Atlas Phẫu Thuật Vi Phẫu Mạch Máu (Atlas of Microvascular Surgery)

MODIFIED WRAP-AROUND FLAP
429
Figure 8–69
Donor closure
(see text for details).
Figure 8–68
Prefabrication of the harvested ap.
1. Dorsalis pedis a., deep peroneal n., greater saphenous v.
4. Lateral PDA and n.
Prefabrication of the Harvested
Flap (Fig. 8–68)
The plantar portion of the wrap-around ap is brought
back and advanced mediodorsally for closure of the tip
and medial margin of the nail. After the interpositional
iliac bone graft is xed to the distal phalanx by
Kirschner wires, the proxim al portion of the ap is
wrapped around it.
Donor Closure (Fig. 8–69)
At the donor site, the end of the proximal phalanx and
the plantar wound of the big toe are covered by the me-
dial ap, and the dorsal wound is covered with a split-
thickness skin graft.

Figure 8–71
Flap elevation.
1. Dorsalis pedis a. and v., deep peroneal n., greater
saphenous v.
2. PDA and n.
3. Extensor hallucis brevis m.
Note: Based on the same arteriovenous pedicles, the pulp ap
can be tailored and developed, by combining the toenail bed,
the distal phalanx, the interphalangeal joint, or even the distal
segment of the toe, to meet requirements in the recipient hand.
Figure 8–70
Flap design.
1. Dorsalis pedis a. and v., deep peroneal n., greater
saphenous v.
2. PDA and n.
3. Extensor hallucis brevis m.
FREE PULP FLAP
Flap Design (Fig. 8–70)
The rst choice of donor is the big toe, which provides a
larger ap area; the second toe is the next choice. For
reconstruction of the thumb pulp, the ipsilateral foot is
selected; for the index nger, the contralateral foot is
chosen to afford better sensibility to the ulnar side of
the thumb and the radial side of the index. The dimen-
sions and location of the ap vary according to
requirements in the recipient nger.
Flap Elevation (Fig. 8–71)
The
dorsal
super cial
vein
and
the
dorsalis
pedis–FDMA (1) are dissected out, for lengths meeting
the requirements of the recipient vessels. If there is no
adequate dorsal artery, the plantar arterial system (2)
can be used. When the ap is elevated, the distal perfo-
rating artery and the lateral digital nerve (2) should be
included in the ap.
430
II.8 LOWER EXTREMITY: ANKLE AND FOOT

VASCULARIZED JOINT TRANSFER
431
VASCULARIZED JOINT TRANSFER
Arterial Anatomy of the PIP and MTP
Joints (Fig. 8–72)
The PIP joint (8) or MTP joint (7) of the second toe is
chosen as the donor for transfer.
The PIP joint (8) of the second toe is supplied by the
transverse branch (4) of the digital artery. It is a hinge
joint, and its normal range of motion (ROM) is between
0 degrees in extension and 90 degrees in exion.
The MTP joint (7) of the second toe is supplied by
the articular branch (3) originating from the FDMA (1).
It is an ellipsoid joint, and its normal ROM is between
45° in hyperextension and 30° in exion. Ordinarily, the
PIP joint is preferable to the MTP joint.
Free PIP Joint Transfer of the
Second Toe
Incision and Skin Island Design (Fig. 8–73)
A skin island is designed over the dorsum of the PIP
joint as a monitor of graft circulation or as a graft for re-
pair of the skin defect at the recipient site.
Figure 8–73
Incision and skin
island design.
1. FDMA and deep peroneal n.
2. DDA
3. Greater saphenous v.
4. Distal perforating a.
5. PDA and n.
6. MTP joint
7. PIP joint
Figure 8–72
Arterial anatomy of the PIP and MTP joints.
1. FDMA
6. PDA
2. FPMA
7. MTP joint
3. Articular branch of the MTP
8. PIP joint
4. Transverse a.
9. Distal perforating a.
5. DDA

Figure 8–74
Dissection of the neurovascular
bundle.
1. FDMA and deep peroneal n.
2. DDA
3. Greater saphenous v.
4. Distal perforating a.
5. PDA and n.
Dissection of the Neurovascular Bundle
(Fig. 8–74)
In a majority of cases, the greater saphenous vein and the
dorsalis pedis–FDMA (3,1) are dissected through an inci-
sion on the dorsum of the foot, as described previously.
The medial neurovascular bundle is divided at the
DIP joint, taking care to preserve the distal perforating
branch (4) and the articular branches to the PIP joint.
432
II.8 LOWER EXTREMITY: ANKLE AND FOOT

VASCULARIZED JOINT TRANSFER
433
Figure 8–75
Disarticulation, osteotomy, and
completion of harvesting.
1. FDMA and deep peroneal n.
2. DDA
3. Greater saphenous v.
4. Distal perforating a.
5. PDA and n.
6. MTP joint
7. PIP joint
Note:The defect resulting from removal of the joint can be
treated either by arthroplasty or, preferably, by fusion,
using bone removed from the hand. In the event that two
PIP joints are needed, the second plantar metatarsal
artery is used as an arterial pedicle for the donor second
and third toes.
Disarticulation, Osteotomy, and Completion
of Harvesting (Fig. 8–75)
The lateral skin with the lateral neurovascular bundle is
separated from the digital bones and joint. Both ends of
the extensor tendon are divided. Usually, the extensor
and exor tendons can be included in the graft. The PIP
joint (7) with vascular pedicles (1,3) is then isolated by
disarticulation through the DIP joint and osteotomy
through the proximal phalanx.

