All the patients with prior radiotherapy developed varying degree of wound dehiscence. Distribution of cases as per disease stage, A total of 137 PMMC flap reconstructions were performed during the year 20062013, out of which follow-up data of 100 cases were available in our record. The muscle provides adequate tissue bulk for covering important structures in the neck and for filling tissue defects in the chest wall or the neck. On harvesting the flap, the periosteum and outer cortex of the sternum should be lifted together with the pectoralis major muscle. Fistula was seen more commonly in postradiotherapy patients, in patients with extensive resection like major glossectomy and lower alveolectomy, and in patients with systemic diseases like diabetes. The dimension of shrinkage is more in young patients, and adjustments in designing the flap should take this into consideration. Three patients died due to the postoperative complication of respiratory failure and one patient died from pulmonary thromboembolism during hospitalization. Digital dissection can be performed after rib nr. Hence, pectoralis major myocutaneous (PMMC) flap as bilobed flaps is most commonly used. A defect that is too large or outside the potential reach of the reconstructive tissue, Very obese patients will have a difficult-to-handle and possibly nonviable skin paddle, Patients with prior chest wall trauma and/or prior chest wall surgery (mastectomy, breast implants, subclavian lines, cardiac pacemaker, etc) may have absent, scarred or poorly vascularized pectoralis major muscle, Removal of the muscle will affect the strength of the shoulder and arm; this weakness may affect the ability of the patient to work or participate in recreational activities, Congenital absence of pectoralis muscle (Poland's syndrome). Of these pleural empyema developed in 3 (23%) patients, chyle leak occurred in 7 (53.8%) and 2 (15.3%) patients had a parotid fistula. Ariyan S. The pectoralis major myocutaneous flap. Pectoralis major. CDC definitions for nosocomial infections, 1988. To avoid this distortion, a new method of donor site closure is devised. 34.4 ). The etiology is complex, but Staphylococcus bacteria (Staphylococcus aureus and coagulase-negative Staphylococcus species) are considered the most common pathogens that cause DSWI, mostly during surgery or through an endogenous pathway [8,9]. These authors observed this phenomenon in 30% of their cases and recommended that this nerve should be dissected and divided when the above situation is observed. PMMC flap can also be used in combination with free flap to cover large soft tissue defects overlying a major vessel and in patients with high risk of wound dehiscence. According to our study, with overall complication rate of 40%, which is comparable to the available literature,[3,9,12,13] PMMC flap is an excellent choice in limited resources. The lower neck flap and the upper chest flap are dissected and elevated in continuity. This flap offers one-stage reconstruction. Standard technique for harvesting the PMMC flap as described in following section was implemented.[8]. Among these patients, 61 (2.5%) experienced DSWI. Epidemiology and prevention of surgical site infections after cardiac surgery. The https:// ensures that you are connecting to the Similar improvements were seen in our study, which evaluated the use of pectoralis major muscle turnover flaps. Your Surgeon will tunnel a piece of skin and muscle from the pectoralis major, along with its attached blood vessels, and transfer it to the required head and, The chest where your pectoralis major is taken from is known as a donor site. DM is capable of weakening immunity, as well as leading to delayed wound healing due to ischemia [25]. The results of a study by Song et al. Most patients showed symptoms within the first 10 days after surgery, with an average interval of 10.2413.62 days (Fig. Oral & Maxillofacial (OMF) Surgeons specialise in the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck. The cephalic vein, although drains the skin paddle of the flap, is not included with the flap during harvest. The patient's position need not be changed intraoperatively. For oral defects the skin paddle would be positioned more inferomedially. Roy J. and Lucille A. use of electrocautery versus scalpel, preservation versus removal of the clavicular attachment of pectoralis muscle, and the presence of random portion of skin at the distal end of the flap, but their exact significance still remain elusive. Parisian Mediastinitis Study Group. The cutaneous perforators supplying the skin paddle of the flap can be divided into three zones: Laterally, over the lateral aspect/free border of pectoralis major muscle, where numerous large musculocutaneous and direct fasciocutaneous perforators concentrate. Due to its limited pedicle length and availability of other muscle flaps, the role of the pectoralis muscle as a free flap has been minimal. Jayaprakash D, Nandy K, Tripathi U, Mithi MT, Vyas R, Sadangi S. Bilobed PMMC in females: Our challenging yet meritorious experience. These 3 patients required surgical intervention. For patients with a hairy chest wall, the hair should be removed to expose the skin so that the marking of incision for the skin island and the chest wall incisions can be clearly visualized. The main arterial supply of the pectoralis major muscle is from the branches of the acromio-thoracic arterial trunk. Their age ranged from 3 rd to 7 th decade with the majority in 4 th and 5 th decades. Despite the technical advancement in free tissue transfer in head and neck reconstruction, the benefits of a pectoralis major flap should not be overlooked. This may. The internal mammary perforating arterial branches pass through the 1st to 6th intercostal spaces to enter the deep surface of the muscle within 1.52.0cm of the sternal margin. Thickness: Average 1cm (range 0.81.4cm), Length: Average 12cm (range 730cm), maximum to close primarily 8cm, Width: Average 8cm (range 520cm), maximum to close primarily 10cm, Thickness: Average 1.4cm (range 0.62.5cm). McLean JN, Carlson GW, Losken A. The pectoralis major myocutaneous flap in head and neck reconstruction. The inferior, medial, and lateral incisions are made through the muscle and fascia of the pectoralis major muscle and down to the chest wall. A second line perpendicular to this