The document describes the pectoralis major island flap technique. It can be used for reconstruction of the pharynx, tongue, face, neck, and skullbase defects. The flap has a large arc of rotation from the clavicle to the xiphoid process. It provides a single stage transfer with a muscle carrier but does not match the color and texture of facial skin. The document outlines the surgical technique including flap design, elevation of the vascular pedicle, and closure of the donor site. Variations including osteomyocutaneous flaps with rib bone and use of the flap as a free tissue transfer are also discussed. Complications, risk factors, and modifications to the technique are summarized.

2.  Ariyan 1979
 Work house flap for head and neck reconstruction
 Regional pedicle flap

3. USES
 The pectoralis major island flap can be used in reconstructions
1. Pharynx
2. Tongue
3. Face
4. Neck
5. To cover the carotid artery when this vessel is at risk due to prior
irradiation
6. Skullbase defects.

4. PREOPERATIVE CONSIDERATIONS
 TIMING : trauma-related avulsive wound is delayed
 ARC OF ROTATION :The arc of rotation extends in an oblique fashion from the
lateral head of the clavicle to the xiphoid process.
 SIZE OF THE DEFECT : 6*6 cm without having to skin graft the chest wall
 COLOR MATCH : does not provide tissue of similar color as the facial skin
 TRAUMA TO THE THORACOACROMIAL AXIS-previous accidents,subclavian
vein puncture

5. ANATOMY
Insertion:Lateral lip of bicipital groove
of humerus
Origin: medial half od clavicle,upper six
costal cartilage,medial sternum,sheath
of abdominus rectus oblique

7. NERVES AND VESSELS
Thoracoacromian artery,lateral thoracic
artery,superior thoracic artery,intercostal
perforators from internal mammary artery
medial (C5–C7) and lateral (C8-T1)
pectoral nerves

11. Deep relations of pectoralis major
vascular pedicle, the pectoralis minor muscle,
the costal cartilages, and inferiorly the costal
attachments and the external oblique muscle

13. Ariyan technique

15. Flap design
 Muscular or musculocutaneous flap, with or without the 4th or 5th ribs

16. Positioning, prepping and draping
 Supine position with the chest exposed and prepped up to the midline, and
inferiorly to the costal margin.
 The upper arm is abducted slightly to expose the anterior axillary fold and
lateral chest wall.

17. Surface markings of vascular pedicle
Ariyan line:drawing a line
from the shoulder to the
xiphisternum and another line
vertically from the midpoint
of the clavicle to intersect the
1st line

19. Skin paddle design
•Over the pectoralis major muscle along the
course of the pectoral branch of the
thoraco-acromial artery
•The distance between the top of the skin
paddle and the inferior edge of the clavicle
should equal or exceed the distance
between the recipient site for the flap and
the inferior edge of the clavicle
•Skin paddle should be
marked on the inferomedial portion of the
flap corresponding
to the size of the defect

21. Medial incision
Lateral incision line

22. Elevation of skin paddle
Bevel the dissection radially so
as to include as many
myocutaneous perforators as
possible that supply the skin
paddle
An incision is extended
laterally from the peripheral
margin of the skin paddle along
the anterior axillary fold, which
corre-sponds with the lateral
margin of the pec-toralis major
muscle

23. Exposure of pectoralis major muscle
The skin paddle is tacked to the
underlying pectoralis major muscle with a
few sutures so as to minimise the risk of
shearing injury to the myocutaneous per-
forators
The skin and breast tissue above the skin
paddle is then widely elevated from the
pectoralis major muscle with diathermy
up to the clavicle

24. Elevation of pedicle
•The dissection plane between the
pectoralis minor and major muscles
and the vascular pedicle is found by
dissecting along the lateral border
of the pectoralis major muscle
along the clavipectoral fascia
•The plane is avascular and can be
opened easily with blunt dissection

25. Vascular pedicle seen in
the fascia beneath the
pectoralis major

27. Rotated pmmc
Degree of rotation
The arc of rotation extends
in
an oblique fashion from the
lateral head of the
clavicle to the xiphoid
process
Improving arc of rotation-
1. Remove insertion part
into humerus
2. Sacrifice lateral and
medial pectoral nerves

28. Clinical Atlas Of Muscle And
Musculocutaneous Flaps
Mathes and Nahai

29. Gaining additional length
•The 1st is to transect the
pectoralis major muscle
just below the clavicle,
taking great care to
preserve the vascular
pedicle
•The 2nd maneuver to
gain additional length is
to pass the flap behind
the clavicle

30. Closure of donor site defect
 The donor site is either closed primarily with a closed suction drain, or a
split skin graft is applied. Primary closure may be facilitated by
undermining the surrounding skin.

31. Osteomyocutaneous flap
 Ribs and sternum can be used

32. rib
•Given by Ariyan
•Fourth or fifth rib is taken along with the periosteum
•7 -11 cm of bone is available

33. sternum
•Proposed by Green in 1981
•Taken as outer table alone or in full thickness

35. advantages
 Single stage transfer
 Insetting based on a muscle carrier
 Improved bone vascularity
 Less operating time as compared to free flap

36. disadvantages
 Perforation of pleura
 removal of the full thickness of the sternum is on the left side, the patient
has postoperative discomfort due to heart palpitations. Therefore only the
outer table of the sternum should be removed
 Limited bone amount
 Unwanted soft tissue bulk

37. Ao plate and osteomyocutaneous flap

38. Advantages
 Large skin territory
 Can be transferred without any delay
 Large arc of rotation
 If the muscle flap is used to cover intraoral defects, the muscular surface
mucosalizes even without the use of a skin paddle