Figure 8–77
Dissection of the vascular systems.
1. FDMA and deep peroneal n.
2. DDA
3. Greater saphenous v.
7. PIP joint
Figure 8–76
Incision and skin island
design.
1. FDMA and deep peroneal n.
2. DDA
3. Greater saphenous v.
4. Distal perforating a.
5. PDA and n.
6. MTP joint
7. PIP joint
Free MTP Joint Transfer of the
Second Toe
Incision and Skin Island Design (Fig. 8–76)
A skin paddle is designed over the dorsum of the
MTP joint.
Dissection of the Vascular Systems (Fig. 8–77)
During the dissection of the FDMA (1) in the in-
terosseous muscle, the articular branch to the MTP joint
should be carefully protected from dam age. While
dividing the rst deep transverse metatarsal ligament
and ligating the digital artery of the big toe, attention
should be paid to preserving the distal perforating
branch to the joint to keep it communicating with the
dorsal and plantar arterial nets around the m edial
aspect of the MTP joint.
434
II.8 LOWER EXTREMITY: ANKLE AND FOOT

VASCULARIZED JOINT TRANSFER
435
Figure 8–78.
Osteotomy and completion of harvesting.
1. FDMA and deep peroneal n.
2. DDA
3. Greater saphenous v.
4. Distal perforating a.
5. PDA and n.
6. MTP joint
7. PIP joint
Osteotomy and Completion of Harvesting
(Fig. 8–78)
Both ends of the extensor tendon, the metatarsal and
proxim al phalanx bones, and the second deep trans-
verse m etatarsal ligam ent are divided. The MTP joint
(6) with the overlying skin and extensor tendon, is
isolated. If needed, the exor tendon can be included in
the graft.

Figure 8–79
Dissection of the vascular systems.
1. Dorsalis pedis a. and v., and deep peroneal n.
2. Greater saphenous v.
3. FDMA
4. Arcuate a.
5. Second dorsal metatarsal a.
6. Extensor tendons
7. Flexor tendons
8.
Plantar digital n.
Second and Third Toe Transfer En Bloc
Dissection of the Vascular Systems (Fig. 8–79)
To obtain a better blood supply to the third toe, the
second dorsal metatarsal artery (5) should be included
in the arterial pedicle, if one exists. However, if the
arcuate artery (4) is absent, the FDMA (3) is usually able
to supply the third toe, with its lateral circulation
through the second toe and web space.
436
II.8 LOWER EXTREMITY: ANKLE AND FOOT

VASCULARIZED JOINT TRANSFER
437
Figure 8–80
Completion of harvesting.
1. Dorsalis pedis a. and v. and deep peroneal n.
2. Greater saphenous v.
6. Extensor tendons
7. Flexor tendons
8. Plantar digital n.
Completion of Harvesting (Fig. 8–80)
After dividing the rst and third deep transverse
m etatarsal ligam ents and disarticulating the second
and third MTP joints or osteotomy of their metatarsals,
the second and third toes are isolated en bloc with their
sensory nerves (8) and extensor (6) and exor (7) ten-
dons, on the greater saphenous vein and the dorsalis
pedis– rst and second dorsal m etatarsal arterial
system (1,2).
Closure of the Donor Defect
The distal halves of the second and third m etatarsal
bones are rem oved. Then the heads of the rst and
fourth m etatarsals are approximated as closely as pos-
sible. The ends of the m etatarsal bones are covered
with local interosseous muscles, and the whole site is
covered with a split-thickness skin graft.

Figure 8–81
Incision.
1. Extensor hallucis brevis m.
2. Extensor hallucis longus tendon
3. Inferior extensor retinaculum
4. Extensor digitorum longus tendon
5. Dorsalis pedis a. and v. and deep peroneal n.
6. Lateral tarsal a. and v.
7. Tarsal branch of deep peroneal n.
Figure 8–82
Exposure of the extensor hallucis longus muscle.
1. Extensor hallucis brevis m.
2. Extensor hallucis longus tendon
3. Inferior extensor retinaculum
4. Extensor digitorum longus tendon
RECIPIENT SITE EXPOSURES
Exposure of the Dorsalis Pedis Artery
Incision (Fig. 8–81)
An incision is m ade from the m idpoint between the
medial and lateral malleoli to the proximal end of the
rst metatarsal interspace.
Exposure of the Extensor Hallucis
Longus Muscle (Fig. 8–82)
The deep fascia and inferior extensor retinaculum (3)
are divided, and the extensor hallucis brevis muscle (1)
and extensor hallucis longus tendon (4) are then ex-
posed.
438
II.8 LOWER EXTREMITY: ANKLE AND FOOT

RECIPIENT SITE EXPOSURES
439
Figure 8–83
Identi cation of the artery.
1. Extensor hallucis brevis m.
2. Extensor hallucis longus tendon
3. Inferior extensor retinaculum
5. Dorsalis pedis a., v., and deep peroneal n.
6. Lateral tarsal a. and v.
7. Tarsal branch of deep peroneal n.
Identi cation of the Artery (Fig. 8–83)
The extensor hallucis brevis muscle (1) is mobilized and
retracted laterally. The dorsalis pedis artery (5), accom-
panied by two veins, can subsequently be identi ed ly-
ing on the tarsal bones, and isolated. The deep peroneal
nerve (5) lies lateral to the artery.