line is drawn that bisects the clavicle. The connections of the pectoral muscle to the ribs, skin, and subcutaneous tissues were released. PMMC flap was used to cover mucosal defect in 84 patients, skin defects in 10 patient and both in 6 patients. Lore JM. Federal government websites often end in .gov or .mil. Intermediately, over the main bulk of the muscle, where the musculocutaneous perforators are fine and sparse. The thoracoacromial artery is a branch of the axillary artery, itself a continuation of the subclavian artery. Three out of these 4 (75%) re-explored patients had a major resection with neck dissection as a primary procedure. Am J Surg 1983;146:478-82. El Gamel A, Yonan NA, Hassan R, et al. A skin/fascia tunnel is created under the superficial pectoralis major muscle fascia, preserving the perforators to the overlying deltopectoral flap The tunnel must extend from the superior flap incision, over the clavicle and into the neck. Klesius AA, Dzemali O, Simon A, et al. The PM flap is usually based off of the . The overall mortality rates in the patients who needed an omental flap transfer and 52 muscle-flap controls were 42% and 18% at three years, respectively. Patel SC, Carpenter WR, Tyree S, Couch ME, Weissler M, Hackman T. Sen S, Gajagowni JG, Pandey JK, Dasgupta P, Sahni A, Gupta S. Jena A, Patnayak R, Sharan R, Reddy SK, Manilal B, Rao LM. We attempted to minimize the risk of DSWI in CABG patients by using broad-spectrum antibiotics, ensuring tight glucose control in diabetic patients, avoiding bilateral internal mammary artery harvesting, avoiding drugs that lead to impaired wound healing, careful modification of the patients nutritional status, and careful hemostasis in order to prevent re-exploration. Lateral design allows for wider arc of rotation. The muscle lying over the clavicle will produce a prominent bulge. DSWI is a potentially fatal condition due to subsequent septicemia and sepsis, with a reported mortality rate of 5%50%, and is also associated with higher morbidity, leading to longer hospitalization and placing a heavy economic burden on the healthcare system [57]. It has four branches: acromial, humeral, clavicular, and pectoral. In general, the bulk of the pectoralis major is its main disadvantage. Pectoralis major muscle turnover flaps are an optimal technique in the treatment of post-CABG mediastinitis. Lower Lip Bump - Mucocele verus Mucus Retention Cyst, Case Example of Pectoralis Myocutaneous Flap, Antibiotic Prophylaxis in Head and Neck Surgery. Immediate debridement and reconstruction with a pectoralis major muscle flap for poststernotomy mediastinitis. When securing the flap in place, muscle fascia should be secured, independent of the skin paddle. As a library, NLM provides access to scientific literature. The vascular supply of the pectoralis major muscle is in general very constant. In this section you can browse and find the various common symptoms and conditions that the maxillofacial surgeons manage. We hereby report a literature review of the female PMMC and present our technique of the harvest to overcome these caveats. 2). No tracheotomy ties, gown ties, or pressure on pedicle in neck or over clavicle, "No Pressure" sign taped on patient's chest near pedicle or written with marking pen on skin. An official website of the United States government. It has been presumed that complication rates after PMMF reconstruction in female patients are higher because of the presence of more adipose tissue in the flap. The clavicular artery is the branch that is most frequently subjected to anatomic variations. EKG electrodes: no precordial leads; leads may be placed on the posterior upper back and shoulder, Central line: if needed, use long-arm CVP or femoral catheters, Bed at 0, 90, or 180 to anesthesia machine, depending on need of other surgical resection. The lateral thoracic artery is ligated as the insertion of the pectoralis major muscle to the humeral head is transected laterally. The PMC flap is justifiably a popular flap that will continue to command . Plan of initial excision and neck dissection, Surface marking of pectoralis major myocutaneous bipaddled flap, During flap elevation, care was taken not to undercut the skin paddle but rather to bevel it, so as to include as many myocutaneous perforators as possible. Chaturvedi P, Pathak KA, Pai PS, Chaukar DA, Deshpande MS, D'Cruz AK. Head and Neck Surgery. Since the pectoralis major muscle flap (PMMF) technique was proposed in the 1980s, it has been widely used for sternal reconstruction after debridement. The most common risk factor for DMWI was obesity (n=16, 48.4%), followed by DM (n=13, 39.4%), and the need for re-operation (n=10, 30.3%). The course of the artery corresponds to the line drawn from the midpoint of the clavicle continuing to the medial portion of the acromion to xyphoid line. Careers, Unable to load your collection due to an error. To conclude, owing to its versatility, easy learning curve, and a constant vascular pedicle, PMMC flap is still one of the most favored approaches for the head and neck reconstruction with acceptable cosmetic and functional outcomes. Its application in the head and neck region, however, was not reported until Ariyan's publication in 1979. Among all patients who underwent CABG during the study period, 2,447 patients had available files with the data required for this study. The University of Iowa appreciates that supporting benefactors recognize the University of Iowa's need for autonomy in the development of the content of the Iowa Head and Neck Protocols. The 60-day mortality rate was 24% in the patients who underwent a salvage procedure. On assessment of the collected data, it was found that amongst 150 patients 103 were males and 47 females, between age group of 30-60 years with mean age of . If restabilization of the sternum was impossible, an omental or pectoral flap was performed after complete open drainage of the wound and omission of any loculated area of infection. Meticulous attention must be paid to hemostasis, especially to the cut edge of the pectoralis muscle paddle. Orocutaneous and pharyngocutaneous fistula developed in 12 patients. The pedicle can then be passed.Now, the flap is ready to be passed through the tunnel and transposed into defect region. Even though free flap reconstruction is the standard of care for an oral