Ectoralis Ajor Lap: Tor Chiu

16
Pectoralis
Major Flap
Tor Chiu
Radial Forearm Flap 145

Pectoralis
Major Flap
FLAP TERRITORY muscle and is usually divided when the flap

is raised.
The pectoralis major myocutaneous
flap (PMMF) is useful in head and neck The course of the pectoral branch of the
reconstruction. The extent of coverage thoraco-acromial artery can be identified
and the reach of the flap are dependent by drawing a line from the xiphoid to the
on the anatomy of the patient but the acromion. A second line is made vertically
upper limits are generally considered the from the midpoint of the clavicle to
zygomatic arch externally and the tonsillar intersect the first line. The course of the
bed internally. artery corresponds to the line drawn from
the midpoint of the clavicle continuing
to the medial portion of the acromion to
VASCULAR ANATOMY
xiphoid line. Figure 1
The PMMF is mainly supplied by perforators
of the pectoral branch of the thoraco- FLAP HARVEST
acromial artery which runs on the
underside of the PM. Identify the clavicle, ipsilateral sternal
border, xiphoid, and humeral insertion of
The lateral thoracic artery provides a
the PM.
secondary blood supply but is usually
sacrificed to maximize the reach of the Design the size and location of the skin
flap. paddle over the PM.
The superior thoracic artery contributes Skin overlying any portion of the muscle
supply to the lateral superior portion of the may be utilized. The size and and location
Pectoralis Major Flap 147

Pectoralis
Major Flap
of skin paddle depends on reconstructive and allows identification of the medial and
requirements. In most cases, the skin inferior extents of the muscle. At this point,
paddle is located at the infero-medial the skin paddle can be moved inferiorly
border of the PM between the nipple and or superiorly so that most of it lies over
the edge of the sternum. In women, the muscle.
skin paddle can be designed below the
The other incisions are made down to the
breast in the inframammary fold.
muscle. The skin paddle can be temporarily
The larger the skin paddle harvested, the sutured to the fascia.
higher the likelihood the skin will survive The superior skin flap is elevated to
the transfer due to the increased number clavicle whilst preserving perforators to the
of myocutaneous perforators. deltopectoral flap. A tunnel can be created
For additional length, the skin paddle may to the neck where needed. Figure 3
be extended as a random-pattern flap The inferior skin flap is elevated to
beyond the inferior edge of the muscle. reveal the lower edge of the PM and the
Excessive thickness of the fatty tissue muscle is then elevated off the chest wall.
is associated with a higher risk of skin There are normally numerous chest wall
necrosis. Figure 2 perforators at the muscular attachments. In
live patients, take care to control bleeding
The first incision is made from the lateral
as vessels can retract into the chest.
edge of the skin paddle toward the
anterior axillary line (defensive incision - The pedicle can be identified on the deep
which preserve the deltopectoral flap). surface of the superior part of the muscle.
This incision is carried down to the muscle Figure 4 Cut the muscle close to the sternal
148 Dissection Manual
Figure 4
PM muscle raised to show the pectoralis minor
(blue arrow) and pedicle (red arrow) running on
the under surface
Figure 1
Schematic diagram to locate the pedicle of PM
flap
Figure 2
Design of the skin island in PM flap with “defensive
incision”
Figure 3
Identify the free edge (blue arrow) of PM
muscle and ensure the skin island is “within” the
boundary of PM muscle

Pectoralis
Major Flap
attachments, taking care with the internal

mammary perforators. Laterally, cut the
muscle taking care to preserve the pedicle.
The lateral thoracic artery is usually
sacrificed to increase length and rotation.
Figure 5
When insetting the flap, take care not

to overly rotate, kink, or compress the
proximal flap.
Flap reach can be increased by dividing

the clavicular portion of the muscle above
the pedicle and by splitting and removing
the middle one-third of the clavicle.
Figure 5
Raised PM flap to show the pedicle (red arrow)
from thoraco-acromial artery
150 Dissection Manual
KEY POINTS
1. The PMMF is mainly supplied by the pectoral branch of the

thoraco-acromial artery and a secondary blood supply from the
lateral thoracic artery.
2. The course of the pedicle can be identified by locating the
landmarks including the xiphoid, acromion and midpoint of the
clavicle.
3. Place the skin paddle over the infero-medial border of the PM.
4. Defensive incision preserves the deltopectoral flap for future

use.
5. Flap reach can be increased by dividing the lateral thoracic
artery and the clavicular portion of the muscle above the
pedicle.

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16

Radial Forearm Flap 145

FLAP TERRITORY muscle and is usually divided when the flap

Pectoralis Major Flap 147

Pectoralis Major Flap 149

attachments, taking care with the internal

When insetting the flap, take care not

Flap reach can be increased by dividing

1. The PMMF is mainly supplied by the pectoral branch of the

4. Defensive incision preserves the deltopectoral flap for future

Pectoralis Major Flap 151

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