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Refinements in pectus carinatum correction: the pectoralis muscle split technique
Journal of Pediatric Surgery (2008) 43, 771–774
www.elsevier.com/locate/jpedsurg
Operative techniques
Refinements in pectus carinatum correction: the pectoralis muscle split technique Anton H. Schwabegger⁎, Johannes Jeschke, Tanja Schuetz, Barbara Del Frari Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria Ludwig-Boltzmann Institute for Quality Control in Plastic and Reconstructive Surgery (Head: Univ.-Prof. H. Piza-Katzer, MD), Innsbruck Medical University, A-6020 Innsbruck, Austria
Key words: Pectus carinatum; Surgery; Pectoralis muscle splitting
Abstract Background: The standard approach for correction of pectus carinatum deformity includes elevation of the pectoralis major and rectus abdominis muscle from the sternum and adjacent ribs. A postoperative restriction of shoulder activity for several weeks is necessary to allow stable healing of the elevated muscles. To reduce postoperative immobilization, we present a modified approach to the parasternal ribs using a pectoralis muscle split technique. Methods: At each level of rib cartilage resection, the pectoralis muscle is split along the direction of its fibers instead of elevating the entire muscle as performed with the standard technique. From July 2000 to May 2007, we successfully used this technique in 33 patients with pectus carinatum deformity. Results: After the muscle split approach, patients returned to full unrestricted shoulder activity as early as 3 weeks postoperatively, compared to 6 weeks in patients treated with muscle flap elevation. Postoperative pain was reduced and the patients were discharged earlier from the hospital than following the conventional approach. Conclusions: The muscle split technique is a modified surgical approach to the parasternal ribs in patients with pectus carinatum deformity. It helps to maintain pectoralis muscle vascularization and function and can reduce postoperative pain, hospitalization, and rehabilitation period. © 2008 Elsevier Inc. All rights reserved.
The standard approach to correction of pectus carinatum (PC) deformity is well described and has been assessed in a large series of patients by Ravitch et al [1-6]. Since then, no major modifications in surgical technique have been devel-
⁎ Corresponding author. Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria. Tel.: +43 512 504 80442; fax: +43 512 504 22735. E-mail addresses: [email protected] (A.H. Schwabegger), [email protected] (J. Jeschke), [email protected] (T. Schuetz), [email protected] (B. Del Frari). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.12.066
oped. The conventional technique includes elevation of the skin, raising of pectoralis major muscle (PMM) and rectus abdominis muscle (RAM) flaps, parasternal subperichondrial cartilage resection, optional sternum osteotomy, perichondrial reefing sutures, and anatomical refixation of the muscle flaps. For 6 weeks postoperatively, the patients' physical activity is restricted at the shoulder girdle to guarantee stable muscle healing and reattachment. This may result in PMM and RAM inactivity—atrophy, reduction of shoulder joint motility, thus leads to a prolonged rehabilitation period. As an alternative to the conventional procedure, we present a modified surgical approach that includes splitting the
772
Fig. 1 Splitting the muscle along its fibers to expose the deformed rib. The fourth rib on the right is elevated with the rib dissector preserving the perichondrial sleeve.
pectoralis muscle along its fibers for exposing each individual rib without the need for muscle flap elevation. Through preservation of muscle innervation and vascularization, the technique should allow the patient to resume postoperative activity earlier compared to the standard technique.
A.H. Schwabegger et al. (age range, 13-26 years; mean age, 18 years; 25 males and 8 females) underwent corrective surgery using the Ravitch procedure but modified by the muscle split technique. The muscle split technique was selectively used in mild and moderate PC deformity in both symmetrical and asymmetrical cases. The remaining 7 patients estimated as having too extensive deformity for the muscle split approach because of potential major damage of muscle innervation thus were operated on with the conventional flap elevation technique. For 6 weeks postoperatively, all patients had to wear a custom-made “keel chest brace” with a silicone-covered front for at least 23 hours per day. The purpose of the brace was to provide additional stability and continuous immobilization and compression to the area of remodeling. The use of silicone coverage at the compression pad was intended to prevent hypertrophic scarring. Because of a low number of prior patients (before year 2000) and only few actual cases with extensive expression of deformity, which were surgically treated with the conventional muscle flap elevation technique, we are not able to provide with comparable scientific valid data between the two (muscle flap vs muscle split technique). This article may represent clinical experience only.