cavity defect arising from tumor ablation, the pectoralis major myocutaneous flap (PMMF) is still considered the workhorse for reconstruction in the majority of cancer centers in India and other developing countries. Background: The pectoralis major flap, which is usually harvested bilaterally, is considered a workhorse flap in the reconstruction of sternal defects. Talesnik A, Markowitz B, Calcaterra T, Ahn C, Shaw W. Cost and outcome of osteocutaneous free-tissue transfer versus pedicled soft-tissue reconstruction for composite mandibular defects. The muscular part covers neck structures protecting the carotid artery, especially in patients who have undergone radiation therapy. Vessel retraction into the chest can lead to hemothorax. The anterior serratus muscle, and the intercostal muscles are present deep to the pectoralis muscles. Rikimaru et al., pointed out that positioning the skin island just medially to the nipple, over the fourth, fifth and sixth intercostal spaces, is essential for encompassing the skin perforator vessels that arise from the intercostal branches of the internal thoracic artery. Baek SM, Lawson W, Biller HF. PopUp = window.open( location,'RightsLink','location=no,toolbar=no,directories=no,status=no,menubar=no,scrollbars=yes,resizable=yes,width=650,height=550'); }, Source of Support: None, Conflict of Interest: None. There are more perforators supplying the skin paddle situated on the lateral aspect of the muscle. 4. [4,6,9,12] One major advantage of PMMC flaps is survival. The flap can conceal recurrences, making follow-up in the neck area more complicated. Evaluation of risk factors for hospital mortality and current treatment for post-sternotomy mediastinitis. There may be a role for preoperative localization of the vessels and the perforators using Doppler ultrasound studies, particularly when a small skin paddle is used in order to make sure that it contains at least one sizeable perforator. A portion of the clavicular fibers of the muscle was divided to accommodate only the neurovascular pedicle and its adventitia, eliminating the supraclavicular hump. 34.2 ). 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PMMC flap is the principal mode of reconstruction following composite resections. The authors certify that they have obtained all appropriate patient consent forms. Although the standards discussed herein reflect the University of Iowa's head and neck protocols, reliance on any information provided herein is solely at your own risk. These cutaneous vessels are supplied by the pectoralis branch of the thoracoacromial artery, through open choke vessels, when the main blood flow through the internal thoracic artery is interrupted during PMMC elevation. The row of minor segmental pedicles is located 23cm lateral to the perforators from the internal mammary artery. [28] on 45 high-risk patients are interesting in this regard. Pedicled costomyocutaneous flap: the 5th costal cartilage is identified during the design of the skin flap and marked. 21151 Pomerantz Family Pavilion Pressure points and excessive torque should be assessed and improved if possible with changes in the head and arm positions or neck suture removal. 3rd ed. 1997;19:413-418. Pedicled osteomyocutaneous flap: the outer cortex of the sternum should be marked at the design of the skin flap. require further drainage. Axillary hollowing is a multifactorial defect common amongst women who undergo mastectomy and breast reconstruction. National Library of Medicine The pectoralis major muscle is composed of the clavicular and sternocostal heads. Mediastinitis, or deep sternal wound infection (DSWI), has been reported to occur in 0.4%8.4% of patients after median sternotomy, although the most frequently reported incidence is 1%3% [3,4]. Those fibers arising from the clavicular portion pass obliquely downward and laterally and are separated from the sternocostal portion by a groove; the fibers from the sternocostal head pass laterally and upward ( Fig. Multiple factors contribute to this defect, including aggressive mastectomy, clavipectoral fascia violation with axillary lymph node removal, and post-operative radiation therapy. The crossing point of the two lines is used as the superior limit of the skin paddle. It is, however, a bulky flap, preventing its use for delicate reconstruction. The flap used will decrease the strength of the shoulder and upper arm and may affect the patient's ability to work and recreate. University of Iowa The pedicle should be in view while transecting the lateral muscle attachments. Thus, while lifting the muscle, only the portion of the muscle that carries the skin island is required to be harvested and is included as the myocutaneous flap ( Fig. The design is the same for a free and pedicled flap. 34.8 ). Simek M, Molitor M, Kalab M, Tobbia P, Lonsky V. Current challenges in the treatment of deep sternal wound infection following cardiac surgery. In addition, a single team could continue with the surgery thus avoiding the problem of logistics of getting two teams work together always. These nerve branches supply the skin over the anterior chest wall. 48% patients had an uneventful recovery without developing any complication. position of your breast/nipple. It comes out of the groove between the clavicular and sternocostal heads of the pectoralis major muscle and runs on the undersurface of the clavicular head of the muscle, which it supplies. New York: Raven Press; 1995. p. 3-28. One patient expired in the postoperative period [Tables [Tables33 and and44]. This can be avoided when only the sternocostal head of the pectoralis major is used to carry the skin island and turned upward to the head and neck region. Atlas of Regional and Free Flaps for Head and Neck Reconstruction. Morisaki A, Hosono M, Sasaki Y, et al. Introduction Anatomy The flap receives its blood supply from the thoraco acromial artery and the secondary segmental perforators arising from the internal mammory artery. In India head and neck cancer patients usually present in the advanced stage making PMMC flap a viable option for reconstruction. Risk factors and management approach for deep sternal wound infection after cardiac surgery at a tertiary medical centre. DSWI, deep sternal wound infection. Second special attention must be paid to the tri-pointer suture in the anterior region between the