British Journal of Plastic Surgery (2005) 58, 170 174 Endoscopic assisted harvest of the pedicled pectoralis major muscle flap Arif Turkmen*, A. Graeme B. Perks Plastic Surgery Department, Nottingham City Hospital, Hucknal Road, Nottingham NH5 1PB, UK Received 2 May 2004; accepted 15 October 2004 KEYWORDS Endoscope; Pectoralis major muscle; Head and neck reconstruction; Minimal invasive Surgery Abstract The Pectoralis Major flap is a reliable and versatile flap for head and neck reconstruction. However, it is associated with donor site scarring on the anterior of the chest wall. Endoscopic assisted harvest of a pedicled pectoralis major muscle flap was performed on three patients for head and neck reconstruction. The average incision length was 4.5 cm, the average time taken to harvest the muscle was 37 min. All patients were discharged from hospital on the 5th to 8th postoperative day and one patient had a seroma. Endoscopic harvest of the pedicled Pectoralis major muscle flap minimises postoperative scarring. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Minimal access and endoscopically assisted surgery throughout all surgical specialties is well established. These techniques were initially applied in plastic surgery to facial surgery with browlift/corrugator muscle resection and augmentation mammoplasty being the most commonly performed procedures. 7 Endoscopically assisted dissection at donor sites has been described for a wide range of tissues such as latissimus dorsi, rectus abdominis, gracillis, tensor fascia lata muscle, omentum, jejunum, and sural nerve. 5,6,8,11 There has been no report on endoscopic assisted harvesting of the pectoralis major muscle flap. We report on three patients in whom endoscopic * Corresponding author. Tel.: C44 115 9691169. E-mail address: turkmenarif@yahoo.com (A. Turkmen). assisted harvest of a pedicled pectoralis major muscle flap for head and neck reconstruction has been performed through three different surgical approaches. Surgical technique The pectoralis major muscle (PMM) flap with thoracoacromial vessel as the pedicle is designed for head and neck reconstruction. A 308 oblique viewing, 10 mm scope was mounted on an Emory endoretractor (Fig. 1) connected to a three chip camera monitor system, bipolar scissors an endohook and monopolar scissors, medium size liga-clips for dealing with blood vessels and a basic plastic surgery set. The patient was positioned supine with S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.10.019
Endoscopic assisted harvest of the pedicled pectoralis major muscle flap 171 Figure 1 Endoretractor. the arms abducted 70 808. The tumour was excised from the head or neck then reconstruction was planned. Initially, a 4 cm long incision on the anterior axillary fold was performed deep to the pectoralis muscle. The lateral edge of the pectoralis major muscle was identified. An optical cavity was created underneath the pectoralis muscle by sharp, blunt and electro dissection. The thoracoacromial artery was visualised and preserved then soft tissue was elevated off the pectoralis muscle in the suprafascial plane (Figs. 2 and 3). The inferior and medial attachment of PMM was released by electro dissection. More attention should be given during the dissection of the inferio medial edge of the PMM because the location of the anterior branch of the 4 6th intercostal arteries. 10 The Figure 3 muscle. humeral attachment of the PMM was divided and the muscle flap was then tunnelled into the neck and sutured into place. A split skin graft was applied on the surface of the muscle. A redivac suction drain was left in the cavity after local anaesthetic infiltration. Case 1 Endoscopic view of the pectoralis major An 84 year old, male presented with an extensive cutaneous squamous cell carcinoma on the left Figure 2 Circulation of pectoralis major muscle. Figure 4 Post-operative picture, case 1.