1.1. Surgical technique
1. Patients and methods From July 2000 to May 2007, 40 patients were operated on because of PC deformity. Of these 40 patients, 33 patients
A presternal midline incision is made and the parasternal area of the PMM surface is exposed. In 4 female patients who did not require a sternal osteotomy, a bilateral submammary incision was used. Instead of elevating the entire PMM, as
Fig. 2 Schematic drawing of the conventional correction of PC on the left compared to the muscle split technique on the right. 1 indicates elevated PMM flap with exposed ribs, cartilages already resected; 2, pectoralis major muscle left attached with muscle split exposure of the ribs (3, 4); 5, rectus abdominis muscle left attached with muscle split exposure of the ribs; 6, osteotomized sternum, refixed with bioabsorbable plates.
Refinements in pectus carinatum correction
773
2. Results
Fig. 3 Schematic depiction of the pectoralis nerves, distally coursing along muscle fibers in a metameric fashion. The parallel orientation allows longitudinal splitting of muscle for exposure of the rib cartilages without nerve transsection. 1 indicates medial pectoral nerves; 2, lateral pectoral nerves; 3, neurovascular hilus at the deep surface of the pectoralis major muscle.
performed in the conventional technique, the muscle is split along the direction of its fibers exactly above each rib needing resection (Figs. 1 and 2). The length of the muscle splitting depends on the extent of rib cartilage resection but possibly should not exceed 6 cm to preserve the segmentally orientated pectoralis muscle innervation (Fig. 3). After retraction of the muscle, the perichondrium of the rib is incised. Preserving the perichondrial sleeve, the deformed cartilage is resected. The perichondrium is then shortened and closed with bioabsorbable reefing sutures (3-0 PDS). An osteotomy of the sternum, if needed for chest remodeling, is still possible with the muscle split technique through the midline incision. After osteotomy, the sternum is stabilized with bioabsorbable plates and screws [7]. In female patients, the muscle split technique can be performed through submammary incisions leading to a favorable cosmetic result. However, a sternal osteotomy is not possible through submammary incisions in most cases. Therefore, the submammary approach is limited to patients not requiring a sternal osteotomy and is best indicated in cases where the deformity affects mainly the lower rib cartilages [7].
The surgical time required for the modified technique did not differ essentially from that needed for the conventional technique. Compared to the flap elevation technique, the muscle splitting technique seems to produce lesser blood loss because no major perforator vessels (from intercostal arteries) need to be transsected. No blood transfusion was necessary in any case. All patients were operated on by the corresponding author. The need for systemically administered analgesics could be reduced by the modified technique. Estimation of postoperative pain reduction is derived from the time (average, 2 days with the muscle split vs 3 days with flap elevation technique) the peridural catheter needed to remain in place and is derived from reduced administration of analgesics thereafter and indirectly by the earlier discharge. Because of this reduced postoperative pain and a shorter recovery period after surgery with the muscle split technique, patients could be discharged (average, 4-5 days) 2 to 3 days earlier than patients operated on by the conventional technique (average, 7 days). All patients after the muscle split technique resumed full range of passive and active motion of the upper extremities as early as 3 weeks postoperatively. In contrast to that, unrestricted activity of the shoulder was not allowed earlier than 6 weeks postoperatively following the conventional technique. There were no intra- or postoperative complications, except superficial (epidermal) skin irritation caused by inappropriate pressure from the keel brace in 2 cases. Generally, the results of PC deformity correction obtained using the modified muscle split procedure were equal to those we obtained using the conventional method. Evaluation included pre- and postoperative standardized measurements of the horizontal and vertical chest diameter using a caliper. The aesthetic result was evaluated objectively by independent surgeons and subjectively by each individual patient. Hypertrophic scarring was apparent (range of followup, 6 weeks to 36 months) in no case.
