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The Deltopectomyomammary Flap: A New Flap for Use in Coverage of Large Anterior Chest Wall Defects

Spiess, Alexander M. M.D.; Baciewicz, Frank A. Jr M.D.; Gursel, Eti M.D.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 226e-227e
doi: 10.1097/01.prs.0000305387.70989.49
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Sir:

After Bakamjian’s description of the deltopectoral fasciocutaneous flap in 1965,1 it was used extensively for head and neck reconstruction. In 1976, Robinson described the use of the deltopectoral flap for chest wall reconstruction.2 In 1978, Arnold and Pairolero described the pectoralis major muscle flap for use in coverage of anterior chest wall defects.3 Utilization of the breast to cover chest wall defects was first advocated by Schepelmann in 1924.4 Since then, several articles in the literature have advocated the use of breast skin flaps and myocutaneous breast flaps to cover anterior thoracic defects, as outlined by Hallock5 and Hughes et al.6 We describe a modification of the Bakamjian flap that includes elements of the pectoralis major muscle flap and the cutaneous breast flap. This deltopectomyomammary flap was used to successfully cover a 30 × 40-cm2, left-sided anterior thoracic wall defect.

The patient had a history of left breast cancer, underwent radical mastectomy, and years later developed an anterior chest wall recurrence that was treated with radiation therapy. She developed a chronic chest wound that was reconstructed with a left pedicled latissimus dorsi flap and, later, a right pedicled rectus abdominis flap, each of which failed secondary to underlying untreated chest wall osteomyelitis. All of her previous treatment was at outside institutions. She presented with chronic mucopurulent drainage from the left side of her chest wall wound that required debridement and reconstruction. Previous use of the left latissimus dorsi and right rectus abdominis muscles narrowed the list of reconstructive options. Free flap closure was also impossible, given the limited availability of local donor vessels secondary to this destructive chest wall process. Preoperatively, we designed a modification of the Bakamjian flap, which included carrying the right breast (skin and breast tissue) and pectoralis major muscle with the flap, thus creating a deltopectoral myocutaneous breast flap for reconstruction. A suspicious mass discovered within the right breast tissue during preoperative mammography necessitated right mastectomy at the time of left chest wall reconstruction. To maintain the integrity of our flap design, a skin-sparing mastectomy was to be utilized to preserve the overlying breast skin, which was intended to be included in our flap.

Debridement of her wound left a chest wall defect of soft tissue and bone measuring 30 × 40 cm2. A right subcutaneous mastectomy was performed through an inframammary fold incision, preserving the medial perforators from the right internal mammary artery to the overlying breast skin. The pectoralis major was then elevated off of its inferior chest wall, humeral, and lateral clavicular attachments, including ligation of the right thoracoacromial trunk, leaving the muscle attached to the chest wall by only its superomedial clavicular and sternal attachments. What remained was a huge breast skin flap attached to the pectoralis major muscle superomedially and supplied only by the first few right internal mammary artery perforators (Fig. 1). The flap was then rotated over on its pedicle, tailored to fit the defect, and inset into the wound (Fig. 2).

Fig. 1.
Fig. 1.:
Chest wall defect after debridement. Flap elevation and rotation: the pedicle is marked with an arrow.
Fig. 2.
Fig. 2.:
Inset flap.

We have presented a patient with a significant anterior chest wall defect and limited reconstructive options. She successfully underwent reconstruction of this defect with a modification of the Bakamjian deltopectoral flap, which included a pectoralis major and breast skin myocutaneous component. We describe and illustrate the elevation and rotation of this deltopectomyomammary flap as another potential pedicled, myocutaneous composite flap for reconstruction of large anterior chest wall defects.

Alexander M. Spiess, M.D.

Frank A. Baciewicz, Jr., M.D.

Eti Gursel, M.D.

Allegheny General Hospital

Pittsburgh, Pa.

REFERENCES

1. Bakamjian, V. Y. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast. Reconstr. Surg. 36: 173, 1965.
2. Robinson, D. W. The deltopectoral flap in chest wall reconstruction. Br. J. Plast. Surg. 29: 22, 1976.
3. Arnold, P. G., and Pairolero, P. C. Chondrosarcoma of the manubrium: Resection and reconstruction with pectoralis major muscle. Mayo Clin. Proc. 53: 54, 1978.
4. Schepelmann, E. Zur plastische Deckung nach Mammaamputation. Zentralbl. Gyneaekol. 48: 1902, 1924.
5. Hallock, G. G. The breast musculocutaneous flap for complete coverage of the median sternotomy wound. Plast. Reconstr. Surg. 112: 199, 2003.
6. Hughes, K. C., Henry, M. J., Turner, J., and Manders, E. K. Design of the cyclops flap for chest-wall reconstruction. Plast. Reconstr. Surg. 100: 1146; discussion 1152, 1997.

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