Ann Thorac Surg 2009;88:2044-2046. doi:10.1016/j.athoracsur.2009.04.062
© 2009 The Society of Thoracic Surgeons
How To Do It
Serratus Anterior Transposition Muscle Flaps for Bronchial Coverage: Technique and Functional Outcomes
Shawn S. Groth, MD,
Bryan A. Whitson, MD, PhD,
Jonathan D'Cunha, MD, PhD,
Rafael S. Andrade, MD,
George H. Landis, MD,
Michael A. Maddaus, MD*
Department of Surgery, University of Minnesota, Minneapolis, Minnesota
Accepted for publication April 9, 2009.
* Address correspondence to Dr Maddaus, Department of Surgery, University of Minnesota, MMC 207, 420 Delaware St, SE, Minneapolis, MN 55455 (Email: madda001{at}umn.edu).
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Abstract
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Because of its consistent anatomy, long vascular pedicle, malleability, low complication rate, and low donor site morbidity, we prefer serratus anterior transposition muscle flaps for prophylactic coverage of irradiated bronchi and treatment of bronchopleural fistulas. Our surgical technique is described, and our outcomes are discussed. Serratus anterior transposition muscle flaps can be performed with minimal morbidity and minimal impairment of upper extremity function.
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Introduction
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The incidence of bronchopleural fistulas is 0.4% to 4% after lobectomy [1] and 1.5% to 15% after pneumonectomy [2], depending on surgeon experience, use of neoadjuvant chemoradiation therapy, side of the pneumonectomy, length of the bronchial stump, type of bronchial closure, predicted postoperative pulmonary function, and prolonged mechanical ventilation [3]. Because of the significant increase in morbidity and mortality associated with bronchopleural fistulas, prophylactic tissue reinforcement (with omentum, pericardial tissue, or muscle) of a bronchial stump after pneumonectomy [3] or radiation [1] is recommended; muscle flaps are preferable [1, 4, 5].
Use of a serratus anterior transposition muscle flap has a number of distinct advantages, including: (1) consistent anatomy, (2) long vascular pedicle, (3) low complication rates (including flap failure), and (4) malleability [6, 7]. We herein describe our operative technique and discuss our outcomes.
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Technique
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Operative Procedure
For patients undergoing prophylactic reinforcement of an irradiated bronchus, we construct a serratus anterior transposition muscle flap and cover the bronchus immediately after the indicated pulmonary resection. For patients with a bronchopleural fistula and pleural space infection, we perform a staged procedure. First, the empyema is evacuated, and an Eloesser flap is constructed. Once the pleural space infection resolves, we cover the bronchopleural fistula with a serratus anterior transposition muscle flap. In this circumstance, the chest is packed open and subsequently closed, as described by Clagett and Geraci [8].
To construct the muscle flap, we perform a posterolateral thoracotomy and separate the serratus anterior muscle from the (overlying) latissimus dorsi and (underlying) rib cage. The thoracodorsal vascular pedicle is identified and protected throughout the entire dissection. The caudal five or six slips of the serratus muscle are liberated from the chest wall and scapular border for transposition into the chest (Fig 1). We leave the cranial three or four slips of the serratus anterior muscle intact to reduce the probability of winging of the scapula and shoulder disability.
After freeing the serratus anterior muscle, we resect a 6-cm midaxillary segment of the second rib to create an entrance site for intrathoracic transfer of the muscle flap. To prevent torsion of and tension on the vascular pedicle, we tack the muscle to the entrance site using 2-0 absorbable suture. Once mobilized and transferred, the serratus anterior transposition muscle flap remains well-vascularized and provides ample tissue for tension-free bronchial coverage. We use concentric circles of 4-0 monofilament suture to secure the muscle flap around the bronchus (Fig 2). We prefer a monofilament suture (over braided suture) to reduce the nidus of infection. After closing the thoracotomy, a 15-mm round drain is placed in the extrathoracic space and is removed 2 to 5 days later.