3. Discussion Although the technique of Ravitch may vary depending on the exact location of the thoracic deformity and the degree of asymmetry, it includes certain standard features. The PMM and RAM are detached from the sternum and the ribs are then reflected laterally and caudally to expose the deformed cartilages. We have modified this conventional approach by splitting the PMM and RAM fibers at each individual level of cartilage resection, which offers several advantages. In contrast to muscle flap elevation with dissection of the perforator vessels emerging from the internal mammary vessels, muscle splitting does not impair vascularization of the PMM and RAM margins. Considering
774 the neural innervation of the PMM, the muscle is supplied by the medial and lateral pectoral nerves from the medial and lateral cord of the brachial plexus. These nerves enter the muscle's deep surface rather laterally and are then course along the vessel branches in a segmental fashion. More medially, a broad dispersal of the terminal nerve branches is present with the nerve branches running parallel to the muscle fiber orientation [8-10].Thus, parallel muscle fiber dissection by gentle muscle splitting should preserve these nerve branches. Occasionally, terminal nerve branches may be visualized during the muscle splitting procedure and may gently be retracted for further rib dissection. The procedure, as long as it is limited to several centimeters, does not compromise muscle function, guarantees rapid healing of the affected muscle, and as a consequence, allows early postoperative rehabilitation. In our experience, about 6 weeks are needed for healing of osteotomized and remodeled sternum using bioabsorbable osteosynthetic implants [7]. Patients operated on with the muscle split technique could be discharged from the hospital several days earlier than those operated on in the conventional way. Furthermore, the need for systemically administered analgesics during hospitalization could be reduced. Finally, the modified technique enables patients to resume physical activity much earlier postoperatively compared to the conventional Ravitch procedure. It must be noted, however, that the muscle split windows provide a rather restricted view of the cartilages and therefore the rib cartilage dissection must be carried out with great caution to avoid damage to the pleura and lung. For the same reason, the technique is not recommended for repair of extensive PC deformities. If resection of more than 5 cartilages on one side is necessary and the deformity extends very laterally, we do not recommend using the muscle split technique secondary to potential nerve damage at several muscle segments. Furthermore, in late adolescence and/or athletic individuals, the technique might be difficult because of well-trained and thickened muscle mass. This muscle split approach is presented as a valuable and less invasive alternative to the conventional muscle flap elevation technique in correction of PC deformity. It allows a reduced hospital stay, early functional rehabilitation of the
A.H. Schwabegger et al. shoulder, and provides good aesthetic results. We recommend the technique for patients with mild to moderate PC deformity when no more than 5 ribs are needed to be resected on each side. In females, a submammary approach may be performed also with favorable aesthetic results. The muscle split technique has been developed because it was apparent that long immobilization of the shoulder girdle after pectoralis muscle flap elevation technique produces discomfort and a long rehabilitation period. That is why we have abandoned the flap elevation technique in the mild and moderate cases, but not in extensive cases, where numerous long muscle splitting would endanger the innervation of the pectoralis muscle. In our opinion and from previous experiences, the reduced period of immobilization discomfort represents a clear indication for using the muscle split technique in the mild and moderate forms of PC, although statistical valid comparative data cannot be presented.
References [1] Davis JT, Weinstein S. Repair of the pectus deformity: results of the Ravitch approach in the current era. Ann Thorac Surg 2004;78:421-6. [2] Fonkalsrud EW, Beanes S. Surgical management of pectus carinatum: 30 years' experience. World J Surg 2001;25:898-903. [3] Ravitch MM. The operative correction of pectus carinatum (pigeon breast). Ann Surg 1960;151:705-14. [4] Robicsek F, Cook JW, Daugherty HK, et al. Pectus carinatum. J Thorac Cardiovasc Surg 1979;78:52-61. [5] Robicsek F. Surgical treatment of pectus carinatum. Chest Surg Clin North Am 2000;10:357-76. [6] Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. J Pediatr Surg 1987;22:48-53. [7] Schwabegger AH, Harpf C, Ninkovic M, et al. Technical refinements in planning and surgical therapy of pectus carinatum. Chirurg 2002;73: 1191-6. [8] Manktelow RT, McKee NH, Vettese T. An anatomical study of the pectoralis major muscle as related to functioning free muscle transplantation. Plast Reconstr Surg 1980;65:610-5. [9] Morain WD, Colen LB, Hutchings JC. The segmental pectoralis major flap: a function-preserving procedure. Plast Reconstr Surg 1985;75: 825-30. [10] Tobin GR. Pectoralis major segmental anatomy and segmentally split pectoralis major flaps. Plast Reconstr Surg 1985;75:814-24.