Figure 8–84
Incision.
1. Posterior tibial a. and v.
6. Flexor digitorum longus tendon
2. Tibial n.
7. Flexor hallucis longus tendon
3. Achilles tendon
8. Medial malleolus
4. Laciniate ligament
9. Tuberosity of navicular bone
5. Tibialis posterior tendon
10. Abductor hallucis m.
Exposure of the Posterior Tibial
Artery behind the Medial Malleolus
Incision (Fig. 8–84)
A curved incision begins midway between the medial
malleolus and Achilles tendon, keeping 1 cm posterior
to the medial malleolus and running distally and ante-
riorly toward the tuberosity of the navicular bone.
440
II.8 LOWER EXTREMITY: ANKLE AND FOOT

RECIPIENT SITE EXPOSURES
441
Figure 8–85
Exposure of the artery.
1. Posterior tibial a. and v.
2. Tibial n.
3. Achilles tendon
4. Laciniate ligament
5. Tibialis posterior tendon
6. Flexor digitorum longus tendon
7. Flexor hallucis longus tendon
8. Medial malleolus
9. Tuberosity of navicular bone
10. Abductor hallucis m.
Exposure of the Artery (Fig. 8–85)
Dividing the deep fascia and laciniate ligam ent (4),
which forms a bridge between the medial malleolus (8)
and calcaneus, the posterior tibial artery (1), accompa-
nied by two veins, is identi ed between the exor digi-
torum longus (6) and exor hallucis longus (7) tendons.
The tibial nerve (2) lies posterior to the vessels. Under
the origin of the abductor hallucis (10), the posterior
tibial artery divides into m edial and lateral plantar
arteries.

Figure 8–86
Incision.
1. Medial plantar a., v., and n.
6. Flexor digitorum longus tendon
2. Lateral plantar a., v., and n.
7. Tibialis posterior tendon
3. Posterior tibial a. and v. and tibial n.
8. Calcaneus
4. Abductor hallucis m.
9. Tuberosity of navicular bone
5. Flexor hallucis longus tendon
Exposure of the Medial Plantar Artery
and Its Bifurcation with the Lateral
Plantar Artery
Incision (Fig. 8–86)
A curvilinear incision is made from the medial aspect of
the head of the rst metatarsal via the tuberosity of the
navicular bone to the m edial prom inence of the
calcaneus.
442
II.8 LOWER EXTREMITY: ANKLE AND FOOT

RECIPIENT SITE EXPOSURES
443
Exposure of the Artery (Fig. 8–87)
Dividing the deep fascia and laciniate ligam ent, the
abductor hallucis muscle and tendon (4) are exposed.
Using the tendon as a guide, the less distinctive margin
of the belly is separated from the tuberosity of the nav-
icular bone (9) and laciniate ligament.
Detaching the abductor hallucis from the m edial
side of the calcaneus (8), it is retracted plantarly,
taking care to save a pair of branches from the m edial
plantar nerve to the abductor hallucis. Now, the
medial plantar artery (1) and its bifurcation with the
lateral plantar artery (2) are identi ed distal to the me-
dial malleolus, and 5 cm behind the tuberosity of the
navicular bone (9), under the abductor hallucis (4).
Then the m edial plantar artery (1) runs distally
between the abductor hallucis and exor digitorum
brevis, whereas the lateral plantar artery (2) goes under
the exor digitorum brevis, obliquely toward the base
of the fth m etatarsal. The m edial plantar nerve (1) is
lateral to the artery.
Figure 8–87
Exposure of the artery.
1. Medial plantar a., v., and n.
6. Flexor digitorum longus tendon
2. Lateral plantar a., v., and n.
7. Tibialis posterior tendon
3. Posterior tibial a., v., and tibial n.
8. Calcaneus
4. Abductor hallucis m.
9. Tuberosity of navicular bone
5. Flexor hallucis longus tendon

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(Trang không có chữ)

Part III
Trunk

(Trang không có chữ)