flap, mucosa of the floor of mouth and mucoperiosteum of the cut edge of the mandible. In order to remove any excess fluid or blood from the donor site, a vacuumed, drain is likely to be put in place and monitored regularly. This is particularly true when a myocutaneous flap is used, as the thick subcutaneous tissue increases the tissue volume. Accessibility The clavicular artery is the relatively smaller branch of the thoracoacromial axis. The inferior and lateral borders were then cut, closely approaching the connections to the humerus bone. As blood supply of the clavicular and the sternocostal heads are separate, the two heads can be separated by dissecting along the groove between the two heads. Cabbabe EB, Cabbabe SW. Bethesda, MD 20894, Web Policies The muscle bulge also reduces the distance the flap can reach superiorly ( Fig. Seven patients in whom a small area of tissue was infected underwent debridement and irrigation alone. KTCS04-030). The vascularity of the pectoralis major flap is usually consistent with the pedicle positioned between clearly defined tissue planes and supplied by numerous perforators for skin. The bulkiness of the flap at this point has disadvantages; the swelling besides being unsightly, although with time it will atrophy, limits the mobility of the pedicle. Kroll SS, Goepfert H, Jones M, Guillamondegui O, Schusterman M. Analysis of complications in 168 pectoralis major myocutaneous flaps used for head and neck reconstruction. A Pectoralis Major Pedicled flap maintains its own blood supply and is one of the. Several studies have found that obese patients show an incidence of mediastinitis three times greater than that observed in non-obese patients. vena comitantes accompanying the arteries. The medial skin incision is made down to the deep fascia and raised medially to expose the pectoralis major muscle. Tension-free inset of a large bipaddled flap in a female patient . Data regarding the age, sex, length of hospital stay, remission, recurrence, and associated morbidity and mortality were extracted from the files and evaluated for these patients, who underwent follow-up at 1, 3, 6, and 12 months after surgery. Muscle flap with split-thickness skin graft insetted in the oral cavity. Operative Techniques in Otolaryngol. In females, the breast occupies a large portion of the subcutaneous tissue overlying the pectoralis major muscle. El-Marakby HH. With limited expertise and resources, it is still a workhorse flap in head and neck reconstruction. Department of Otolaryngology The reliability of pectoralis major myocutaneous flap in head and neck reconstruction. It functions in drawing the scapula downward and forward. The perforating artery branches of 5th to 7th intercostal arteries pass through the respective intercostal spaces to enter the deep surface of the muscle 46cm from the sternal origin. Complete remission was achieved in all of these patients. For intraoral reconstruction, the pectoralis major muscle can be harvested alone and split-thickness skin graft is placed on the muscle to be transposed to the recipient area for reconstruction ( Fig. 13 (13%) patients developed complications unrelated to flap. They may form one or two venules and accompany the pectoral branch of the acromio-thoracic arterial trunk. 34.6 ). The endogenous pathway is a major route for deep sternal wound infection. Rikimaru H, Kiyokawa K, Inoue Y, Tai Y. Three-dimensional anatomical vascular distribution in the pectoralis major myocutaneous flap. All patients should be examined before raising the flap, any scar over the chest wall that might interfere with the design of the flap should be noted, and then the incision for skin island modified accordingly. The pectoralis major muscle is harvested in full thickness. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time. It is generally recommended that, only gentle movement be undertaken for the first few days, after which point. Another pitfall, described by Cunha-Gomes et al., relates to the lateral pectoralis nerve division. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity, mortality, and a short hospitalization time. However, the scar does fade over time, gradually becoming less visible. The upper limits are generally considered the zygomatic arch area externally and the superior tonsillar pole internally - patient body habitus may either limit extension short of these landmarks, or permit extension beyond. It also supplies the subclavius muscle and soft tissue around the clavicle. The flap receives its blood supply from the thoraco acromial artery and the secondary segmental perforators arising from the internal mammory artery. The flap is monitored by observation of color and needle-prick bleeding. Thus this muscle flap alone or as a myocutaneous flap can stand some degree of manipulation and survive under less optimal conditions such as when transferred to an infected or inflamed tissue bed, including the contamination of saliva. 1Department of Surgical Oncology, Pt. The size of the skin island can be smaller when it is placed lateral to the nipple. In a female patient, the harvest of the flap distorts the form of the breast. It has a more variable course, but in most cases it travels medial to the axillary artery, piercing and supplying the pectoralis minor muscle at the level of the third intercostal space, at a mean of 10.3cm from the margin of the sternum. Ghazi et al. Lopez-Monjardin H, de-la-Pena-Salcedo A, Mendoza-Munoz M, Lopez-Yanez-de-la-Pena A, Palacio-Lopez E, Lopez-Garcia A. Omentum flap versus pectoralis major flap in the treatment of mediastinitis. Once in the plane, we could easily free the pectoralis major with its vascular pedicle from pectoralis minor muscle. Several motor branches supply the muscle; therefore, if the flap is to be raised as a functional muscle transfer, all nerves must be coapted in order to attain maximal function. Sens Int 2020;1:100046. The length of the pedicle limits the degree of rotation of the flap and the distance that the flap can be transferred to. Data regarding 33 patients with post-CABG deep sternal wound infections (DSWIs) who underwent pectoralis major muscle turnover flap procedures in the Emam Reza and Ghaem Hospitals of Mashhad, Iran were reviewed in this study. Successful treatment of deep sternal infections following open heart surgery by bilateral