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Fig 2. (A) Intrathoracic transfer of a serratus anterior muscle flap and (B) securing the muscle flap to the bronchus with concentric circles of suture. (Artwork by Lisa D'Cunha.)
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Because the serratus anterior muscle is involved in protraction of the scapula, and upward rotation of the glenoid fossa (above the horizontal plane), use of a serratus anterior muscle flap could result in upper extremity functional impairment. Due to a lack of objective information in the literature, we also examined upper extremity functional outcomes after serratus anterior transposition muscle flap bronchial coverage.
Patients
The Institutional Review Board of the University of Minnesota approved this retrospective review of our surgical outcomes using our prospectively maintained database, and waived the need to obtain informed consent for each patient. We studied the charts of all consecutive patients at our institution that underwent serratus anterior transposition muscle flap coverage of an irradiated bronchus or a bronchial defect from July 1, 1998 through August 30, 2007. We collected information on postoperative complications. Deceased patients were identified through medical records and by using the Minnesota Death Certificates Index (http://people.mnhs.org/dci/).
DASH
The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is a 30-item survey that was developed in 1996 by the joint initiative of the American Association of Orthopedic Surgeons and the Institute of Work and Health (Toronto, Ontario, Canada) to assess physical function and symptoms in patients with a variety of musculoskeletal conditions [9]. For each question, patients are asked to rate their response on a scale of 1 ("no difficulty") to 5 ("unable"). The sum of the responses is transformed into a score (scale, 0 to 100); higher scores indicate increased disability.
The DASH questionnaire was administered over the telephone to surviving patients by trained interviewers who followed a script.
Results
During the study period, 25 patients (median age, 54 years; range, 41 to 81) underwent bronchial coverage with a serratus anterior transposition muscle flap. Three had benign disease; 22 had malignant pathology. The indications for bronchial coverage with a serratus anterior muscle flap were prophylactic coverage of an irradiated bronchus (n = 15), closure of a bronchopleural fistula (n = 8), and repair of iatrogenic injuries (n = 2). A seroma developed in 4 patients. A bronchopleural fistula developed in 1 patient who underwent radiation therapy and a completion pneumonectomy at an outside institution who was referred to our institution for treatment. After draining his empyema, we used a serratus anterior transposition muscle flap to close his bronchopleural fistula. Unfortunately, the flap became necrotic, and a second muscle flap (latissimus dorsi) was constructed to cover the bronchopleural fistula. No other patient required a second muscle flap. There were no other muscle flap-related complications.
Twelve patients are alive. Eleven patients (median age, 53 years; range, 45 to 79) completed the DASH questionnaire; 1 patient could not be located. All 11 patients had nonsmall small cell lung cancer. The indications for bronchial coverage with a serratus anterior muscle flap were prophylactic coverage of an irradiated bronchus (n = 7) and closure of a bronchopleural fistula (n = 4). The median follow-up time between surgery and administration of the questionnaire was 22 months (range, 8 to 99 months). The median DASH score was 28.3 (range, 7.1 to 75).
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Comment
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Because of a number of practical advantages, serratus anterior muscle flaps are becoming increasingly popular choices for intrathoracic use [4]. Technical advantages include: (1) consistent anatomy, (2) a long vascular pedicle, and (3) malleability. Because of these features, serratus anterior muscle transposition flaps provide an ample amount of well-vascularized tissue for bronchial coverage.
In addition to the technical advantages, serratus anterior muscle flaps are associated with low donor site morbidity rates. Derby and colleagues [7] collected follow-up data for their series of 34 patients who underwent serratus anterior free-muscle flaps. Most patients had no postoperative pain (74%) and no numbness at the donor site (75%).
We also noted a low donor site morbidity rate. Overall, a seroma developed in 4 of our patients (16%). Similarly, Derby and colleagues [7] noted a seroma rate of 15% in their series of 34 patients [7]; Whitney and colleagues' [6] reported a seroma rate of 7% in their series of 100 patients [6]. Flap necrosis developed in 1 patient (4%). Similarly, the rate of flap loss in Whitney and colleagues' [6] series was 4%.