www.elsevier.com/locate/jpedsurg
Operative techniques
Refinements in pectus carinatum correction: the pectoralis muscle split technique Anton H. Schwabegger⁎, Johannes Jeschke, Tanja Schuetz, Barbara Del Frari Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria Ludwig-Boltzmann Institute for Quality Control in Plastic and Reconstructive Surgery (Head: Univ.-Prof. H. Piza-Katzer, MD), Innsbruck Medical University, A-6020 Innsbruck, Austria
Key words: Pectus carinatum; Surgery; Pectoralis muscle splitting
Abstract Background: The standard approach for correction of pectus carinatum deformity includes elevation of the pectoralis major and rectus abdominis muscle from the sternum and adjacent ribs. A postoperative restriction of shoulder activity for several weeks is necessary to allow stable healing of the elevated muscles. To reduce postoperative immobilization, we present a modified approach to the parasternal ribs using a pectoralis muscle split technique. Methods: At each level of rib cartilage resection, the pectoralis muscle is split along the direction of its fibers instead of elevating the entire muscle as performed with the standard technique. From July 2000 to May 2007, we successfully used this technique in 33 patients with pectus carinatum deformity. Results: After the muscle split approach, patients returned to full unrestricted shoulder activity as early as 3 weeks postoperatively, compared to 6 weeks in patients treated with muscle flap elevation. Postoperative pain was reduced and the patients were discharged earlier from the hospital than following the conventional approach. Conclusions: The muscle split technique is a modified surgical approach to the parasternal ribs in patients with pectus carinatum deformity. It helps to maintain pectoralis muscle vascularization and function and can reduce postoperative pain, hospitalization, and rehabilitation period. © 2008 Elsevier Inc. All rights reserved.
The standard approach to correction of pectus carinatum (PC) deformity is well described and has been assessed in a large series of patients by Ravitch et al [1-6]. Since then, no major modifications in surgical technique have been devel-
⁎ Corresponding author. Department of Plastic and Reconstructive Surgery, Innsbruck Medical University, Anichstrasse 35, A-6020 Innsbruck, Austria. Tel.: +43 512 504 80442; fax: +43 512 504 22735. E-mail addresses: [email protected] (A.H. Schwabegger), [email protected] (J. Jeschke), [email protected] (T. Schuetz), [email protected] (B. Del Frari). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2007.12.066
oped. The conventional technique includes elevation of the skin, raising of pectoralis major muscle (PMM) and rectus abdominis muscle (RAM) flaps, parasternal subperichondrial cartilage resection, optional sternum osteotomy, perichondrial reefing sutures, and anatomical refixation of the muscle flaps. For 6 weeks postoperatively, the patients' physical activity is restricted at the shoulder girdle to guarantee stable muscle healing and reattachment. This may result in PMM and RAM inactivity—atrophy, reduction of shoulder joint motility, thus leads to a prolonged rehabilitation period. As an alternative to the conventional procedure, we present a modified surgical approach that includes splitting the
772
Fig. 1 Splitting the muscle along its fibers to expose the deformed rib. The fourth rib on the right is elevated with the rib dissector preserving the perichondrial sleeve.
pectoralis muscle along its fibers for exposing each individual rib without the need for muscle flap elevation. Through preservation of muscle innervation and vascularization, the technique should allow the patient to resume postoperative activity earlier compared to the standard technique.
A.H. Schwabegger et al. (age range, 13-26 years; mean age, 18 years; 25 males and 8 females) underwent corrective surgery using the Ravitch procedure but modified by the muscle split technique. The muscle split technique was selectively used in mild and moderate PC deformity in both symmetrical and asymmetrical cases. The remaining 7 patients estimated as having too extensive deformity for the muscle split approach because of potential major damage of muscle innervation thus were operated on with the conventional flap elevation technique. For 6 weeks postoperatively, all patients had to wear a custom-made “keel chest brace” with a silicone-covered front for at least 23 hours per day. The purpose of the brace was to provide additional stability and continuous immobilization and compression to the area of remodeling. The use of silicone coverage at the compression pad was intended to prevent hypertrophic scarring. Because of a low number of prior patients (before year 2000) and only few actual cases with extensive expression of deformity, which were surgically treated with the conventional muscle flap elevation technique, we are not able to provide with comparable scientific valid data between the two (muscle flap vs muscle split technique). This article may represent clinical experience only.
