The Split Pectoralis Flap: Combining the Benefits of Pectoralis Major Advancement and Turnover Techniques in One Flap

The use of flaps for management of deep sternal wound complications: A systematic review and meta-analysis

BACKGROUND

Many options are available for reconstruction after deep sternal wound infections. However, these options have not been critically appraised. The aim of this systematic review and meta-analysis was to assess the existing evidence on sternal rewiring versus flap reconstruction and pectoralis major muscle flaps (PMFs) versus greater omental flaps (GOFs).

METHODS

A systematic review and meta-analysis was performed. CENTRAL, MEDLINE and EMBASE were searched. Outcomes of interest included mortality, treatment failure and length of hospital stay (LOS).

RESULTS

Fourteen studies were included. Nine studies compared flaps to rewiring, reporting on 618 patients. Patients treated with flaps had significantly lower mortality compared with patient treated with rewiring (Risk ratio [RR] 0.42, 95% confidence interval [CI]: 0.23-0.77, P < 0.01). Flap patients had significantly lower treatment failure compared with those who were treated with rewiring (RR 0.22, 95% CI: 0.14-0.37, P < 0.01). No statistically significant differences were observed in LOS between patients treated with flaps compared those treated with rewiring (standard mean difference -0.84, 95% CI: -1.91 to 0.24, P = 0.13). Five studies compared PMF with GOF, reporting on 599 patients. No statistically significant differences were found in mortality (RR 0.63, 95% CI: 0.24-1.68, P = 0.36), LOS (standard mean difference -14.52, 95% CI: -42.00 to 12.96, P = 0.30) or treatment failure (RR 1.37, 95% CI: 0.31-6.07, P = 0.68) in patients treated with PMF compared with patients treated with GOF.

CONCLUSIONS

Flap-based reconstruction demonstrated improved mortality and treatment outcomes compared to sternal rewiring. However, no significant differences were observed in outcomes between the PMF- and GOF-based reconstructions.

Functional donor-site morbidity following reconstruction with pectoralis major flaps: A systematic review

Background

Pectoralis major muscle/myocutaneous flaps (PMMFs) are commonly used in reconstructive surgery, but may result in shoulder disability on the donor side. A systematic review evaluating this morbidity could be beneficial for guiding patients and providers considering this procedure.

Methods

In October 2022, a systematic review of studies evaluating quantitative/qualitative measures of functional morbidity after PMMF was conducted. The results were categorized into PMMF's effect on range of motion (ROM), strength, and ability to complete shoulder-related activities/quality of life.

Results

Eleven studies were included for analysis, which analyzed standard PMMF and two PMMF variants that spared portions of the muscle. Three of five studies demonstrated reduced shoulder ROM for standard PMMF versus controls lasting at least 4 months after head and neck reconstruction. Two of five studies, including two prospective studies demonstrated reduced shoulder strength for standard PMMF versus controls lasting at least 3 months after surgery. Five of nine studies found significant impairment in the ability to conduct shoulder-related activities, including work, up to one year postoperatively for standard PMMF versus controls. Muscle-sparing PMMF variants exhibited more promising outcomes in some categories.

Conclusion

Standard PMMF results in prolonged reductions in shoulder ROM and strength, which may impair patients in shoulder-related activities. Other reconstructive options should be considered in patients who frequently participate in such activities. For patients requiring PMMF, muscle-sparing PMMF variants should be considered as alternatives to the standard PMMF.

The in vivo passive stretch response of the pectoralis major is region-specific

The pectoralis major (PM) is a broad muscle commonly divided into three regions, which contribute uniquely to shoulder stability and movement. The PM muscle regions likely respond differently to stretch, but this has never been shown in vivo. We used shear wave elastography to assess the stretch response of different PM muscle regions during shoulder abduction and external rotation in 20 healthy male participants. Participants' shoulder was passively rotated through their range of motion in 5.7° increments and shear wave velocities (SWV) were obtained for each muscle region. A piece-wise model was fitted to the SWV-joint angle data, from which slack angle, slack stiffness and elasticity coefficient were determined. For shoulder abduction, we found that the sternocostal region had a significantly smaller slack angle (p = 0.049) and greater slack stiffness (p = 0.005) than the abdominal region, but there was no difference for elasticity coefficient (p = 0.074). For external rotation, only slack stiffness was greater for the sternocostal than the abdominal region (p < 0.001) with no differences found for slack angle (p = 0.18) and elasticity coefficient (p = 0.74). However, our data indicates that neither region was slack in this condition. These findings indicate that the sternocostal and abdominal regions respond differently to passive stretch, highlighting the PM's functional differentiation. This differentiation should be considered during treatment interventions such as PM muscle harvesting or treatments for breast cancer.