172 A. Turkmen, A.G.B. Perks Figure 5 Pre operative picture, case 2. Figure 7 Post operative picture, case 2. preauricular area. The tumour had infiltrated parotid tissue and the external auditory meatus. Tumour resection included skin, superficial parotid, ear, part of the mastoid bone. Endoscopic assisted harvesting of the pedicled PMM flap was performed through an infra mammary approach allowing simultaneous flap harvest and tumour resection. Harvesting of PMM took approximately 65 min. The patient had an uneventful recovery (Fig. 4). Case 2 An 83 year old male presented with a recurrent squamous cell carcinoma on the right side of the neck. This was treated with radiotherapy 7 years previously (Fig. 5). The tumour was excised from the neck then endoscopic assisted harvest of the pedicled PMM flap was performed using a transaxillary approach (Fig. 6). The primary defect was covered with muscle and split skin graft. The patient made an uneventful recovery and was discharged on 6th postoperative day (Fig. 7). Case 3 A 67 year old, female had previously undergone 1 cm wide excision of a 9 mm malignant melanoma on the left supra orbital region within the last 12 months and tumour had spread to the contralateral neck lymph nodes but she refused surgery until the tumor had ulcerated and began to smell. There was a separate in-transit nodule on the right delto pectoral groove. She eventually agreed to surgery and underwent radical neck dissection and in transit nodule excision with 1 cm excision margins. This excision from the delto-pectoral groove allowed endoscopic harvesting of the PMM without performing an extra incision. The operation time for the muscle harvest was 34 min (Fig. 8). The patient made an uneventful recovery. A seroma developed on the chest wall, and responded to aspiration and antibiotics (Figs. 9 11). Discussion Figure 6 Intra operative picture, case 2. Pectoralis major myocutaneous (PMMC) flap in head and neck reconstruction has been well established and modified since it was first described by Ariyan in 1979. 1,2 The large surface area and regional proximity make the pectoralis major muscle flap an ideal source of vascularised tissue for a variety of reconstruction in the head and neck. 2,4 The simple anatomy of the PMM flap provides for quick and easy
Endoscopic assisted harvest of the pedicled pectoralis major muscle flap 173 Figure 10 Intra operative picture, case 3. Figure 8 Pre operative picture, case 3. Traditional incision for PMM harvest leaves a cosmetically poor site defect, particularly on the female anterior chest wall. 9 Endoscopic assisted harvest of the pedicled PMM flap reduces length of chest scar. Post-operatively, patients did not complain of donor site pain but they complained of discomfort on the chest wall. One of the patients who had an in transit nodule on clavicle had a seroma treated conservatively. In our experience the axillary approach is preferred in order to see the pedicle and release harvest. The overall complication rates in published series for the PMMC range from 8, 9% 63%. 3 The bulkiness of the PMMC flap with adipose tissue between muscle and skin is believed to contribute to the unreliability of the distal skin paddle. Figure 9 Intra operative picture, case 3. Figure 11 Post operative picture, case 3.
174 the muscle. However, an infra mammary approach can be made when two surgical teams work simultaneously. One of the technical difficulties of endoscopic assisted harvesting free tissue is the creation and maintenance of the optical cavity. However, this was not a problem in endoscopic harvesting of the PMM flap. Endoscopic harvest of the PMM flap fulfills the criteria by Eaves, 6 which are small incision length, short operating time high success rate and reduced morbidity rate. Our incisions were on average 4.5 cm and operation time on average 37 min for harvesting muscle. No long term results can be shown because all three patients died, two elderly men from natural causes and one 67 year old woman from metastatic malignancy. Conclusion In our limited experience on four patients using three different surgical approaches, endoscopic harvest of the PMM flap in head and neck reconstruction has been relatively simple and gives satisfactory results. References A. Turkmen, A.G.B. Perks 1. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg 1978;63(1):73 81. 2. Ariyan S. Further experience with the pectoralis major myocutaneous flap for the immediate repair of defects from excision of head and neck cancers. Plast Reconstr Surg 1979; 64(5):605 12. 3. Mehrhof AI, et al. The pectoralis major myocutaneous flap in the head and neck reconstruction. Am J Surg 1983;146:478 82. 4. Palmer JH, Batchelor AG. The functional pectoralis major musculocutaneous island flap in head and neck reconstructon. Plast Reconstr Surg 1990;85(3):363 7. 5. Miller MJ. Minimally invasive techniques of tissue harvest in head and neck reconstruction. Clin Plast Surg 1994;21: 149 55. 6. Eaves III FF, Nahai F, Bostwick III J, Jones G. Early clinical experience in endoscopic assisted muscle flap harvest (Discussion). Ann Plast Surg 1994;33:469 72. 7. Ramirez OM, Daniel RK. Endoscopic plastic surgery. Boston: Springer; 1995. 8. Sawaizumi M, Onishi K, Maruyama Y. Endoscope-assisted rectus abdominis muscle flap harvest for chest wall reconstruction. Ann Plast Surg 1996;37(3):317 21. 9. Zbar RI, et al. Pectoralis major myofascial flap. Head Neck 1997;19:412 8. 10. Kiyokawa K, et al. A method that preserves circulation during preparation of he pectoralis major myocutaneous flap in the head and neck reconstruction. Plast Reconstr Surg 1998;102(7):2336 45. 11. Ramakrishnan V, Southern S, Hart NB, Tzafetta K. Endoscopically assisted gracilis harvest for use as a free and pedicled flap. Br J Plast Surg 1998;51:594.