Pectoralis Major Perforator Flap for Filling the Lower Part of the Sternal Reconstruction Defect

Sir: One-stage sternectomy defect reconstruction with vascularized muscle is always a challenge for pectoralis major muscle flaps in the lower part of the defect because of its limited reach.1–5 The rectus abdominis can be used to fill the entire defect but comes at the price of abdominal wall morbidity, especially in overeaters. We have easily filled the lower part of the defect with a rotated pectoralis muscle perforator flap islanded on one or two of the inferior internal mammary artery perforators. A left pectoralis flap islanded on the thoracoacromial vessels adequately fills the upper two-thirds of the sternal defect (Fig. 1). A right pectoralis major is raised and completely islanded on four or five internal mammary artery perforators originating below the medial first to fifth ribs, and its thoracoacromial vessels and muscle attachments are completely detached from the chest wall (Fig. 2). The largest, most medial and inferior of the perforators is chosen. The other perforators are temporarily clamped with vascular microclamps for 10 minutes to ensure that circulation through the chosen perforator(s) is adequate to perfuse the entire muscle. Examination of the pectoralis major blood flow on the far edges of the muscle following the aforementioned time will ensure that the entire muscle is viable before rotating it into the inferior sternal defect. Nonessential perforators that impede the rotation and inferior reach of the muscle flap are clipped and cut, leaving a pectoralis flap based on only one or two of the third, fourth, or fifth perforator(s) of the internal mammary artery. The flap is then rotated into the lower defect easily, without strain on the supplying perforator(s).Fig. 1.: Left pectoralis muscle islanded on the thoracoacromial vessels covering the upper sternal defect. Right pectoralis muscle islanded on the third internal mammary artery perforator filling the lower sternal defect.Fig. 2.: Right pectoralis muscle completely islanded on the internal mammary perforators below the first though fourth ribs, with the clamps on the first, second, and fourth perforators. Muscle perfusion is through the third internal mammary artery perforator only.It is our observation that the pectoralis muscle perforator flap is another option for the filling of the lower sternal defect for outcome improvement in this difficult reconstructive situation. Robin J. Evans, M.D. McMaster University Medical School Hamilton, Ontario Gillard Barnsley, M.D. Department of Plastic Surgery Dalhousie University Saint John, New Brunswick, Canada Geoffrey Cook, M.D. Department of Plastic Surgery Dalhousie University Saint John, New Brunswick, Canada Donald H. Lalonde, M.D. Department of Plastic Surgery Dalhousie University Saint John, New Brunswick, Canada DISCLOSURES There have been no external sources of funding. No author has any financial interest, commercial associations, or financial relationships associated with the content of this article.

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