9
Thorax
PECTORALIS MAJOR FLAP
Anatomy (Fig. 9–1)
The muscle origin consists of three subunits: a clavicu-
lar segment (1) from the medial half of the clavicle, a
sternocostal segment (2) from the sternum and anterior
surface of the upper six costal cartilages, and an ab-
dominal segment (3) from the anterior rectus sheath.
There is usually a distinct intermuscular septum with
loose connective tissue between the clavicular and ster-
nocostal segments. The abdominal segment, which has
a width of ~2 to 4 cm, is commonly fused morphologi-
cally to the sternocostal segment. It often has an inde-
pendent neurovascular supply, but its vascular supply is
somewhat variable.
Muscle insertion is on the lateral lip of the intertu-
bercular sulcus of the humerus, with a at tendon 5 cm
in width. The anterior layer of insertion is from the
bers of the clavicular segment and the middle portion
of the sternocostal segment. The posterior layer of inser-
tion is from the lower portion of the pectoralis major.
The muscle is broad, at, and fan-shaped. Its func-
tion is adduction and medial rotation of the arm. On av-
erage, the total width is 27.5 cm (the muscle belly, 22.7
cm; the tendon, 4.9 cm); its total length is 16 cm, and its
approximate thickness is 1.5 cm.
Blood Supply
The source of blood supply to the muscle includes the
thoracoacrom ial artery (5), the lateral thoracic artery
(10), the internal mammary artery, and the intercostal
artery. Among these vessels, the dominant blood sup-
ply is from the thoracoacromial artery (5), which arises
from the second part of the axillary artery. It courses
along the medial edge of the pectoralis minor for 1.5 to
3 cm before piercing the clavipectoral fascia and divid-
ing into four branches: pectoral (6), acrom ial (8), clavic-
ular (9), and deltoid (7).
The pectoral branch (6) descends between the
pectoralis m ajor and m inor m uscles. It enters the
sternocostal portion of the pectoralis m ajor 5 to 6 cm
below the m idpoint of the clavicle, or 3 to 5 cm
after its takeoff from the thoracoacrom ial trunk (5),
and ~5.5 cm lateral to the edge of the sternum . The
sternocostal and abdom inal portions of the m uscle
(2,3) (the lower four fths) can be nourished by this
branch.
The deltoid branch (7) usually arises with the acro-
m ial branch (8) and runs laterally with the cephalic
vein, crossing over the pectoralis m inor to supply the
deltoid muscle. In its course, it gives off one or two ma-
jor branches to supply the clavicular portion of the pec-
toralis m ajor (1), and a fasciocutaneous perforator
running through the deltopectoral groove to supply the
overlying skin of the clavicular portion of the pectoralis
m ajor and of the deltoid muscle.
The acrom ial branch (8) and clavicular branch (9)
are much smaller and less important. The former runs
laterally over the coracoid process and under the del-
toid, whereas the latter goes medially to the sternoclav-
icular joint and the subclavius.
The lateral thoracic artery (10) descends along the
lateral border of the pectoralis minor to the side of the
chest and runs to the serratus anterior, subscapularis,
and breast. In m ore than 70% of cases, it gives off a
branch with a diameter of ~1 mm , entering the abdom-
inal portion of the pectoralis major (3) ~5 cm inferior to
its origin from the axillary artery and ~1.5 cm medial to
the lateral edge of the muscle.

454
III.9 TRUNK: THORAX
Figure 9–1
Anatomy for
pectoralis major ap.
1. Clavicular segment
2. Sternocostal segment
3. Abdominal segment
4. Axillary a.
5. Thoracoacromial a.
6. Pectoral branch
7. Deltoid branch
8. Acromial branch
9. Clavicular branch
10. Lateral thoracic a.

PECTORALIS MAJOR FLAP
455
Innervation
The lateral pectoral nerve arises from the lateral cord of
the brachial plexus and then crosses the axillary artery
and vein anteriorly. After piercing the clavipectoral
fascia, it divides into several branches to supply the
clavicular portion and the upper part of the sterno-
costal portion of the pectoralis m ajor. It also form s
a loop with the m edial pectoral nerve to supply the
pectoralis minor.
The medial pectoral nerve arises from the m edial
cord of the brachial plexus and runs forward between
the axillary artery and vein under the deep surface of
the pectoralis m inor. It then divides into several
branches. One or two supply the pectoralis minor; two
or three pierce the pectoralis minor to supply the lower
part of the sternocostal portion of the pectoralis major;
and another passes around the lateral border of the
COMMENT AND INSIGHTS
Based on experience with local transfer for restoration
of elbow exion, the pectoralis major muscle ap was
one of the revascularized muscle transfers developed
comparatively early. Because of cosmetic disadvantages
(such as its proximity to the breast) and its short neu-
rovascular pedicle, the pectoralis major ap has not or-
dinarily been selected for free transfer. However, it is
frequently used for reconstruction of the neck, face, oral
cavity, or m andible, using local transfer, as a myocuta-
neous ap or as an osteomyocutaneous ap, because of
its particular anatomic location.
The abdominal segment of the muscle is not always
reliable for free transfer because the vascular pedicle
from the lateral thoracic artery is somewhat variable.
Generally, the sternocostal and abdom inal segm ents
are combined to provide a muscle ap of large or medium
size based on the pectoral branch of the thoracoacromial
artery. This type of muscle or myocutaneous ap was
rst reported in application for functional reconstruc-
tion of the exor m usculature in Volkmann’s ischemic
contracture.
The clavicular segm ent can be independently iso-
lated based on the deltoid branch of the thoracoacro-
m ial artery to provide a muscle ap of small size for free
transfer. The medial anterior half of the clavicle is avail-
able for inclusion in the m uscle ap. This procedure
was rst reported in application for intraoral recon-
struction and extrem ity reconstruction.
Clinical experience has indicated that the loss of the
pectoralis major muscle has minimal functional conse-
quences, particularly if one segment is preserved, either
the clavicular segment or another. The donor scar is
somewhat conspicuous and all the described procedures
should be used prudently, especially for young women.
pectoralis m inor to supply the abdominal portion of the
pectoralis m ajor.
Measurements
Diameter (mm)
Thoracoacromial (trunk)
Artery
3.2
Vein
3.5
Pectoral branch
Artery
2.0
Vein
3.0
Deltoid branch
Artery
2.0
Vein
3.0
Acromial branch
Artery
1.4
Vein
2.0
Clavicular branch
Artery
1.2
Vein
2.0
Lateral thoracic
Artery
1.6
Vein
2.0