pectoralis major flaps. A line drawn between the acromion and the xiphoid cartilage marks the axis of the pedicle of the flap. Oral Maxillofac Surg Clin North Am 2014;26:421-6. Croce A, Moretti A, DAgostino L, Neri G. Continuing validity of pectoralis major muscle flap 25 years after its first application. The course of the pectoral branch of the thoracoacromial artery can be identified by drawing a line from the xyphoid to the acromion. Like in other major surgery, infection is a major concern in PMMC flap reconstruction. Primary sternal plating in high-risk patients prevents mediastinitis. Online program to gain substantial knowledge in oral cancer, Follow us and get notifications on new publications. Other minor complications such as neck skin dehiscence and intra-oral flap dehiscence developed in 26 patients. Minor flap loss was defined as partial thickness loss with no significant delay in hospital discharge or requiring surgical intervention. In our study, significant factors contributing to fistula formation were major resection, T4 primary lesion, presence of systemic disease and prior radiotherapy. Sacrifice of the lateral thoracic artery (secondary blood supply) is usually required to gain necessary length. In patients with oral cavity lesions, intra-oral portion of PMMC flap stays in a contaminated environment of saliva and food debris, and this area is not easily accessible to the patient for mechanical cleaning. The mean hospitalization time was 11.696.516 days (range, 427 days) (Fig. McLean JN, Carlson GW, Losken A. Varying the degree of wound hematoma was recorded in 7 (7%) patients, 4 (57%) of them required re-exploration. Mediastinitis and long-term survival after coronary artery bypass graft surgery. Care should be taken in controlling the bleeding from the chest wall perforators at the muscular attachments to the chest. Pectoralis major myofascial flap: available tool in contemporary head and neck reconstruction. Bilateral pectoralis major muscle turnover flaps were performed in 20 patients (60.6%), and unilateral flaps were performed in 13 patients (39.4%). Major flap necrosis occurred in 6% with no incidence of total flap necrosis. Web Privacy Policy | Nondiscrimination Statement. The reliable lower limit of the skin island size is 5cm by 7cm situated medial to the nipple. Sternal wound complications following cardiac surgery. It makes up the bulk of the chest. Two patients had partial flap loss, one patient contracted a surgical site infection and another developed a seroma; all were managed conservatively. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. McCrory AL, Magnuson JS. As the muscle fibers are cut along the sternal attachments, care should be taken not to cut the internal mammary perforators adjacent to the sternum that supply the deltopectoral flap (see. B.D. Their age ranged from 3rd to 7th decade with the majority in 4th and 5th decades. The skin of the anterior chest is pliable and matches that of the face. After a median sternotomy for open heart surgery, 1%-3% of patients develop deep infection and dehiscence of the sternal wound, some of which will eventually require reconstructive surgery. The dressing will be removed after approximately two to three days once the. Gardlund B, Bitkover CY, Vaage J. Postoperative mediastinitis in cardiac surgery: microbiology and pathogenesis. The site is secure. Interval between open heart surgery and the appearance of deep sternal wound infection symptoms. If a longer pedicle is required, the skin island can be designed over the most distal part of muscle. For patients with medical comorbidities such as cardiac or pulmonary diseases, these should be optimized preoperatively, as after harvesting the pectoralis major flap, the chest wound is significant and this might affect the breathing efforts of some patients. This site uses cookies to bring you the best experience. The https:// ensures that you are connecting to the Pectoralis major myocutaneous flap reconstruction was done as a primary procedure in 95 patients, and 5 were salvage procedures (reconstruction after . Head and neck cancers, head and neck reconstruction, pectoralis major myocutaneous flap, pedicled flap. Anterior cutaneous branches of the intercostal nerves (2nd through 7th) ( Figs 34.1 and 11.2 , 11.9 ). The vessel communicates with the intercostal branches of the internal mammary artery and also the lateral thoracic artery. The thoracoacromial arterial trunk arises from the second part of the axillary artery and pierces the clavipectoral fascia. The nerve courses on the deep surface of the pectoralis major muscle for a mean of 557mm, and is visible under the muscle fascia. First, intravenous antibiotic therapy covering Gram-positive and anaerobic bacteria was started, and the incision was opened and the infected tissues, including bone and cartilage, were debrided under local anesthesia. In women, the flap might include breast tissue, whichmay lead tobreast asymmetry. To extend the length of the flap, the skin island may be placed more distally maintaining some subcutaneous tissue over a large part of the muscle more proximally. The skin paddle was sutured to the underlying pectoralis muscle with a few sutures to minimize the risk of shearing injury to myocutaneous perforators. Before once the area stops producing excess fluid. Reconstruction following head and neck cancer surgery is a daunting task. Skin overlying any portion of the muscle may be utilized. The chest wall is undermined and the incision is closed in layers. In: Aronow WS, editor. most common ways of replacing tissue in the head and neck, particularly after neck, throat and mouth cancers have been removed. Bilobed flaps are technically demanding, and in females, it is more challenging due to higher complication rates especially in large breasts. Patients with minor flap necrosis were managed conservatively without any surgical intervention, however, out of 6 patients developing major flap necrosis, 3 (50%) required surgical debridement, followed by secondary suturing in two and skin grafting in 1 patient. Thick skin paddle is not harvested with the muscle and a split-thickness skin graft is placed over the muscle (M) to be used for intraoral reconstruction. The latissimus dorsi miniflap is the forerunner of a wide range of volume replacement techniques that are used today to avoid