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|Year : 1987 | Volume
| Issue : 1 | Page : 35-6
Pectoralis major myocutaneous flap for reconstruction of radionecrotic chest wall ulcer (a case report).
|How to cite this article:|
Bhathena H H. Pectoralis major myocutaneous flap for reconstruction of radionecrotic chest wall ulcer (a case report). J Postgrad Med 1987;33:35
|How to cite this URL:|
Bhathena H H. Pectoralis major myocutaneous flap for reconstruction of radionecrotic chest wall ulcer (a case report). J Postgrad Med [serial online] 1987 [cited 2019 May 23];33:35. Available from: http://www.jpgmonline.com/text.asp?1987/33/1/35/5304
Post-radiation necrotic ulcers are difficult problems to treat. These are ulcers involving not only the skin but also the thoracic wall i.e. rib and in this particular case also the clavicle and manubrium sterni, hence causing the difficult reconstructive problem.
A 42 year old male patient was operated elsewhere in May 1977 for a firboadenoma of the left breast. He developed local recurrence with palpable axillary nodes and was seen at this hospital in August 1977. An en block dissection of the axillary nodes and excision of the recurrence alongwith the underlying pectoralis muscles was performed at this hospital. The histopathology report was a malignant fibrohystiocytoma; no metastases in the nodes were seen. Following the surgery, he received radiotherapy with telecobalt 60, 4500 r 18 fields in 26 days, to the chest wall locally from 7-10-1977 to 1-11-1977. He remained disease free for the next 2½ years.
He came back with a local recurrence on 17-4-1980. Histopathology on biopsy confirmed the clinical findings. He again received radiation with Tele 60Co; 2000 rads in 9 days to the infraclavicular region from 28-4-1980 to 6-5-1980.
Following this radiotherapy, the patient developed a non-healing ulcer in the left sternoclavicular region involving the sternoclavicular joint, the clavicle and the 1st and 2nd ribs.
Repeated biopsies were negative. From the year 1980 to 1982 he was treated by conservative dressings etc. to help the healing unsuccessfully, and then referred to our unit in October 1982. Pre-operative control of infection was obtained with the help of appropriate antibiotics and frequent saline dressings.
The ulcer was widely excised en bloc removing the medial 2/3 of the clavicle with the left half of the manubrium sterni, sternoclavicular joint and two ribs. Right pectoralis major myocutaneous flap, 16 x 15 cm in size, was raised on a vascular pedicle, keeping the horizontal head of the pectoralis major muscle intact and brought over to the defect under the skin bridge. The flap was sutured into the defect. Two negative suction drains were kept. The donor area on the right chest was primarily grafted with split skin graft from the thigh. [Fig. 1].
Post-operative period was uneventful and the patient was allowed to go home after 7 days. [Fig. 2].
The radionecrotic ulcer over the chest wall is a difficult problem to treat, especially when the underlying ribs are involved. The reduced healing power of this tissue can be augmented by bringing in a more vascular tissue. This was achieved by using the nearest, easily available pectoralis major myocutaneous flap. The lost components i.e. the ribs, clavicle and manubrium sterni were replaced by bulky pectoralis major myocutaneous flap from the opposite side raised on a vascular pedicle., It did well without any stabilisation of the chest wall. The fascia lata was not used because the parietal pleura was reflected.
The skeletal support could be possible with this composite flap by including a rib segment. The pectoralis major myocutaneous flap could be raised on a vascular pedicle or on a muscle pedicle. The flap raised on a vascular pedicle added into the manoeuverability of the flap to reach the defect site. The technique used in this case minimised the functional loss by keeping the horizontal head of the pectoralis major muscle intact. The anterior axillary fold was reconstructed by suturing the lateral tendinous edge of the muscle to the chest wall.
It was a one stage simplest procedure to bring in the vascular tissue for primary reconstruction of post-radionecrotic ulcer involving the skin and deeper structures i.e. ribs, clavicle and manubrium sterni.
|1.||Brown, R. G., Fleming, W. H. and Jurkiewicz, M. S.: An island flap of the pectoralis major muscle. Brit. J. Plast. Surg., 30: 161-165. 1977. |
|2.||Freeman, J. L., Walker, E. P., Wilson, J. S. P. and Shaw, H. J.: The vascular anatomy of the pectoralis major myocutaneous flap. Brit. J. Plast. Surg., 34: 3-10, 1981. |
|3.||McCraw, J. B., Dibbell, D. G. and Carraway, J. H.: Clinical definition of independent myocutaneous vascular territories. Plast. and Reconstr. Surg., 60: 341-352, 1977. |
|4.||Mendelson, B. C. and Masson, J. K.: Treatment of chronic radiation injury over the shoulder with a latissimus dorsi myocutaneous flap. Plast. and Reconstr. Surg., 60: 681-691, 1977. |