PECTORALIS MAJOR MUSCLE FLAP
Sternocostal and Abdominal
Segments Combined
This procedure m ay provide at m axim um a m uscle ap
20 cm wide, 15 cm long, and 1.5 cm thick when it in-
cludes both segm ents. If the vascular anatomy of the
lateral thoracic artery is adequate (in ~70% of cases),
the abdom inal segm ent with a width of 4 cm at m ini-
m um can be independently isolated for vascularized
transfer.
456
III.9 TRUNK: THORAX
Figure 9–2
Incision.
1. Pectoralis major m.
2. Serratus anterior m.
3. External oblique m.
4. Clavicular head
5. Pectoralis minor m.
6. Deltoid m.
7. Lateral thoracic a. and v. and
medial pectoral n.
8. Thoracoacromial a. and v. and
lateral pectoral n.
Incision (Fig. 9–2)
An incision is made from the coracoid process, running
along the deltopectoral groove and the lateral border of
the pectoralis major toward the xiphoid.

Exposure of the Muscle (Fig. 9–3)
The lateral border of the muscle (1) is identi ed and the
skin ap over the m uscle is raised with undermining
and turned medially to expose the anterior surface of
the muscle (1).
PECTORALIS MAJOR MUSCLE FLAP
457
Figure 9–3
Exposure of the muscle.
1. Pectoralis major m.
2. Serratus anterior m.
3. External oblique m.
4. Clavicular head

Detachment of Its Origin and Elevation of
the Distal Muscle Flap (Fig. 9–4)
The origins of the muscle are detached from the anterior
rectus sheath, the sternum, and the ribs, according to the
width requirements of the muscle ap. However, detach-
ment is usually limited below the level of the sternal angle
because the muscle bers over this level are dominantly
supplied by the clavicular branch on occasion.
The upper part of the anterior rectus abdom inis
sheath can be included in the m uscle ap because it
serves to secure the ap to the tendons at the recipient
site. As the ap is raised from the chest wall proximally,
the neurovascular bundles of the pectoral vessels (8)
and the lateral thoracic vessels (7) are gradually dis-
played in the undersurface of the muscle.
458
III.9 TRUNK: THORAX
Figure 9–4
Detachment of its origin
and elevation of the distal muscle ap.
4. Clavicular head
5. Pectoralis minor m.
7. Lateral thoracic a. and v. and medial
pectoral n.
8. Thoracoacromial a. and v. and lateral
pectoral n.

Identi cation of the Neurovascular
Structure (Fig. 9–5)
The posterior layer and a part of the anterior layer of
the muscle insertion are detached. Dissection and eval-
uation of the neurovascular pedicles (7,8), the lateral
thoracic vessels (7), the medial pectoral nerve (7), the
pectoral vessels (8), and the lateral pectoral nerve (8)
follow at the lateral and m edial borders of the pec-
toralis minor (5) and in front of it. Subsequently, the en-
trances of these neurovascular pedicles are de ned.
PECTORALIS MAJOR MUSCLE FLAP
459
Figure 9–5
Identi cation of the
neurovascular structures.
4. Clavicular head
5. Pectoralis minor m.
6. Deltoid m.
7. Lateral thoracic a. and v. and
medial pectoral n.
8. Thoracoacromial a. and v. and
lateral pectoral n.

Pedicle Dissection and Flap Completion
(Fig. 9–6)
With care taken to protect these neurovascular bundles,
the muscle bers are split at the proposed level of the pec-
toralis major m uscle and the ap (with sternocostal and
abdominal segments combined) is raised from the chest
wall. The vascular pedicles can be dissected to their parent
trunks—the lateral thoracic vessels and thoracoacromial
vessels—obtaining pedicle lengths of 3 to 4 cm.
As mentioned previously, it is usual for the pectoral
artery to nourish both sternocostal and abdominal seg-
m ents dom inantly. Although an abdom inal segm ent
only ~4 cm wide is needed, the lateral thoracic artery
(7) should also be carefully evaluated. Flap innervation
m ay be determined by electrically stimulating each of
the branches.
460
III.9 TRUNK: THORAX
Figure 9–6
Pedicle dissection
and ap completion.
4. Clavicular head
5. Pectoralis minor m.
7. Lateral thoracic a. and v. and
medial pectoral n.
8. Thoracoacromial a. and v. and
lateral pectoral n.