1.1. Surgical technique
1. Patients and methods From July 2000 to May 2007, 40 patients were operated on because of PC deformity. Of these 40 patients, 33 patients
A presternal midline incision is made and the parasternal area of the PMM surface is exposed. In 4 female patients who did not require a sternal osteotomy, a bilateral submammary incision was used. Instead of elevating the entire PMM, as
Fig. 2 Schematic drawing of the conventional correction of PC on the left compared to the muscle split technique on the right. 1 indicates elevated PMM flap with exposed ribs, cartilages already resected; 2, pectoralis major muscle left attached with muscle split exposure of the ribs (3, 4); 5, rectus abdominis muscle left attached with muscle split exposure of the ribs; 6, osteotomized sternum, refixed with bioabsorbable plates.
Refinements in pectus carinatum correction
773
2. Results
Fig. 3 Schematic depiction of the pectoralis nerves, distally coursing along muscle fibers in a metameric fashion. The parallel orientation allows longitudinal splitting of muscle for exposure of the rib cartilages without nerve transsection. 1 indicates medial pectoral nerves; 2, lateral pectoral nerves; 3, neurovascular hilus at the deep surface of the pectoralis major muscle.
performed in the conventional technique, the muscle is split along the direction of its fibers exactly above each rib needing resection (Figs. 1 and 2). The length of the muscle splitting depends on the extent of rib cartilage resection but possibly should not exceed 6 cm to preserve the segmentally orientated pectoralis muscle innervation (Fig. 3). After retraction of the muscle, the perichondrium of the rib is incised. Preserving the perichondrial sleeve, the deformed cartilage is resected. The perichondrium is then shortened and closed with bioabsorbable reefing sutures (3-0 PDS). An osteotomy of the sternum, if needed for chest remodeling, is still possible with the muscle split technique through the midline incision. After osteotomy, the sternum is stabilized with bioabsorbable plates and screws [7]. In female patients, the muscle split technique can be performed through submammary incisions leading to a favorable cosmetic result. However, a sternal osteotomy is not possible through submammary incisions in most cases. Therefore, the submammary approach is limited to patients not requiring a sternal osteotomy and is best indicated in cases where the deformity affects mainly the lower rib cartilages [7].
The surgical time required for the modified technique did not differ essentially from that needed for the conventional technique. Compared to the flap elevation technique, the muscle splitting technique seems to produce lesser blood loss because no major perforator vessels (from intercostal arteries) need to be transsected. No blood transfusion was necessary in any case. All patients were operated on by the corresponding author. The need for systemically administered analgesics could be reduced by the modified technique. Estimation of postoperative pain reduction is derived from the time (average, 2 days with the muscle split vs 3 days with flap elevation technique) the peridural catheter needed to remain in place and is derived from reduced administration of analgesics thereafter and indirectly by the earlier discharge. Because of this reduced postoperative pain and a shorter recovery period after surgery with the muscle split technique, patients could be discharged (average, 4-5 days) 2 to 3 days earlier than patients operated on by the conventional technique (average, 7 days). All patients after the muscle split technique resumed full range of passive and active motion of the upper extremities as early as 3 weeks postoperatively. In contrast to that, unrestricted activity of the shoulder was not allowed earlier than 6 weeks postoperatively following the conventional technique. There were no intra- or postoperative complications, except superficial (epidermal) skin irritation caused by inappropriate pressure from the keel brace in 2 cases. Generally, the results of PC deformity correction obtained using the modified muscle split procedure were equal to those we obtained using the conventional method. Evaluation included pre- and postoperative standardized measurements of the horizontal and vertical chest diameter using a caliper. The aesthetic result was evaluated objectively by independent surgeons and subjectively by each individual patient. Hypertrophic scarring was apparent (range of followup, 6 weeks to 36 months) in no case.