39. Disadvantages :-
 The loss of the skin paddle caused by possible shearing of the perforators
during surgery.

40. complication
 Recipient site complication:
1. partial or total flap necrosis
2. wound infection
3. fistula formation
4. wound dehiscence
5. Muscle twitching

41.  Donor site complication
1. Uncontrolled bleeding
2. Hematoma
3. Dehiscence
4. Infection
 Rare complications
1. Rib osteomyelitis
2. Metastatic spread of tumour to base of flap

42. Risk factors
 who are greater than 70 years of age, female, overweight were more likely at
risk to develop complications
 who have albumin levels less than 4 g/dL;
 presence of systemic diseases, such as diabetes mellitus, hypertension,
atherosclerotic heart disease, peripheral vascular disease,renal failure, and
collagen vascular disease
 Previously irradiated patients

43. precautions
 Take larger skin paddle
(lead to a greater capture of vessel perforators leading to decreased loss of
the skin paddle compared with smaller skin paddles that lead to vascular
insufficiency)
 Suture the skin paddle to the muscle
(Prevents shearing of the perforators and, therefore, prevents loss of the
skin paddle)
 Judicious use of the electrocautery
(excessive use can lead to coagulation of the vessels and compromising the
vascular pedicle through retrograde thrombosis)

44. contraindication
 Prior radical axillary nodal dissection
 Morbidly obese patients
 Congenitally missing the pectoralis muscle,as patients with Poland
syndrome
 Patients with previous trauma or surgery to the chest wall
 Patients with vocations requiring full range of motion in their shoulders
and arms

45. Poland syndrome
underdevelopment or absence of the chest muscle
(pectoralis) on one side of the body, and usually also
webbing of the fingers (cutaneous syndactyly) of the hand
on the same side (the ipsilateral hand).

47. Modification
Bipaddle pectoralis major myocutaneous flap

48. Free flap
 Tissue along with its blood supply is completely detached from its original
location and then transferred to another location and circulation in the
tissue is re established by anastamosis of artery and vein.

49. references
 Functional oromandibular reconstructionusing a sternum pectoralis
major osteomyoctaneous composite flap
Int. J. Oral Maxillofac. Surg. 1987: 16:604-608
 Clinical Atlas Of Muscle And Musculocutaneous Flaps
Mathes and Nahai
 Pectoralis major myocutaneous flap
Oral Maxillofacial Surg Clin N Am 15 (2003) 565–575

50.  Pectoralis Major Myocutaneous Flap
Ketan Patel, DDS, PhDa,*, Diana Jee-Hyun Lyu, DDSb, Deepak Kademani,
DMD, Mda
Oral Maxillofacial Surg Clin N Am 26 (2014) 421–426
 The pectoralis major flap
Johan Fagan
Otolaryngology, Head & Neck Operative Surgery

51.  Two volume Petersons
 Mathes volume 1 Plastic Surgery

52.  Thank you

53. Quazi Ghazwan Ahmad*, Suresh Navadgi, Ritu Agarwal, Harsh Kanhere,
Kanti P. Shetty, R. Prasad
Journal of Plastic, Reconstructive & Aesthetic Surgery (2006) 59, 166–173

54. Perforators of pectoralis major
 P1: along the medial edge of the muscle, direct musculocutaneous
branches from the internal mammary artery
 P2: 2–4 cm medial to the nipple, coming from the anterior intercostal
branch of internal mammary artery
 P3: fine branches reaching the skin by curving around the lateral border
of the muscle.
 Some branches of the lateral thoracic artery are found in the skin lateral
to the nipple at the level of 4th rib

55.  rich anastomotic network within the muscle, blood supply from
acromiothoracic artery safely reaches the skin even after ligation of the
branches of the internal mammary and lateral thoracic artery

56. Flap design and operative technique
 The paddle is placed horizontally, including the nipple, extending from
midline medially and crossing the lateral border of the muscle laterally

57.  The lateral paddle bearing the areola is inset into the lining defect.
 The paddle for the skin defect is placed on the medial edge of the muscle
based on P1 perforators.

58. An elliptical incision is then
made involving both paddles and deepened till the muscle.
If the nipple is prominent then it is excised
and closed with a single stitch
Then the skin between the paddles is
incised till the subcutaneous fat to facilitate inset of the
medial paddle into the cutaneous defect

59. advantage
 As the paddle is placed along the transverse axis, the reach of flap is not
compromised

60. Material and methods
 47 patients with full thickness cheek defects and segmental
mandibulectomy who underwent reconstruction with bipaddle PMMC
flaps between May 2000 and July 2004.

61.  24 patients had lesions involving left buccal mucosa, 19 with right buccal
mucosa, one involving the middle 1/3 of alveolus and floor of mouth, one
with left alveolar carcinoma, one with right alveolar carcinoma and one
patient had involvement of right buccal mucosa and cheek, extending to
infra temporal fossa.

62.  All patients underwent composite resection (wide excision of the primary
tumour with segmental mandibulectomy and neck dissection in
continuity).

65. results
 The size of the paddle used for mucosal defect cover ranged from 5*3 to 9*7
cm and the size of the paddle used for skin cover ranged from 4*4 to 9*8
cm. The total size of flap ranged from 10*5 to 17*7 cm.

67.  All patients were male.
 One patient had complete loss of flap (2.12%). Sixteen patients had minor
complications all of which settled with conservative management. The
follow up period varied from 1 month to 4 years

68. CONCLUSION
Authors conclude that this method of bipaddling the
pectoralis major myocutaneous flap is a useful
technique for reconstruction of complex composite
cheek defects in male patients

69.  The end

70.  It leads to atrophy of the flap that is beneficial for head and neck defects,
especially if gross contour defects are visible extraorally