The subclavicular versus the supraclavicular route for pectoralis major myocutaneous flap: a cadaveric anatomic study

Abstract

The aim of this paper was to determine if the subclavicular route of rotation improved the pectoralis major myocutaneous flap's ability to reach head and neck sites in comparison to the traditional supraclavicular rotation. We dissected 50 flaps in 25 fresh adult male cadavers. The length of the pedicle and the flap's ability to reach five anatomical head and neck sites (laryngeal prominence of thyroid cartilage, mentum, angle of the mandible, external auditory canal, and orbit) were tested by supraclavicular and subclavicular rotation. Although the average length of the flap's pedicle was higher when the subclavicular rotation was employed, there was no statistical difference between the two techniques concerning the flap's ability to reach the studied sites. Our results suggest that the subclavicular route apparently adds little to the reconstruction of head and neck defects using the pectoralis major myocutaneous flap. We believe that the indication of this technique should be evaluated on a case-by-case basis before it is recommended to keep from unnecessarily increasing the potential morbidity of the reparative procedure.

Pectoralis Major Myocutaneous Flap for Head and Neck Defects in the Era of Free Flaps: Harvesting Technique and Indications

“…We harvested the PMMF using the following techniques: the skin paddle is designed caudally-medially to the areola; the third intercostal perforating branch of the internal thoracic artery is included in the flap; the clavicle portion and part of the sternal portion of the pectoralis major is left intact; and the flap is sent to the recipient site via the sub-muscular tunnel over the clavicle and beneath the platysma flap after the clavipectoral fascia is divided. Although each of these modifications has been reported previously1202122232425, the combination of all these modifications results in the following advantages: (1) skin paddle caudally-medially to the nipple not only avoids using the potential compromised blood supply skin paddle over the rectus, but also reduces the cosmetic impairment at the donor site; (2) including the third intercostal perforating branch of the internal thoracic artery ensures the blood supply of the distal part of the skin paddle due to choke anastomosis of the internal thoracic artery and the thoracoacromial artery23; (3) in contrast to the previous reported modification of preserving only the clavicular portion of the pectoralis major muscle, we transect the pectoralis major horizontally along the muscular fiber axis at the level where the terminal of the pectoral branch could be identified and skeletonize the vascular pedicle to its origin. We have found this novel modification to have the benefit of further elongating the vascular pedicle length (the length of the pedicle reach 8–10 cm in our series), decreasing excessive bulk in the neck, and minimizing the deformity of and functional impairment of the donor site; (4) passing the flap via the sub-muscular tunnel over the clavicle avoids additional injury to the clavicle thus further reducing subsequent shoulder dysfunction.…”

“…In order to circumvent the natural drawbacks of the PMMF, technique modifications have been attempted1202122232425. We harvested the PMMF using the following techniques: the skin paddle is designed caudally-medially to the areola; the third intercostal perforating branch of the internal thoracic artery is included in the flap; the clavicle portion and part of the sternal portion of the pectoralis major is left intact; and the flap is sent to the recipient site via the sub-muscular tunnel over the clavicle and beneath the platysma flap after the clavipectoral fascia is divided.…”

Thoracoacromial vessels as recipients for head and neck reconstruction and cause of vascular complications

“…Kerawala et al and Vanni et al described that using the subclavicular root in pectoralis major myocutaneous flaps is safe and helpful. 16,17 We can obtain longer thoracoacromial vessels from the cervical region and reduce the risk of external compression via the subclavicular route. However, this may complicate the operative procedure.…”

Pectoralis Major Muscle Free Flap: Anatomical Studies on Pedicle Length and Vessel Diameter

“…The pedicle's length is considered the only major limitation of this versatile flap. 2 The use of ''the'' pedicled flap at the lateral skull base is impossible due to the limited pedicle length even if the flap is pulled through under the clavicle. 3 Thus, for bridging long distances, a microvascular free flap would be ideal.…”