3. Discussion Although the technique of Ravitch may vary depending on the exact location of the thoracic deformity and the degree of asymmetry, it includes certain standard features. The PMM and RAM are detached from the sternum and the ribs are then reflected laterally and caudally to expose the deformed cartilages. We have modified this conventional approach by splitting the PMM and RAM fibers at each individual level of cartilage resection, which offers several advantages. In contrast to muscle flap elevation with dissection of the perforator vessels emerging from the internal mammary vessels, muscle splitting does not impair vascularization of the PMM and RAM margins. Considering
774 the neural innervation of the PMM, the muscle is supplied by the medial and lateral pectoral nerves from the medial and lateral cord of the brachial plexus. These nerves enter the muscle's deep surface rather laterally and are then course along the vessel branches in a segmental fashion. More medially, a broad dispersal of the terminal nerve branches is present with the nerve branches running parallel to the muscle fiber orientation [8-10].Thus, parallel muscle fiber dissection by gentle muscle splitting should preserve these nerve branches. Occasionally, terminal nerve branches may be visualized during the muscle splitting procedure and may gently be retracted for further rib dissection. The procedure, as long as it is limited to several centimeters, does not compromise muscle function, guarantees rapid healing of the affected muscle, and as a consequence, allows early postoperative rehabilitation. In our experience, about 6 weeks are needed for healing of osteotomized and remodeled sternum using bioabsorbable osteosynthetic implants [7]. Patients operated on with the muscle split technique could be discharged from the hospital several days earlier than those operated on in the conventional way. Furthermore, the need for systemically administered analgesics during hospitalization could be reduced. Finally, the modified technique enables patients to resume physical activity much earlier postoperatively compared to the conventional Ravitch procedure. It must be noted, however, that the muscle split windows provide a rather restricted view of the cartilages and therefore the rib cartilage dissection must be carried out with great caution to avoid damage to the pleura and lung. For the same reason, the technique is not recommended for repair of extensive PC deformities. If resection of more than 5 cartilages on one side is necessary and the deformity extends very laterally, we do not recommend using the muscle split technique secondary to potential nerve damage at several muscle segments. Furthermore, in late adolescence and/or athletic individuals, the technique might be difficult because of well-trained and thickened muscle mass. This muscle split approach is presented as a valuable and less invasive alternative to the conventional muscle flap elevation technique in correction of PC deformity. It allows a reduced hospital stay, early functional rehabilitation of the
A.H. Schwabegger et al. shoulder, and provides good aesthetic results. We recommend the technique for patients with mild to moderate PC deformity when no more than 5 ribs are needed to be resected on each side. In females, a submammary approach may be performed also with favorable aesthetic results. The muscle split technique has been developed because it was apparent that long immobilization of the shoulder girdle after pectoralis muscle flap elevation technique produces discomfort and a long rehabilitation period. That is why we have abandoned the flap elevation technique in the mild and moderate cases, but not in extensive cases, where numerous long muscle splitting would endanger the innervation of the pectoralis muscle. In our opinion and from previous experiences, the reduced period of immobilization discomfort represents a clear indication for using the muscle split technique in the mild and moderate forms of PC, although statistical valid comparative data cannot be presented.
References [1] Davis JT, Weinstein S. Repair of the pectus deformity: results of the Ravitch approach in the current era. Ann Thorac Surg 2004;78:421-6. [2] Fonkalsrud EW, Beanes S. Surgical management of pectus carinatum: 30 years' experience. World J Surg 2001;25:898-903. [3] Ravitch MM. The operative correction of pectus carinatum (pigeon breast). Ann Surg 1960;151:705-14. [4] Robicsek F, Cook JW, Daugherty HK, et al. Pectus carinatum. J Thorac Cardiovasc Surg 1979;78:52-61. [5] Robicsek F. Surgical treatment of pectus carinatum. Chest Surg Clin North Am 2000;10:357-76. [6] Shamberger RC, Welch KJ. Surgical correction of pectus carinatum. J Pediatr Surg 1987;22:48-53. [7] Schwabegger AH, Harpf C, Ninkovic M, et al. Technical refinements in planning and surgical therapy of pectus carinatum. Chirurg 2002;73: 1191-6. [8] Manktelow RT, McKee NH, Vettese T. An anatomical study of the pectoralis major muscle as related to functioning free muscle transplantation. Plast Reconstr Surg 1980;65:610-5. [9] Morain WD, Colen LB, Hutchings JC. The segmental pectoralis major flap: a function-preserving procedure. Plast Reconstr Surg 1985;75: 825-30. [10] Tobin GR. Pectoralis major segmental anatomy and segmentally split pectoralis major flaps. Plast Reconstr Surg 1985;75:814-24.