Because the serratus anterior muscle is involved in upper extremity function, it is also important to assess functional outcomes in these patients. Derby and colleagues [7] noted that most patients have no loss of shoulder strength (74%) and no loss of shoulder mobility (93%) [7]. We believe that there are no other studies in the literature that have more rigorously assessed upper extremity function after construction of a serratus anterior transposition muscle flap.
Using a validated questionnaire that assesses upper extremity disability, we demonstrated that patients who undergo serratus anterior transposition muscle flaps have minimal disability. We recognize several limitations of our analysis. First, the DASH questionnaire was administered over a wide range of follow-up (range, 8 to 99 months). Furthermore, we do not have preoperative DASH results for our patients for baseline comparison. Consequently, we used a control group from the literature. In one study, the mean DASH score for employed 50 to 65 year olds (the age of most of the patients in our series) in the general population was 19 ± 18 (standard deviation) [10]. If we exclude one outlier (DASH score, 75) and 1 patient (DASH score, 63.3) who may be confounding our analysis because a second muscle that impacts upper extremity function (latissimus dorsi) was used after the serratus anterior muscle flap failed, our results (mean score, 25.8 ± 18.1) are similar to the DASH scores of adults in the general population (t = 1.11; degrees of freedom = 233; p = 0.27).
In conclusion, serratus anterior transposition muscle flap bronchial coverage can be performed with minimal morbidity and with minimal impairment of upper extremity function. We are now prospectively collecting preoperative and postoperative DASH questionnaires to more objectively assess the impact of serratus anterior transposition muscle flap bronchial coverage on upper extremity function.
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Acknowledgments
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We would like to thank Lisa D'Cunha for her excellent artwork. We would also like to thank Wadi Gomero-Cure, MD, Andrew P. Windsperger, MD, and Samantha L. Pace, MD, for their assistance with data collection.
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References
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- Greason KL, Miller DL, Clay RP, et al. Management of the irradiated bronchus after lobectomy for lung cancer Ann Thorac Surg 2003;76:180-186.[Abstract/Free Full Text]
- Deschamps C, Bernard A, Nichols 3rd FC, et al. Empyema and bronchopleural fistula after pneumonectomy: factors affecting incidence Ann Thorac Surg 2001;72:243-248.[Abstract/Free Full Text]
- Algar FJ, Alvarez A, Aranda JL, Salvatierra A, Baamonde C, Lopez-Pujol FJ. Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis Ann Thorac Surg 2001;72:1662-1667.[Abstract/Free Full Text]
- Arnold PG, Pairolero PC, Waldorf JC. The serratus anterior muscle: intrathoracic and extrathoracic utilization Plast Reconstr Surg 1984;73:240-248.[Medline]
- Pairolero PC, Arnold PG, Piehler JM. Intrathoracic transposition of extrathoracic skeletal muscle J Thorac Cardiovasc Surg 1983;86:809-817.[Abstract]
- Whitney TM, Buncke HJ, Alpert BS, Buncke GM, Lineaweaver WC. The serratus anterior free-muscle flap: experience with 100 consecutive cases Plast Reconstr Surg 1990;86:481-491.[Medline]
- Derby LD, Bartlett SP, Low DW. Serratus anterior free-tissue transfer: harvest-related morbidity in 34 consecutive cases and a review of the literature J Reconstr Microsurg 1997;13:397-403.[Medline]
- Clagett OT, Geraci JE. A procedure for the management of postpneumonectomy empyema J Thorac Cardiovasc Surg 1963;45:141-145.[Medline]
- Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med 1996;29:602-608.[Medline]
- Jester A, Harth A, Germann G. Measuring levels of upper-extremity disability in employed adults using the DASH Questionnaire J Hand Surg Am 2005;30:1074.e1-1074.e10.[Medline]
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Abstract
Introduction
