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An island flap of the pectoralis major muscle
British Joumal of Plastic Surgery (1977), 30, 161-165
AN ISLAND FLAP OF THE PECTORALIS
MAJOR MUSCLE
By ROBERTG. BROWN,M.D., WILLIAMH. FLEMING,M.D. and M. J. JURKIEWICZ, M.D. The Joseph B. Whitehead Department of Surgey (Plastic and Reconstructive and Thoracic), Emoy University School of Medicine, Atlanta, Georgia
IN repairing defects of the chest wall, one makes use of what materials are available; the various techniques and tissues used in the past have been well reviewed by Fisher and Edgerton (1976). In the present case the pectoralis major muscles were transplanted as island flaps and skin grafted. A 47-year-old man came with the ulcerated basal cell carcinoma shown in Figure I. It had been growing for IO years and particularly rapidly in the past 12 months. Tomograms of the sternum showed erosion of the entire right manubrium and the Chest X-ray was normal. A biopsy confirmed the diagnosis. right proximal sternum.
At operation the tumour was resected with wide margins (Fig. 2). The specimen included the distal 5 of the sternocleidomastoid muscles bilaterally, the proximal 4 of each clavicle, the manubrium and proximal sternum to the level of the 3rd rib. In addition, the rst, 2nd and 3rd costal cartilages were resected. The defect exposed the upper media&rum including the innominate vein, the upper pericardium, both jugular veins and the thyroid (Fig. 3). Gross and microscopic examination showed basal cell carcinoma infiltrating skeletal muscle and the periosteum of the sternum. The margins of resection were widely free of tumour. The pectoralis major muscles were sharply dissected free from the chest wall. The perforating branches of the internal mammary artery and a branch of the lateral thoracic artery entering the pectoralis major muscle laterally, were divided. The insertion of the pectoralis major muscle on the humerus was transected (Fig. 4). The thoracoacromial artery and its associated veins were preserved together with the lateral pectoral nerve. The pectoralis minor muscles were not disturbed. The right pectoralis major muscle was then placed across the bony defect and sutured in place (Fig. 5). The left muscle was advanced across the right muscle to reinforce the closure (Fig. 6). After suturing the skin to the chest wall the resulting defect was covered with meshed (3:r) split skin graft. Postoperatively the patient developed a transient left phrenic nerve palsy which cleared by the 9th postoperative day. He was discharged on the 11th postoperative day with his wound completely healed. He has remained well since and after 2 months returned to full work as a mechanic. There is only a slight flailing of the upper chest, which is not functionally significant. He has mild weakness when lifting heavy weights with his shoulders extended, although he can easily change a car tyre (Fig. 7). DISCUSSION
Ger (1966, 1976) pioneered the use of muscle flaps covered with skin grafts to close defects on the limbs and in this centre we have found the method of great value Address for reprints: Robert
G. Brown, M.D., Emory University Clinic, 1365 Clifton Road, N.E., Atlanta, Georgia 30322, USA. 161
162
BRITISH
FIG. I.
JOURNAL
OF PLASTIC
Basal cell carcinoma of
IO
SURGERY
years duration.
FIG. 2. A, The dotted line is the visible extent of the tumour, and the solid line the planned excision.
FIG. 2. B, The essential anatomy of the area.
AN ISLAND
FLAP
OF THE PECTORALIS
MAJOR
MUSCLE
163
164
BRITISH
JOURNAL
OF PLASTIC
SURGERY
FIG. 5. A and B, The right pectoralis major has been moved across the defect and sutured to the left The left pectoralis major is turned up out of the way. pectoralis minor and the intercostals. FIG, 6. A and B, The left pectoralis major brought across the right to reinforce the repair. were finally covered with a meshed split skin graft.
The muscles
(Vasconez et al., 1974; Mathes et al., 1974) and we would like to extend the concept of muscle flaps to that of a general technique applicable to defects in all areas of the body. Muscle flap use is limited only by the local anatomy and the imagination of the surgeon. REFERENCES FISHER, J. C. and EDGERTON, M. T. (1976). Chest wall reconstnrction, in “Plastic and Reconstructive Surgery of the Breast”, edited by Goldwyn, R. M., p. 485. Boston: Little, Brown and Company. Gsa, R. (1966). The operative treatment of the advanced stasis ulcer. American Journal of Surgery, III, 659. GER, R. (1976). The management of chronic ulcers of the dorsum of the foot by muscle transposition and free skin grafting. British Journal of Plastic Surgery, 29, 199.
AN ISLAND
FLAP
OF THE PECTORAL-IS
MAJOR
MUSCLE
FIG. 7. The healed result z monrhs later. MATHES, S. J., MCCRAW, J. B. and VASCONEZ,L. 0. (1974). Muscle transposition flaps for coverage of lower extremity defects. Surgical Clinics of North America, 54, 1337. VASCONEZ,L. O., BOSTWICK,J. and MCCRAW, J. (1974). Coverage of exposed bone by muscle transposition and skin grafting. Plastic and Reconstructive Surgery, 53, 526.