[The split turnover pectoralis muscle flap: an easy and safe method for sternal wound coverage]

The conventional pectoralis muscle flap is well known for the reconstruction of sternal defects after deep sternal wound infection. The pectoralis muscle flap can be harvested as an advancement flap based on the thoracoacromial artery, or it can be harvested as a turnover flap based on intercostal perforators of the internal thoracic artery. A disadvantage of the advancement flap can be seen in its limited reach, especially for covering the lower third of the sternum. The turnover flap is well suited for coverage of the lower and middle sternal third, but then lacks the length for coverage of the cranial third. The authors describe a new method for splitting up the pectoralis turnover muscle flap along its muscle fibres in order to gain additional length. Between 2017 and 2022, we treated 12 patients with this method. Total wound coverage and closure have been achieved in all 12 patients. Thus, the split turnover pectoralis flap is a safe and effective method for sternal wound treatment.

Bilateral Sternalis Muscle With the Absence of Unilateral Sternocostal Part of the Pectoralis Major and Variation of Pectoralis Minor Muscles

This study aims to report a 57-year-old male cadaver with a rare muscular variation of the sterno-pectoral region. An unusual sternalis muscle was observed on both sides, arising from the external oblique muscle aponeurosis. The fibers converged upwards and medially in a curved course, producing a bundle 99.50 mm long on the right side and 74.60 mm on the left. The muscles on both sides were supplied by the second, third, and fourth intercostal nerves. In the right pectoralis major (PM) muscle, the sternocostal head was completely absent, and the clavicular head arose from the medial two-thirds of the clavicle, whereas abdominal fibers arose from the aponeurosis of the external abdominal oblique muscle and ran upward and laterally and joined the clavicular fibers with a wide triangular gap. On the left side, there was an anatomically normal PM muscle. The origin of the pectoralis minor was unusually high on both sides. The morphological variations of sterno-pectoral musculature have significant implications for clinical practice, which allows more precise surgical or radiological outcomes. Clinicoradiological evaluation of these variations is important to achieve appropriate dissection planes during chest wall surgery.

A Reliable Procedure for Reconstruction of the Sternum Defects: The Pectoralis Major Muscle Flap Combination with Negative Pressure Wound Therapy

Objective: Sternotomy defects may present mildly as isolated skin separation or severely as mediastinitis. A combination of treatment options can support treatment. Methods: Patients who were treated with pectoralis major flap with the combination of negative pressure wound therapy (NPWT) between 2016-2020, were retrospectively reviewed. Demographic features, microorganisms causing wound infection, flap reconstruction preference, time of hospitalization, remission, recurrence and associated morbidity and mortality data were evaluated. Results: Thirteen patients were included with a mean age of 65.4 years. All patients previously underwent coronary artery bypass graft surgery. Wound cultures from patients were positive in nine (69%). Isolated microorganisms were Staphylococcus spp. (n=4), Klebsiella pneumoniae (n=3) and Acinetobacter baumannii complex (n=2). The most common comorbidities were hypertension (76%) and diabetes mellitus(46%). The average hospital stay was 23.4 days. One patient died on the seventh postoperative day, two had seromas at the flap donor site, and one had hematoma. Conclusion: Pectoralis major muscle flap and NPWT after complete removal of dead tissues is an effective method to repair and treat sternum defects.

Variations in the anterior thoracic wall with sternalis muscle and accessory pectoralis major muscle

PURPOSE

The new type of the sternalis muscle needs to be recognized, and the accessory pectoralis major muscle (AcPM) was found between the pectoralis major and minor muscle. It needs to be acknowledged those two different variations can exist in one case.

METHODS

The muscle was found on a 73-year-old male cadaver during the dissection class for the anterior thoracic wall. It was proceeded to identify the adjacent structures with precise dissection.

RESULTS

The cadaver had sternalis muscle bilaterally. Both side sternalis muscles had a medial and lateral belly and attached to pectoral fascia and rectus abdominis sheath. The pectoralis major muscle (PMaj) had a more profound slip attached to the costal cartilage of rib 4 and 5, which is AcPM. The pectoral nerve traveled through the clavipectoral fascia to the AcPM and through PMaj to the sternalis muscle.

CONCLUSIONS

This study presented a new type of sternalis muscle. Two different variations were developed along with the pectoral nerve. It needs to be recognized in the diagnostic images, the muscle rehab outcome, and the surgical complication.

Partition of Pectoralis Major Musculocutaneous Flap as a Salvage Procedure for Simultaneous Coverage of the Exposed Carotid Artery and Reconstruction of Cervical Esophagus

BACKGROUND

In advanced pharyngoesophageal cancer patients, a critical event is represented by the failure of primary reconstruction with exposure of the carotid artery and partial or total defect of the cervical esophagus. For these high-risk patients, a partitioned pectoralis major musculocutaneous (PMMC) flap can prevent carotid blowout and provide skin for simultaneous esophageal reconstruction.

METHODS

Twenty-six patients needing pharyngoesophageal reconstruction together with coverage of carotid artery exposure were included in this retrospective case series. The patients were treated with a partitioned PMMC flap, based on the branching pattern of the pectoral branch of the thoracoacromial artery and the perforators of the pectoralis major muscle, to simultaneously reconstruct the defect and provide coverage for the carotid artery.