PECTORALIS MAJOR
MYOCUTANEOUS FLAP
Flap Design (Fig. 9–7)
The location, size, and shape of the skin paddle can be
variably designed. To avoid the breast, the territory of
the skin paddle is usually de ned below the nipple-
areola in m en or the infram am m ary fold in wom en,
above the costal m argin, lateral to the costochondral
line, and m edial to the anterior axillary line.
PECTORALIS MAJOR MYOCUTANEOUS FLAP
461
Figure 9–7
Flap design.
1. Pectoralis major m.
2. Pectoralis minor m.
3. Deltoid m.
4. Lateral thoracic a. and v.
5. Thoracoacromial a. and
v. and lateral pectoral n.
6. Clavicular head

Flap Harvesting (Fig. 9–8)
The pectoralis m ajor myocutaneous ap can be har-
vested following the principles of the muscle ap pro-
cedure.
462
III.9 TRUNK: THORAX
Figure 9–8
Flap harvesting.
1. Pectoralis major m.
2. Pectoralis minor m.
3. Deltoid m.
4. Lateral thoracic a. and v.
5. Thoracoacromial a. and v. and lateral
pectoral n.
6. Clavicular head

PECTORALIS MAJOR
OSTEOMYOCUTANEOUS FLAP
Flap Design (Fig. 9–9)
Commonly, the fth rib is selected for inclusion in the
ap. The proposed skin paddle and fth rib are marked.
PECTORALIS MAJOR OSTEOMYOCUTANEOUS FLAP
463
Figure 9–9
Flap design.
1. Pectoralis major m.
2. Pectoralis minor m.
3. Fifth rib
4. Lateral thoracic a. and v. and medial
pectoral n.
5. Thoracoacromial a. and v. and lateral
pectoral n.
6. Clavicular head
7. Deltoid m.
8. Pleura
9. Intercostal muscles

Flap Harvesting (Fig. 9–10)
The intercostal muscles (9) of the fth rib space are di-
vided down to the pleura (8) along the upper border of
the sixth rib. The pleura is then carefully separated
from the fth costal segment, and both ends of the rib
are cut to the desired length. The intercostal muscles of
the fourth rib space are divided from their deep surface,
and the pectoralis major (1) with the skin paddle and
fth rib (3) are lifted off the chest wall according to the
principles of the muscle ap procedure.
464
III.9 TRUNK: THORAX
Figure 9–10
Flap harvesting.
1. Pectoralis major m.
2. Pectoralis minor m.
3. Fifth rib
4. Lateral thoracic a. and v. and
medial pectoral n.
5. Thoracoacromial a. and v. and
lateral pectoral n.
6. Clavicular head
7. Deltoid m.
8. Pleura
9. Intercostal m.

CLAVICULAR SEGMENT OF THE
PECTORALIS MAJOR MUSCLE FLAP
The clavicular segment provides a ap with a length of
12 cm, a width of 5 to 6 cm, and a thickness of 0.8 cm.
Incision (Fig. 9–11)
An incision is made from the sternoclavicular joint via
the midpoint of the clavicle and then running along the
deltopectoral groove.
CLAVICULAR SEGMENT OF THE PECTORALIS MAJOR MUSCLE FLAP
465
Figure 9–11
Incision.
1. Deltoid m.
2. Sternocostal head
3. Clavicular head
4. Cephalic v.
5. Clavicle
6. Thoracoacromial a. and v. and lateral pectoral n.
7. Pectoralis minor m.
8. Deltoid a. and v.

Identi cation of the Intermuscular
Septum (Fig. 9–12)
The skin is undermined to expose the cephalic vein (4)
in the groove between the deltoid and the pectoralis
major muscles. The interseptum between the clavicular
(3) and sternocostal (2) portions of the muscle can be
identi ed from the sternoclavicular joint to its inser-
tion, and it is then carefully split.
466
III.9 TRUNK: THORAX
Figure 9–12
Identi cation
of the intermuscular septum.
1. Deltoid m.
2. Sternocostal head
3. Clavicular head
4. Cephalic v.

Dissection of the Neurovascular
Pedicle (Fig. 9–13)
The cephalic vein (4) is isolated and traced to nd the
deltoid artery (8) that accompanies the vein. Then the
insertion of the clavicular portion (3) is divided. Tracing
the deltoid artery from distal to proximal, the neurovas-
cular branches from the artery to the lateral pectoral
nerve (6) are identi ed and the deltoid artery (8) is then
ligated distal to these branches.
CLAVICULAR SEGMENT OF THE PECTORALIS MAJOR MUSCLE FLAP
467
Figure 9–13
Dissection of
the neurovascular pedicle.
1. Deltoid m.
2. Sternocostal head
3. Clavicular head
4. Cephalic v.
5. Clavicle
6. Thoracoacromial a. and
v. and lateral pectoral n.
7. Pectoralis minor m.
8. Deltoid a. and v.

Further Dissection and Muscle Flap
Completion (Fig. 9–14)
Gradually turning the detached insertion medially, the
deltoid artery is dissected further in the clavipectoral
fascia to the thoracoacrom ial trunk (6), ligating the
acrom ial, clavicular, and pectoral arteries. Its pedicle
can be 4 to 6 cm. If a longer pedicle is required, the pec-
toral artery can be dissected and included with the del-
toid artery for reverse ow in the pedicle. The cephalic
vein (4) is also available for a vein graft.
The origin of this portion of the muscle is detached
from the clavicle, and the clavicular segment (3) of the
pectoralis major muscle ap is raised based on the del-
toid artery and the lateral pectoral nerve.
468
III.9 TRUNK: THORAX
Figure 9–14
Further dissection and muscle ap completion.
2. Sternocostal head
3. Clavicular head
4. Cephalic v.
6. Thoracoacromial a. and v. and lateral pectoral n.
7. Pectoralis minor m.
8. Deltoid a. and v.