165
AN ISLAND FLAP OF THE PECTORALIS
MAJOR MUSCLE
By ROBERTG. BROWN,M.D., WILLIAMH. FLEMING,M.D. and M. J. JURKIEWICZ, M.D. The Joseph B. Whitehead Department of Surgey (Plastic and Reconstructive and Thoracic), Emoy University School of Medicine, Atlanta, Georgia
IN repairing defects of the chest wall, one makes use of what materials are available; the various techniques and tissues used in the past have been well reviewed by Fisher and Edgerton (1976). In the present case the pectoralis major muscles were transplanted as island flaps and skin grafted. A 47-year-old man came with the ulcerated basal cell carcinoma shown in Figure I. It had been growing for IO years and particularly rapidly in the past 12 months. Tomograms of the sternum showed erosion of the entire right manubrium and the Chest X-ray was normal. A biopsy confirmed the diagnosis. right proximal sternum.
At operation the tumour was resected with wide margins (Fig. 2). The specimen included the distal 5 of the sternocleidomastoid muscles bilaterally, the proximal 4 of each clavicle, the manubrium and proximal sternum to the level of the 3rd rib. In addition, the rst, 2nd and 3rd costal cartilages were resected. The defect exposed the upper media&rum including the innominate vein, the upper pericardium, both jugular veins and the thyroid (Fig. 3). Gross and microscopic examination showed basal cell carcinoma infiltrating skeletal muscle and the periosteum of the sternum. The margins of resection were widely free of tumour. The pectoralis major muscles were sharply dissected free from the chest wall. The perforating branches of the internal mammary artery and a branch of the lateral thoracic artery entering the pectoralis major muscle laterally, were divided. The insertion of the pectoralis major muscle on the humerus was transected (Fig. 4). The thoracoacromial artery and its associated veins were preserved together with the lateral pectoral nerve. The pectoralis minor muscles were not disturbed. The right pectoralis major muscle was then placed across the bony defect and sutured in place (Fig. 5). The left muscle was advanced across the right muscle to reinforce the closure (Fig. 6). After suturing the skin to the chest wall the resulting defect was covered with meshed (3:r) split skin graft. Postoperatively the patient developed a transient left phrenic nerve palsy which cleared by the 9th postoperative day. He was discharged on the 11th postoperative day with his wound completely healed. He has remained well since and after 2 months returned to full work as a mechanic. There is only a slight flailing of the upper chest, which is not functionally significant. He has mild weakness when lifting heavy weights with his shoulders extended, although he can easily change a car tyre (Fig. 7). DISCUSSION
Ger (1966, 1976) pioneered the use of muscle flaps covered with skin grafts to close defects on the limbs and in this centre we have found the method of great value Address for reprints: Robert
G. Brown, M.D., Emory University Clinic, 1365 Clifton Road, N.E., Atlanta, Georgia 30322, USA. 161
162
BRITISH
FIG. I.
JOURNAL
OF PLASTIC
Basal cell carcinoma of
IO
SURGERY
years duration.
FIG. 2. A, The dotted line is the visible extent of the tumour, and the solid line the planned excision.
FIG. 2. B, The essential anatomy of the area.
AN ISLAND
FLAP
OF THE PECTORALIS
MAJOR
MUSCLE
163
164
BRITISH
JOURNAL
OF PLASTIC
SURGERY
FIG. 5. A and B, The right pectoralis major has been moved across the defect and sutured to the left The left pectoralis major is turned up out of the way. pectoralis minor and the intercostals. FIG, 6. A and B, The left pectoralis major brought across the right to reinforce the repair. were finally covered with a meshed split skin graft.
The muscles
(Vasconez et al., 1974; Mathes et al., 1974) and we would like to extend the concept of muscle flaps to that of a general technique applicable to defects in all areas of the body. Muscle flap use is limited only by the local anatomy and the imagination of the surgeon. REFERENCES FISHER, J. C. and EDGERTON, M. T. (1976). Chest wall reconstnrction, in “Plastic and Reconstructive Surgery of the Breast”, edited by Goldwyn, R. M., p. 485. Boston: Little, Brown and Company. Gsa, R. (1966). The operative treatment of the advanced stasis ulcer. American Journal of Surgery, III, 659. GER, R. (1976). The management of chronic ulcers of the dorsum of the foot by muscle transposition and free skin grafting. British Journal of Plastic Surgery, 29, 199.
AN ISLAND
FLAP
OF THE PECTORAL-IS
MAJOR
MUSCLE
FIG. 7. The healed result z monrhs later. MATHES, S. J., MCCRAW, J. B. and VASCONEZ,L. 0. (1974). Muscle transposition flaps for coverage of lower extremity defects. Surgical Clinics of North America, 54, 1337. VASCONEZ,L. O., BOSTWICK,J. and MCCRAW, J. (1974). Coverage of exposed bone by muscle transposition and skin grafting. Plastic and Reconstructive Surgery, 53, 526.
165