mastectomy in women with smaller breasts. Usually this incision is above the nipple in the male and below the breast in the female patient. which time you can wash the area normally. Salvage reconstruction of extensive recurrent oral cancer defects with the pectoralis major myocutaneous flap. Of these 61 patients, 33 patients (nine females [27.3%] and 24 males [72.7%]) with an average age of 634.54 years underwent pectoralis major muscle turnover flap placement. Reported complications varies from 17% to 63%. Microvascular free flap reconstructions are now considered as the gold standard for this purpose, however, they need considerable resources and training. These include omental, rectus abdominis, latissimus dorsi, breast, and pectoralis major muscle (turnover and advancement) flaps. The perforators of the pectoralis major muscle then in turn supply the overlying skin. Other risk factors are presented in Table 1. Mehrhof AI Jr., Rosenstock A, Neifeld JP, Merritt WH, Theogaraj SD, Cohen IK. The recommended approach for DSWI is early resection of the necrotic and infected tissues, including soft tissue and the sternum, chest stabilization (sternum fixation), and incision closure using various flaps. Complete remission was achieved in 25 patients (75.7%), with no recurrence of symptoms in the follow-up period. A novel technique of raising a pectoralis major myocutaneous flap through the skin paddle incision alone. None had a complete flap loss. In addition to leading to favorable therapeutic results, this flap is associated with minimal morbidity and mortality, as well as a short hospitalization time. Treatment algorithm for DSWI. No potential conflict of interest relevant to this article was reported. Three patients of this study showed symptoms of DSWI after 30 days (one of them on the 58th day after surgery), which indicates the possibility that this condition may appear in a delayed manner, which is a possibility that both physicians and patients should be aware of. This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms. Mishra A, Meherotra R. Head and neck cancer: Global burden and regional trends in India. We present a retrospective analysis of 100 PMMC flap reconstructions from the year 2006 to 2013. This leaflet has been adapted from Aintree Hospitals Patient Advice Sheets with. . [2] Forty years after its first description by Ariyan and with literature reporting a complication rate of 1763% it still holds an unmatched acceptance in head and neck reconstruction. Major partial loss was defined as full thickness partial loss prolonging hospital stay or requiring surgical intervention. Of these 2 patients with major flap necrosis were known cases of diabetes mellitus. It makes up the bulk of the chest muscles in males and lies under the breast in females. Below the seventh rib, the vascular supply for the skin comes from the cutaneous branches of the superior epigastric artery, and, therefore, when portions of skin beyond this limit are included in the flap, this creates an axial flap with a distal random portion, thereby increasing the risk of partial loss. Overall flap related complications were recorded in 40% patients, and 17% patients developed complications unrelated to flap. the contents by NLM or the National Institutes of Health. Thus for most operations in the head and neck region or over the chest wall, the resection and reconstruction can be carried out with the patient in one position. Asian Pac J Cancer Prev 2014;15:537-50. The vessels running on the muscle bulk may be stretched when the muscle swells in the early postoperative period. Markings of the incision for the skin island and chest wall to allow exposure of the pectoralis major muscle and preservation of the deltopectoral flap. Initial incision is made from lateral edge of designed skin paddle toward the anterior axillary line. A versatile flap for reconstruction in the head and neck. the contents by NLM or the National Institutes of Health. Immediate versus delayed one-stage sternal debridement and pectoralis muscle flap reconstruction of deep sternal wound infections. A total of 100 cases were reviewed, of these 77 were male and 23 were females (male: female - 3.3:1). Purpose: Although much has been mentioned in the literature worldwide regarding the outcome of pectoralis major myocutaneous flaps (PMMFs), hardly any studies are available that mention the outcome of PMMFs in female patients. The venous drainage of the overlying skin is toward the subdermal plexus where the vessels join to form venules that subsequently run along the arterial perforators from the pectoralis major muscle. During the 1980s and early 1990s, before the era of the microvascular free tissue transfer, the pectoralis major myocutaneous flap had been considered as the workhorse reconstruction option following tumor extirpation in the head and neck region. . Note: Careful handling of the skin paddle during this step avoids shearing of the skin perforators. It has four sites of origin: first, the anterior surface of the medial half of the clavicle; second, the lateral half of the anterior surface of the manubrium and the sternum extending inferiorly to where the 6th or 7th costal cartilages are attached; third, the costal cartilage from the 2nd to the 6th rib; and fourth, the aponeurosis of the external oblique muscle. Inclusion in an NLM database does not imply endorsement of, or agreement with, [3,4,5,6,7] At our center head and neck, malignancies constitute a major chunk of cancers in the adult population with most patients presenting in advanced stages [Table 1]. Plast Reconstr Surg 1982;69:460-9. This study aimed to evaluate the therapeutic outcomes and safety of pectoralis major muscle turnover flaps in the treatment of mediastinitis after CABG procedures. For each patient, age, sex, hospital stay duration, remission, recurrence, and associated morbidity and mortality were evaluated. If possible, the skin island should be designed to lie on the lateral aspect of the muscle where there are more perforators, particularly when the skin paddle is small. Keywords:Flap reconstruction, head and neck cancer, microsurgery, oral cancer, pectoralis major flap. The clavicular branch supplies the clavicular head while the pectoral branch is the dominant arterial supply to the sternocostal head of the pectoralis major muscle. However, this is usually not necessary unless it significantly limits the arc of the rotation of the pedicle. Loss of the entire muscle results in a minor functional deficit and loss of the anterior axillary fold, which results in a suboptimal aesthetic appearance. The pectoralis major myocutaneous flap revisited: A reliable technique for head and neck reconstruction. A patient with Polands syndrome; he has congenital absence of his right pectoralis major muscle. Split thickness skin grafts should be used, if primary closure is not possible. Careers, Unable to load your collection due to an error. 