁骨膜瓣转位治疗锁骨骨折不愈合的新术式。结果胸大肌锁骨部血供主要来自胸肩峰动脉三角肌支,进入三角肌前发出1～3支进入锁骨部,并参与锁骨骨膜血管的形成。结论胸大肌蒂锁骨的鳃剖学研究为该部位的相关手术操作提供了必要的解剖学数据。根据胸大肌锁骨部的解剖特点设计带胸大肌蒂锁骨膜瓣治疗锁骨骨折不愈合的新术式。     

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。     

Management of necrotic neck wounds with a "sandwich" pectoralis myocutaneous flap

A modified pectoralis major myocutaneous flap was used to stabilize necrotic neck wounds rapidly in irradiated patients. The flap was a "sandwich" flap that included an overlying "parasternal" pectoral skin paddle for pharyngeal reconstruction, the pectoralis muscle for carotid protection, and a meshed skin graft applied to the undersurface of the muscle to replace cervical skin. This flap has been used to reconstruct seven patients with severe wound necrosis from pharyngeal fistula and infection. All patients had carotid exposure in the infected wound. Reconstruction in all patients accomplished restoration of pharyngeal continuity, carotid protection, and cervical skin replacement. Some patients required more than one procedure for closure. There were no carotid "blowouts" in any of the patients. This technique enables the head and neck surgeon to stabilize these contaminated wounds rapidly and to reconstruct complex defects of the pharynx and cervical skin.     

MANAGEMENT OF NECROTIC NECK WOUNDS WITH A “SANDWICH” PECTORALIS MYOCUTANEOUS FLAP

A modified pectoralis major myocutaneous flap was used to stabilize necrotic neck wounds rapidly in irradiated patients. The flap was a “sandwich” flap that included an overlying “parasternal” pectoral skin paddle for pharyngeal reconstruction, the pectoralis muscle for carotid protection, and a meshed skin graft applied to the undersurface of the muscle to replace cervical skin. This flap has been used to reconstruct seven patients with severe wound necrosis from pharyngeal fistula and infection. All patients had carotid exposure in the infected wound. Reconstruction in all patients accomplished restoration of pharyngeal continuity, carotid protection, and cervical skin replacement. Some patients required more than one procedure for closure. There were no carotid “blowouts” in any of the patients. This technique enables the head and neck surgeon to stabilize these contaminated wounds rapidly and to reconstruct complex defects of the pharynx and cervical skin.