Osteomuscular Flap Pattern at This
Donor Site (Fig. 9–15)
If an osteomuscular ap is required, the anteroinferior
half of the clavicle (5) is divided with an oscillating saw,
including in the ap the attachment of the muscle (3)
and leaving the posterosuperior half of the clavicle (5)
intact to support the shoulder.
CLAVICULAR SEGMENT OF THE PECTORALIS MAJOR MUSCLE FLAP
469
Figure 9–15 Osteomuscular ap pattern at this donor site.
1. Deltoid m.
3. Clavicular head
4. Cephalic v.
5. Clavicle
6. Thoracoacromial a. and v. and lateral pectoral n.
7. Pectoralis minor m.

Myocutaneous Flap Pattern at This
Donor Site (Fig. 9–16)
If a myocutaneous ap is required, a skin paddle is out-
lined on or slightly over the territory of the muscle por-
tion that is de ned by three points as a triangle—the
sternoclavicular joint, the m idpoint of the clavicle, and
the muscle insertion.
The myocutaneous ap is raised as previously de-
scribed.
470
III.9 TRUNK: THORAX
Figure 9–16
Flap design for myocutaneous pattern at this donor site.

The lateral thoracic artery (3) arises from the beginning
of the third portion of the axillary artery (2). It gives off
a branch to the pectoralis minor (1) with a diameter of
0.5 to 0.9 mm before it courses around the lateral mar-
gin of the muscle. The direct branch (6) of the axillary
artery arises from the second arterial portion behind
the muscle.
(For the arterial anatomy of the thoracoacrom ial
artery, refer to the section on the details of the pec-
toralis major.)
A branch supplying the upper part of the m uscle
comes from the pectoral artery (5), which then courses
around the medial margin of the muscle.
Venous drainage is variable; there are several veins
including venae comitantes and a direct vein.
PECTORALIS MINOR MUSCLE FLAP
471
Figure 9–17
Applicable anatomy
for the pectoralis minor ap.
1. Pectoralis minor m.
2. Axillary a.
3. Lateral thoracic a.
4. Thoracoacromial a.
5. Pectoral branch
6. Direct branch of axillary a.
PECTORALIS MINOR MUSCLE FLAP
Anatomy (Fig. 9–17)
The origin of the pectoralis minor muscle is the upper
m argins and outer surface of the third to fth ribs
(sometim es including the second rib) near their carti-
lage, and the aponeurosis covering the intercostals. Its
insertion is the medial border of the coracoid process of
the scapula. The muscle functions to depress the shoul-
der and to rotate the scapula downward. The average
muscle length is 12 cm in adults.
Blood Supply
The arterial supply is variable and may be from three
arterial trunks: the lateral thoracic artery (3), the direct
branch (6) of the axillary artery, and the pectoral
branch (5) of the thoracoacrom ial artery (4). Usually,
the branch from the lateral thoracic artery (3) appears
predominant. If it is absent or too slender, the direct
branch (6) of the axillary artery can be a second choice.

Innervation
The lower two or three digitations of the m uscle are
dominantly innervated by a major branch of the m edial
pectoral nerve, whereas the uppermost digitations are
supplied by a tiny branch of the lateral pectoral nerve.
However, a larger branch of the lateral pectoral nerve
also penetrates the muscle (but does not innervate it) to
supply the pectoralis major. Usually, the two nerves join
loosely before entering the pectoralis m inor muscle.
472
III.9 TRUNK: THORAX
Although the vascular structure supplying the pectoralis
minor is variable, the dominant vascular pedicle can
usually be clari ed. Generally, the lateral thoracic vessels
are chosen as the dominant pedicle, but pedicle length is
limited to less than 3 cm. The muscle and its neurovas-
cular structures are deeply located, making the harvest-
ing procedure somewhat dif cult and complicated.
Clinically, the pectoralis m inor m uscle ap has
been reported in functional reconstruction of the facial
m usculature for reanimation in facial palsy. Because of
its adequate shape, small size, atness, and thickness,
this muscle ap is ideally suited for use in the face, es-
pecially because its dual nerve supply allows for inde-
pendent movement of the upper and lower portions.
The function of the pectoralis minor is not signi -
cantly important and there is no disability following its
removal. The donor scar is relatively inconspicuous.
COMMENT AND INSIGHTS
Figure 9–18
Incision.
1. Pectoralis minor m.
2. Pectoralis major m.
3. Serratus anterior m.
4. Lateral thoracic a. and v.
5. Medial pectoral n.
6. Thoracoacromial a. and v.
7. Pectoral branch
8. Lateral pectoral n.
9. Axillary a. and v. and brachial plexus
10. Direct branch of axillary a. and v.
Harvesting Technique
Incision (Fig. 9–18)
With the patient in a supine position, an incision is
made from the coracoid process along the lateral edge
of the pectoralis major to a point below the breast.

