INTRODUCTION
The pectoralis major is a muscle that covers the upper portion of the anterior
chest wall and is the first option for reconstruction of the chest wall,
especially for defects of the sternum and anterior chest. Based on the
thoracoacromial blood supply, it can easily cover sternal and anterior chest
wall defects as an island or advancement flap1.
The pectoralis major muscle flap has been widely used since the late 1970s when
Ariyan described it in 19792.
In the literature, there are not many descriptions regarding this flap in
reconstruction to cover synthesis material in the supraclavicular region.
OBJECTIVE
The work aims to report the partial applicability of the pectoralis major muscle
to cover a clavicle osteosynthesis defect with synthesis material exposure.
CASE REPORT
Male patient, 20 years old, victim of a motorcycle fall, presented a fracture of
the left clavicle, progressing with pain, limited movement, and deformity at
the
fracture site.
In the initial care, he underwent a surgical procedure with the orthopedics team,
osteosynthesis of the left clavicle using a blocked plaque. After 14 days, he
evolved with surgical wound dehiscence and exposure of synthetic material (Figure 1). Soft tissue re-approach and
dehiscence closure were unsuccessful, with new material exposure five days after
surgery (Figure 2).
Figure 1 - Dehiscence of the surgical wound and exposure of synthetic
material.
Figure 1 - Dehiscence of the surgical wound and exposure of synthetic
material.
Figure 2 - New surgical wound dehiscence five days after the surgical
procedure.
Figure 2 - New surgical wound dehiscence five days after the surgical
procedure.
In the preoperative evaluation and study, the defect was 6 cm wide and 4 cm deep,
with exposure of synthesis material and absence of signs of infection.
Reconstruction with muscle flap of the pectoralis was the best option for
closure.
In the intraoperative period, the upper portion of the pectoralis major muscle
was exposed through dissection (Figure 3).
A skin flap is elevated inferiorly, exposing the pectoralis major at the fourth
intercostal space level and laterally towards the border of the deltoid. The
muscle fibers were divided longitudinally towards the muscle’s origin, and the
muscle flap was dissected from the pectoralis minor muscle.
Figure 3 - Exposure of the upper portion of the pectoralis major through
dissection.
Figure 3 - Exposure of the upper portion of the pectoralis major through
dissection.
The medial dissection performed for the medial vascular perforators provided a
divided pectoralis major flap, which can be easily rotated 45º to 60º degrees
to
fill the defect superiorly (Figure 4).
Figure 4 - Divided major pectoral flap.
Figure 4 - Divided major pectoral flap.
The flap was sutured superiorly to the platysma fascia and medially to the
sternal fascia, maintaining good synthetic material coverage (Figure 5).
Figure 5 - Flap sutured superior to the platysma fascia and medially to the
sternal fascia.
Figure 5 - Flap sutured superior to the platysma fascia and medially to the
sternal fascia.
The patient evolved uneventfully in the postoperative period; the coverage was
effective, without bruising, with a satisfactory aesthetic result. He is
currently undergoing late postoperative outpatient follow-up, with preserved
upper limb mobility (Figures 6 and 7).
Figure 6 - Postoperative.
Figure 6 - Postoperative.
Figure 7 - Postoperative.
Figure 7 - Postoperative.
DISCUSSION
The pectoralis major muscle flap is the most widely used pedicled muscle flap to
cover defects in the sternal region, anterosuperior chest, intrathoracic, and
neck regions3.
The standard flap development technique is the complete lateral mobilization of
the pectoralis major muscle close to its insertion. This provides a large
vascularized muscle mass adequate to fill a significant defect but results in
the complete loss of the pectoral’s main function.
In October 1982, Nahai et al.4 described
the technique that preserves the lateral third of the pectoralis major muscle
with the dominant vascular pedicle and motor nerves, with the pectoralis’s
muscle reconstruction major for wound closure in sternotomy with preservation
of
form and function.
It is known that there is no extreme morbidity due to loss of the pectoralis
major muscle since the pectoralis major, serratus anterior, and latissimus
dorsalis muscles can replace the function when working together-however, the
loss of the pectoralis major muscle results in a significant decrease in humeral
flexion strength.
According to the publication by Zehr et al., In 19995, in limited resections, reconstruction can be performed
with a fraction of the pectoralis major muscle, with the technique being used
in
two patients, the first being after resection of a malignant sarcoma involving
the head of the clavicle and, in the second case, resection was necessary for
chronic osteomyelitis caused by Staphylococcus aureus in an intravenous drug
user. No functional deficit was observed because the lower half of the pectoral
muscle was preserved. The described technique preserves the function because
half of the muscle remains intact, as we can see in our case report.
CONCLUSION
The pectoralis major muscle flap proved to be an excellent option for
reconstructing a clavicle osteosynthesis defect with material exposure,
maintaining the upper limb mobility preserved, thus obtaining a satisfactory
result.
REFERENCES
1. Neligan PC. Cirurgia plástica: extremidade inferior, tronco e
queimaduras. 3ª ed. Amsterdam: Elsevier; 2015. v. 4.
2. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap
for reconstruction in the head and neck. Plast Reconstr Surg. 1979 Jan;63(1):73-
81.
3. Clemens MW, Evans KK, Mardini S, Arnold PG. Introduction to chest
wall reconstruction: anatomy and physiology of the chest and indications for
chest wall reconstruction. Semin Plast Surg. 2011
Fev;25(1):5-15.
4. Nahai F, Morales Junior L, Bone DK, Bostwick J. Pectoralis major
muscle turnover flaps for closure of the infected sternotomy wound with
preservation of form and function. Plast Reconstr Surg. 1982
Out;70(4):471-4.
5. Zehr KJ, Reitmiller RF, Yang SC. Split pectoralis major muscle flap
reconstruction after clavicular-manubrial resection. Ann Thorac Surg. 1999
Mai;67(5):1507-8.
1. Santa Casa da Misericórdia de Santos,
Plastic Surgery and Burns Service, Santos, SP, Brazil.
Corresponding author: Fabiane
Pinheiro, Avenida Atlântica, 1144, Apto 2501, Centro, Balneário Camboriú,
SC, Brazil. Zip Code: 88330-009. E-mail:
dra.fabi.pinheiro@gmail.com
Article received: July 04, 2019.
Article accepted: January 10, 2021.
Conflicts of interest: none
