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Ann Thorac Surg 2000;69:669-670
© 2000 The Society of Thoracic Surgeons
a Division of Thoracic and Cardiovascular Surgery, Mayo Clinic, 200 First St, SW, Rochester, MN 55905, USA
b Division of Thoracic Surgery, The Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287, USA
To the Editor
We appreciate the comments raised concerning our manuscript [1] by Dr Del Campo. He addresses several points concerning the safety of raising the split pectoralis major muscle flap with partial lateral transection of the muscle, and superior rotation to cover large clavicular-manubrial area defects. He suggests instead, the freeing of the medial aspect of the muscle. This would allow it to continue to be fed by the thoracoacromial artery, which enters the muscle laterally. He suggests that there is a possibility of necrosis of the pectoralis muscle when done in the fashion we suggested.
The pectoralis major muscle indeed receives its blood supply from two main sources, that of the pectoralis branch of the thoracoacromial artery, which enters laterally, and the vascular perforators, which enter through the internal thoracic and intercostal arteries along the medial edge of the muscle. This vascular system anastomoses freely and supplies most of the muscle [2]. This dual blood supply is the reason for its versatility as a reconstructive muscle flap [3, 4]. Not only can it be freed up medially and isolated on the thoracoacromial artery, to be used as a free flap with microvascular replantation, but it also can be completely mobilized laterally and rotated medially while remaining completely vascularized based on the medial vascular perforators. This technique is performed routinely when the pectoralis major muscles are mobilized to fill a large sternal debridement defect, as in severe cases of mediastinitis and sternal osteomyelitis [5].
The thoracoacromial artery gives off a major branch to the pectoralis major muscle, which runs in the epimysium between the pectoralis minor and the pectoralis major laterally. The pectoralis major branch, in turn, gives off feeding arteries to the pectoralis major muscle at intervals along the lateral deep margin of the muscle. During the course of our dissection, only the branches related to the rotational flap were taken. Thus the pectoral branch proper and its branches, which still feed the inferior portion of the pectoralis muscle, remain and in this way, the muscle remaining attached by both origin and insertion were not compromised.
With major manubrial resections, the space defect overlying the great vessels requiring muscle coverage lies significantly more medial than the extent of the pectoralis major muscle fibers. The muscle bulk thins and the fibers fan out towards their insertion on the chest wall. This is particularly true in women. Because of this, we do not feel that there is enough muscle along this medial portion of the pectoralis major muscle to adequately fill the defect, and cover the great vessels in major clavicular-manubrial resections. In our technique, the significant body of the pectoralis major is able to be rolled 45 to 60 degrees, and thus provides thick muscle mass covering of the defect.
An additional concern, when detaching a portion of the muscle medially and transferring it superiorly, is the continued potential tension applied to that muscle, whatever the muscle contracts. Our approach defunctionalizes the portion of the muscle rolled into the defect, and thus creates a tension-free situation.
References
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