Dissection of the Lateral Thoracic
Vessels (Fig. 9–19)
The lateral edge of the pectoralis major m uscle (2) is ex-
posed and retracted medially and anteriorly. Then the
lateral thoracic vessels (4) are identi ed and isolated
under the lateral part of the pectoralis major. Ligating
the branches to the pectoralis m ajor (2) and serratus
anterior (3) muscles, the lateral thoracic vessels (4) are
traced to the undersurface of the pectoralis minor (1).
PECTORALIS MINOR MUSCLE FLAP
473
Figure 9–19
Dissection of the
lateral thoracic vessels.
1. Pectoralis minor m.
2. Pectoralis major m.
3. Serratus anterior m.
4. Lateral thoracic a. and v.
9. Axillary a. and v. and brachial
plexus

Detaching the Insertion and Assessing
the Dominant Pedicle (Fig. 9–20)
The insertion of the pectoralis m inor is then divided
from the coracoid process and retracted downward
with a holding suture, displaying and assessing the
neurovascular structures. It is sometimes necessary to
partially divide the pectoralis major (2) at its insertion
to gain greater access.
The dom inant arterial and venous supplies are
clari ed, and the m edial and lateral pectoral nerves
(5,8) and their com municating loop are identi ed and
dissected.
474
III.9 TRUNK: THORAX
Figure 9–20
Detaching the insertion
and assessing the dominant pedicle.
1. Pectoralis minor m.
2. Pectoralis major m.
4. Lateral thoracic a. and v.
5. Medial pectoral n.
6. Thoracoacromial a. and v.
7. Pectoral branch
8. Lateral pectoral n.
9. Axillary a. and v. and brachial plexus
10. Direct branch of axillary a. and v.

Completion of Harvesting (Fig. 9–21)
Detaching the muscle origin from the third to fth ribs,
the pectoralis minor muscle ap (1) is raised from the
chest wall, based on the dominant neurovascular pedi-
cle (4), which can be dissected up to the axillary vessels
(9), providing a pedicle length of 2 to 3 cm.
PECTORALIS MINOR MUSCLE FLAP
475
Figure 9–21
Completion of harvesting.
1. Pectoralis minor m.
2. Pectoralis major m.
4. Lateral thoracic a. and v.
9. Axillary a. and v. and brachial plexus

SERRATUS ANTERIOR FLAP
Anatomy (Fig. 9–22)
Muscle origin: outer surfaces and superior border of the
upper eight or nine ribs.
Insertion: ventral surface of vertebral border of the
scapula (8).
Shape: broad, at.
Function: moves the scapula forward away from spine
and xes the scapula against the chest wall.
Blood Supply
The muscle receives its blood supply from two sources:
the upper four or ve digitations are from the lateral
thoracic artery, and the lower ve or six digitations are
from the thoracodorsal artery.
The lateral thoracic artery (6), as the main trunk (see
section on details of the pectoralis major ap), follows the
lower border of the pectoralis minor and runs inferiorly
on the surface of the anterior part of the upper digitations
of the muscle. It gives off multiple branches to them.
The thoracodorsal artery (4) (see Chapter 11 on
details of the latissim us dorsi flap) gives off one to
three branches (5) to the serratus anterior. In 66% of
cases, there is only a single branch, 5 cm before the
entrance to the latissim us dorsi, w ith an average
diam eter of 2 m m . In 32% of cases, there are two
branches, 4 and 7 cm before the entrance, w ith diam -
eters of 1 m m . In 2% of cases, there are three or four
branches to the m uscle.
Innervation
The long thoracic nerve (7) formed by the fth, sixth,
and seventh cervical nerves, pierces the substance of
the scalenus medius and descends behind the brachial
plexus and the axillary artery. It reaches the upper bor-
der of the serratus anterior at the apex of the axillary
fossa and then runs downward on the lateral surface of
the muscle between the middle and posterior axillary
line. It joins the serratus branch of the thoracodorsal ar-
tery at the level of the sixth digitation. In its course, the
long thoracic nerve gives off branches to supply each
digitation.
476
III.9 TRUNK: THORAX
Figure 9–22
Applicable anatomy for the serratus anterior ap.
1. Axillary a.
2. Subscapular a.
3. Circum ex scapular a.
4. Thoracodorsal a.
5. Branch to the serratus anterior
6. Lateral thoracic a.
7. Long thoracic n.
8. Scapular bone

SERRATUS ANTERIOR FLAP
477
This is a medium-sized muscle ap with a long pedicle.
The outstanding advantage of the ap is in its possible
combination with vascularized ribs or latissimus dorsi
aps. Following the latissim us dorsi ap, this muscle
ap was one of the earliest applied aps. However, it
has not been widely used, even though its vascular
anatomy is constant and reliable. Surgeons prefer the
latissim us dorsi donor site to that of the serratus
anterior.
The serratus anterior ap has been applied in rean-
im ation of facial paralysis, coverage of hands or feet
with cutaneous aps or skin grafts, reconstruction of
the m andible with an osteomyocutaneous ap, and
chest-wall reconstruction with local transfer. The donor
scar is acceptable and the skin defect after myocuta-
neous ap transfer can usually be closed directly.
To prevent a “winging” scapula and limitations in
arm m ovem ent resulting from loss of m uscle func-
tion, maximal preservation of the upper digitations and
their innervation is suggested. The use of the middle or
lower portion (four or ve digitations) as the donor is
advisable.
COMMENT AND INSIGHTS