We have read the article by Antony et al. with interest.1 First of all, we would like to congratulate the authors for the quality of their work and video. Their technique is based on a very basic though very important principle of plastic surgery: to restore form and function.
The authors describe the use of a cranially based pectoralis major flap by partially dividing the muscle's sternal insertions and by intramuscular division of the flap. Their flap not only allows wide vessel exposure to perform a comfortable anastomosis but also restores almost completely the normal anatomy of the pectoralis major muscle by suturing the muscle back in place. The sutured muscle, according to the video, is sutured slightly cranial to its former position, to leave more space for the anastomosed pedicle.
The technique, as shown by their former article,2 has excellent results. When a negligible (1.5 to 2.0 cm) amount of rib is resected, adequate vessel exposure is obtained and, provided that adequate muscle coverage is maintained, the chest wall deformity is not visible, even in thinner patients.
To create a muscular flap to do this, however, is not necessary. From our experience with perforator flaps, we have all learned that muscle fibers may be separated parallel to their direction without being interrupted while giving excellent exposure.
This is the principle we apply in harvesting the internal mammary vessels. The pectoralis major muscle is retracted at the level of the rib chosen. Its fibers are not divided but only separated along their axis. This allows excellent exposure in a completely bloodless field. To transect a muscle may cause bleeding, which may disturb microvascular anastomosis.
The rest of the technique is similar to the authors' technique. Once the anastomosis is complete, retractors are released and the muscle goes back to its normal position, as its insertions were never severed. The pedicle will not be compressed, and the space left by rib resection will be covered with the muscle, which does not need to be sutured back in place.
The presence of the pectoralis major is never compromising in terms of exposure. When exposure is not adequate, as the authors themselves correctly state, the intercostal muscles are to be resected. Thus, it is not really necessary to create a muscle flap to achieve exposure. We have used this technique for 3 years now, in 60 patients, and neither chest wall deformities nor pedicle compressions have been observed.
Salvatore D'Arpa, M.D.
Francesco Moschella, M.D.
Cattedra di Chirurgia Plastica e Ricostruttiva
Dipartimento di Discipline Chirurgiche ed Oncologiche
Università di Palermo
1.Antony AK, Kamdar M, Da Lio A, Mehrara BJ. Technique of internal mammary dissection using pectoralis major flap to prevent contour deformities. Plast Reconstr Surg
. 2009;123: 1674–1675.
2.Mosahebi A, Da Lio A, Mehrara BJ. The use of a pectoralis major flap to improve internal mammary vessels exposure and reduce contour deformity in microvascular free flap breast reconstruction. Ann Plast Surg
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