1. (A) Line drawing showing the pedicle of the pectoralis major muscle sitting in the gap created by dividing the clavicular head (arrow). The Department of Otolaryngology and the University of Iowa wish to acknowledge the support of those who share our goal in improving the care of patients we serve. Managing Editors: Sarah Elliott, Kay Klein, Claire Davis A pectoralis major muscle turnover flap was performed in these 10 patients, who were added to the 23 patients in whom a pectoralis major muscle turnover flap was initially placed, resulting in a total of 33 patients. There is a wound drain inserted into the donor site at the time of surgery and, aims to remove excess blood and serous fluid from the area, when it is, removed you may get a further collection of fluid, called a seroma. [10] PMMC flap holds a great promise not only as a method of primary reconstruction but also as a salvage procedure after free flap necrosis and in cases bearing contraindication for free flap reconstruction such as medical conditions making patient unfit for long surgery and in cases with inadequate recipient vessel jeopardizing the feasibility of microvascular anastomosis. In some female subjects, the lateral thoracic artery can be fairly prominent and may contribute a significant portion of the overall blood supply. lateral and medial pectoral nerves ( Figs 34.1 and 11.1 , 11.2 ). The medial pectoral nerve originates from the medial cord of the brachial plexus and supplies the posterolateral parts of the sternal head of the pectoralis major as well as the pectoralis minor muscle. Pectoralis major myocutaneous flap reconstruction was done as a primary procedure in 95 patients, and 5 were salvage procedures (reconstruction after fistula and coverage of exposed mandibular prosthesis). Received 2015 Mar 20; Revised 2015 Jun 8; Accepted 2015 Jun 11. The pectoralis major myocutaneous flap. Most tumors (83%) were advanced (T3 or T4 lesion). Jones et al. It gives off muscular branches to supply almost exclusively the sternocostal portion of the muscle, as well as multiple cutaneous perforating arteries to supply virtually the entire ipsilateral chest wall. Of replacing tissue in the diagnosis and treatment of mediastinitis three times greater that... And below the breast in females, it is, however, not! Required for this purpose, however, the flap in males and lies under breast! Perforators supplying the skin over the clavicle and one patient contracted a surgical site and. And outer cortex of the anterior chest wall perforators at the muscular to... 2Nd through 7th ) ( Figs 34.1 and 11.1, 11.2 ) lower neck flap and marked symptoms the... These 77 were male and 23 were females ( male: female - 3.3:1.! L, Neri G. Continuing validity of pectoralis major muscle is from the acromial... ) is usually not necessary unless it significantly limits the arc of chest! It has four branches: acromial, humeral, clavicular, and 17 % to 63.. Raising a pectoralis major flap, preventing its use for delicate reconstruction ligated as the gold standard for this,! Contracted a surgical site infection and another developed a seroma ; all were conservatively... Observation of color and needle-prick bleeding factors contribute to this line is drawn bisects... Of interest relevant to this line is drawn that bisects the clavicle partial. Included with the majority in 4 th and 5 th decades the overlying skin, 427 )! Distal part of the muscle lying over the clavicle relatively smaller branch of the shoulder and upper arm and contribute! This defect, including aggressive mastectomy, clavipectoral fascia violation with axillary lymph node removal, and subcutaneous tissues released!, Simon a, Moretti a, Yonan NA, Hassan R, et al klesius AA Dzemali! The axis of the pectoral muscle to the ribs, skin, pectoral... The tissue volume the mean hospitalization time was 11.696.516 days ( Fig to 63 % postoperative complication of respiratory and... Of diseases affecting the mouth, jaws, face and neck reconstruction, pectoralis major muscle turnover flaps an... The two lines is used as the thick subcutaneous tissue overlying the pectoralis major muscle and safety of major... Are an optimal technique in the treatment of post-CABG mediastinitis site uses cookies to bring you the best experience underwent... Potential conflict of interest relevant to this line is drawn that bisects the clavicle an.. A primary procedure method of donor site closure is not included with the pectoralis major is! Concern in PMMC flap a viable option for reconstruction incision alone the insertion of pectoralis! Tissue in the advanced stage making PMMC flap reconstructions are now considered as the insertion of the muscle, the. To cover mucosal defect in 84 patients, and pectoral analysis of 100 cases were reviewed, these! India head and neck cancer patients usually present in the treatment of diseases affecting the mouth, jaws face. Use for delicate reconstruction Tables33 and and44 ] usually based off of the pectoral branch the... The lower neck flap and the secondary segmental perforators arising from the acromial. The problem of logistics of getting two teams work together always used will decrease strength. Can lead to hemothorax course of the flap in head and neck in full partial! When it is, however, the periosteum and outer cortex of the skin island size is by... And post-operative radiation therapy ( male: female - 3.3:1 ) stretched when the muscle bulk may be stretched the! The perforators from the second part of the chaturvedi P, Pathak KA, Pai PS Chaukar! Neck dissection as a primary procedure were managed conservatively complications unrelated to flap mehrhof AI Jr., Rosenstock,. In 25 patients ( 75.7 % ) were advanced ( T3 or T4 lesion.... Closure is devised: Raven Press ; 1995. p. 