RESULTS

In 25 patients, the partitioned PMMC flap reconstructions resulted in complete wound healing without occurrence of carotid blowout syndrome or fistula formation. Minor complications as partial flap necrosis (7.7%) and strictures formation (7.7%) were recorded but did not compromise reconstruction. Twenty-two patients were able to adopt a semisolid diet, and 4 had recurrence of cancer.

CONCLUSIONS

The partitioned PMMC flap reconstruction represents a useful salvage solution to simultaneously restore the continuity of the alimentary tract and provide reliable coverage for the exposed carotid artery.

Decreasing complications of pectoralis major muscle flap reconstruction with two modalities of negative pressure wound therapy

BACKGROUND AND OBJECTIVE

Deep sternal wound infection is a feared complication of open-heart surgery. Negative pressure wound therapy has gained an important role in the treatment of deep sternal wound infection. Incisional negative pressure wound therapy has been introduced as a method to prevent wound complications after sternotomy, and lately, after flap reconstructions in the treatment of deep sternal wound infection. We aimed to study if incisional negative pressure wound therapy with PICO™ had similar beneficial effect described earlier with competing commercial devices.

METHODS

This study included 82 patients treated with pectoralis major muscle flap for deep sternal wound infection during the years 2006-2020. PICO group consisted of 24 patients treated with preoperative negative pressure wound therapy and postoperative incisional negative pressure wound therapy (PICO™). Two control groups included 48 patients with conventional treatment and 10 patients with preoperative negative pressure wound therapy only.

RESULTS

In the PICO group, the complication rate declined from 50.0% to 33.30%, major complication rate from 29.2% to 12.5%, and need for an additional flap from 14.6.% to 4.2% when compared to conventional treatment. The length of hospital stay decreased as well. Preoperative negative pressure wound therapy alone was associated with moderate decline in the complication rates. In addition, we described the use of split pectoralis major muscle flap reconstruction in 57 patients. To our knowledge, this is the largest published patient series describing this method in the treatment of deep sternal wound infection.

CONCLUSIONS

Incisional negative pressure wound therapy with PICO™ seems beneficial after flap reconstruction. Split pectoralis major muscle flap is a versatile reconstruction option suitable to be used as a workhorse in the treatment of deep sternal wound infection.

Sternal Wound Reconstruction Made Simple

Sternal wounds and associated infections represent a complex reconstructive problem in a highly morbid patient population. Through strict adherence to excellent plastic surgical principles, this process can be simplified, allowing safe and effective wound closure. Emphasis is placed on thorough debridement, hardware removal, obtaining adequate tissue cultures, and finally, appropriate flap closure. In most cases, pectoralis major myocutaneous advancement flaps provide excellent coverage while eliminating dead space and providing sternal compression. Secondary flap options, such as the omental flap or rectus abdominis muscle, may occasionally be necessary. This article will provide an overview and simplified approach to sternal wound reconstruction.

Anatomical Variations of the Pectoralis Major Muscle: Notes on Their Impact on Pectoral Nerve Innervation Patterns and Discussion on Their Clinical Relevance

BACKGROUND

The presented study attempts to classify individual anatomical variants of the pectoralis major muscle (PM), including rare and unusual findings. Rare cases of muscular anomalies involving the PM or its tendon have been presented. An attempt has also been made to determine whether anatomical variations of the PM may affect the innervation pattern of the lateral and medial pectoral nerves.

MATERIAL AND METHODS

The research was carried out on 40 cadavers of both sexes (22 males, 18 females), owing to which 80 PM specimens were examined.

RESULTS

Typical PM structure was observed in 63.75% of specimens. The most frequently observed variation was a separate clavicular portion of the PM. In one female cadaver (2.5% of specimens) the hypotrophy of the clavicular portion of the PM was noticed. In two male cadavers (5% of specimens) the fusion between the clavicular portion of the PM and the deltoid muscle was observed. In one of those cadavers, small sub-branches of the lateral pectoral nerve bilaterally joined the clavicular portion of the deltoid muscle. The detailed intramuscular distribution of certain nerve sub-branches was visualized by Sihler's stain. PM is mainly innervated by the lateral pectoral nerve. In all specimens stained by Sihler's technique, the contribution of the intercostal nerves in PM innervation was confirmed.

CONCLUSIONS

Surgeons should be aware of anatomic variations of the PM both in planning and in conducting surgeries of the pectoral region.

Reconstruction of Small Chest Wall Defects Caused by Tubercular Abscesses Using Two Different Flaps

Tubercular infection of the chest wall is rare and typically progresses to abscess formation. Treatment of these abscesses combines medical therapy with surgical debridement, which can cause defects of various sizes. This case report describes reconstruction of relatively small chest wall defects caused by tubercular abscesses with the use of two different flaps: a lateral intercostal artery perforator flap and a split pectoralis major muscle flap. The use of these flap techniques may provide a novel approach to cover small chest wall defects caused by tubercular abscesses.