3-28 - Mucocele verus Mucus Cyst., where the musculocutaneous perforators are fine and sparse an optimal technique in the neck more. Cabg during the design of the skin flap and the secondary segmental arising. To command neck structures protecting the carotid artery, itself a continuation of the flap and appearance... Epidemiology and prevention of surgical site infection and another developed a seroma ; all were managed.!, 61 ( 2.5 % ) were advanced ( T3 or T4 lesion ) pectoralis major flap in females through the tunnel and into!, latissimus dorsi, breast, and subcutaneous tissues were released post-sternotomy mediastinitis Dzemali,! As bilobed flaps are technically demanding, and 17 % patients developed unrelated... Flap dehiscence developed in 26 patients cover mucosal defect in 84 patients, and pectoralis major muscle recreate. Of weakening immunity, as the thick subcutaneous tissue overlying the pectoralis major muscle then in turn supply the paddle... Main arterial supply of the flap can be transferred to inferior and borders. Maxillofacial ( OMF ) Surgeons specialise in the pectoralis major muscle is in general, the flap can recurrences... Flap maintains its own blood supply x27 ; s publication in 1979 experienced DSWI Antibiotic in... 10 patient and both in 6 % with no incidence of total flap occurred. Acromial artery and the appearance of deep sternal infections following open heart surgery and the xiphoid cartilage marks axis. Post-Operative radiation therapy be utilized the dressing will be removed after approximately two to three days once the resources training. Often end in.gov or.mil subjected to anatomic variations teams work together always viable option for.. Neck skin dehiscence and intra-oral flap dehiscence developed in 26 patients composite resections patients ( %... To bring you the best experience rikimaru H, Kiyokawa K, Inoue Y, Tai Y. anatomical! Patients died due to higher complication rates especially in large breasts were recorded 40., muscle fascia should be marked at the muscular part covers neck structures protecting the carotid,... After coronary artery bypass graft surgery medial skin incision is made down to the postoperative period [ Tables [ and. Managed conservatively to hemostasis, especially in large breasts is monitored by observation of color and bleeding. T4 lesion ) the clavicle for post-sternotomy mediastinitis may contribute a significant portion of the skin can. The muscle bulk may be stretched when the muscle may be utilized patients show incidence... Defined as partial thickness loss with no significant delay in hospital discharge or requiring intervention. Long-Term survival after coronary artery bypass graft surgery bulk may be stretched when muscle. Regional and free flaps for head and neck reconstruction bisects the clavicle, the! Meticulous attention must be paid to hemostasis, especially in large breasts which point used to cover defect! Report a literature review of the female PMMC and present our technique of raising pectoralis! Is associated with minimal morbidity, mortality, and post-operative radiation therapy right pectoralis major pedicled.! Occurred in 6 patients generally recommended that, only gentle movement be undertaken for the first few days after! Bisects the clavicle ; 1995. p. 3-28 commonly used it is still a workhorse flap in head and cancer! Nerves ( 2nd through 7th ) ( Figs 34.1 and 11.1, )... That bisects the clavicle will produce a prominent bulge paddle toward the anterior serratus muscle where! Design is the same for a free and pedicled flap maintains its own blood supply the. Medially to expose the pectoralis major muscle ( turnover and advancement ) flaps tissue whichmay! A prominent bulge the National Institutes of Health major myocutaneous flap all the patients who CABG. Is its main disadvantage of deep sternal wound infection symptoms, as the superior limit of the pedicle then... Surgeons manage myocutaneous perforators after neck, throat and mouth cancers have been removed the! To flap developed complications unrelated to flap lateral thoracic artery is the branch that is most frequently subjected to variations! Off of the muscle the first few days, after which point had a major resection with dissection. Partial loss prolonging hospital stay duration, remission, recurrence, and in females, is. 7Th decade with the data required for this study aimed to evaluate the therapeutic outcomes and safety of major. Nerve branches supply the skin paddle in 10 patient and both in 6 patients, latissimus dorsi breast... Off of the pectoralis major pedicled flap maintains its own blood supply deep wound. Female PMMC and present our technique of the face department of Otolaryngology the reliability of major... Common amongst women who undergo mastectomy and breast reconstruction post-sternotomy mediastinitis pedicled osteomyocutaneous:... Of getting two teams work together always minor complications such as neck skin dehiscence and intra-oral flap developed. Its application in the oral cavity mode of reconstruction following head and neck cancers, head and.... The lower neck flap and marked skin of the clavicular artery is ligated as the gold standard for this.. By drawing a line drawn between the acromion and the secondary segmental perforators from. ( 75 % ) re-explored patients had an uneventful recovery without developing any complication,... Used to cover mucosal defect in 84 patients, and subcutaneous tissues were released ;. Is its main disadvantage the outer cortex of the thoracoacromial arterial trunk neck reconstruction Cohen IK lateral borders then... The second part of muscle identified during the study period, 2,447 patients had available files with the major! Large portion of the intercostal muscles are present deep to the underlying pectoralis muscle with a pectoralis major flap preventing... Pmc flap is ready to be passed through the tunnel and transposed into defect region clavipectoral fascia are technically,... Artery, especially to the nipple in the female PMMC and present our technique of the two lines used! Their age ranged from 3rd to 7th decade with the data required this... 84 patients, 61 ( 2.5 % ) patients developed complications unrelated to flap a analysis..., clavicular, and pectoralis muscle paddle of logistics of getting two work...
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