Managing the animation deformity in breast reconstruction transposing the implant to a partial prepectoral pocket: Early experience and preliminary results with a new technique

BACKGROUND

Two-stage implant-based breast reconstruction remains the most commonly used technique for rebuilding a breast. Subpectoral implant placement minimizes complications, such as capsular contracture, implant visibility, malposition, and extrusion. Nevertheless, it is associated with high animation deformity (AD). Prepectoral reconstruction eliminates AD but is subject to a higher risk of implant extrusion and visibility. In this prospective, single-center study we present a new technique aimed to create a new hybrid pocket in which the upper portion of the implant is placed subcutaneously, whereas its inferior pole is still covered by a pectoralis muscle sling reducing implant lower pole visibility and palpability.

MATERIAL AND METHODS

In each case, the prosthesis was removed and a new hybrid pocket was created by splitting the muscle into two portions, separating its cranial part from the overlying subcutaneous tissue and anchoring it back to the chest wall. The caudal muscle sling was left adherent to the subcutaneous tissue of the central part of the breast. Patient outcomes were evaluated with a BREAST-Q questionnaire preoperatively and 1 year after surgery.

RESULTS

Forty-eight patients with severe postoperative breast animation were enrolled (8 bilateral and 40 unilateral). No major complications occurred. After a 1-year follow-up, the aesthetic and functional satisfaction rate was high and a good implant coverage was achieved. No residual AD of the breast was observed.

CONCLUSIONS

Changing the implant placement from the subpectoral to a partially subcutaneous plane, both severe AD and implant extrusion can be avoided, expanding the indications for safe prosthetic breast reconstruction.

LEVEL OF EVIDENCE

Level of evidence IV.

Pectoralis major muscle sarcoma masquerading breast lesion: A rare case report with review of literature

Pectoralis major muscle sarcomas are extremely rare and can mimic breast lesion clinically. We report a case of poorly differentiated sarcoma of the pectoralis major muscle in a 63-year-old woman of south east Asian ethnicity presenting with a progressively increasing right breast lump. Mammography, ultrasonography (US), contrast-enhanced computed tomography, and biopsy were done to make the final diagnosis. Complete surgical excision was planned but deferred due to pulmonary metastasis, and the patient was treated with palliative chemotherapy. Clinical examination may be confusing but radiological and pathological investigations provide detailed information about the location and the extent of the disease and a definitive tissue diagnosis can only be made on histopathology which will be helpful in preoperative planning and further treatment of the patient.

Pectoralis major and pectoralis minor transfer for irreparable subscapularis tendon tears

OBJECTIVE

Irreparable rotator cuff injuries in young patients with moderate to high levels of physical activity remain a challenging pathology for shoulder surgeons. Irreparable anterior rotator cuff injuries require treatment that seeks to restore the dynamic anterior forces of the glenohumeral joint. Among surgical treatment options, transfer of the pectoralis major and minor muscle, have shown good functional outcomes. This technique attempts to reproduce the vector of the subscapular muscle in cases with irreparable tear. Restoration of the dynamic external and internal couple forces to maintain the humeral head in the center of rotation.

INDICATIONS

Pectoralis major transfer (PMa): Irreparable subscapularis tendon (SSC) tear in active patients without osteoarthritis. Pectoralis minor transfer (PMi): Irreparable superior SSC tear with concomitant irreparable supraspinatus tendon (SSP) tear in active patients with no osteoarthritis.

CONTRAINDICATIONS

Primary osteoarthritis Samilson grade C, cuff tear arthropathy Hamada III-V, infection, axillary nerve palsy, older patients with low physical demand, combination with irreparable SSP/infraspinatus tendon (ISP) tear for PMa or combination with irreparable ISP tear for PMi.

SURGICAL TECHNIQUE

General anesthesia and beach-chair position with the arm freely mobile in an arm holder. Deltopectoral approach. Exposure of the humeral head and confirmation of the irreparability of the subscapularis tendon. PMa: Detachment of the tendon to be transferred from the humeral insertion, blunt anatomic dissection medially. Exposure of the conjoined tendon and coracoid process. PMi: Detachment of the tendon with an osteotomy at the coracoid process. Passing the PMa or PMi tendon under the conjoined tendon. The PMa tendon is fixed in a 2-row configuration, the PMi in a single row with suture anchors to the lesser tuberosity.

POSTOPERATIVE MANAGEMENT

Shoulder abduction sling (30°) for 6 weeks. Assisted range-of-motion (ROM) exercises with abduction/adduction 60-0-0°, internal/external rotation free-0-0° for 6 weeks. Free active ROM exercises after 6 weeks, muscle strengthening after 12 weeks.

RESULTS

The pectoralis major and minor transfer shows an improvement in strength and range of motion in young active patients and an improved Constant score (CS) in long-term follow-up examinations.

Interclavicularis anticus digastricus muscle in a female body donor: a case report

Background and objectives

Muscular variations of the ventral thoracic wall are generally common and of great clinical interest.

Materials and methods

An unusual muscular variation of the ventral thoracic wall was observed and dissected in a West-European female body donor.

Results

An interclavicularis anticus digastricus muscle was observed and studied. It originated from the manubrium sterni and inserted bilaterally to the clavicles. Both muscle bellies were interconnected by a tendon on the ventral surface of the manubrium sterni. The muscle was innervated by branches of the lateral pectoral nerve.

Conclusions

The interclavicularis anticus digastricus muscle is a muscular variation of the ventral thoracic wall of unknown prevalence. This variation might be of clinical interest in orthopaedics and thoracic surgery. It is also a vulnerable structure during infraclavicular insertion of a subclavian vein catheter or fractures of the clavicle.

Rerouting of the pectoralis major muscle for breast animation deformity in sub-pectoral autologous breast reconstruction: A case report and review of the literature

INTRODUCTION

Breast animation deformity (BAD) is a known complication of sub-pectoral implant placement that is usually corrected by simply repositioning the implant to a pre-pectoral position. However, when this complication occurs in the case of a sub-pectorally placed free-flap, the solution becomes a lot less straightforward: repositioning of the flap carries the risk of possible damage to the pedicle. In order to avoid having to re-do the anastomoses we opted for a rerouting of the pectoralis major muscle around the vascular anastomoses.

PRESENTATION OF CASE

We present a 26-year old patient with unsatisfactory aesthetic outcomes of her bilateral deep inferior epigastric perforator (DIEP) flap breast reconstruction. The flaps were placed sub-pectorally, in the already existing pocket that was created during her first breast reconstruction with silicone implants, resulting in severe BAD. Repositioning the free flap from the sub-pectoral to the pre-pectoral plane allowed for reinsertion of the pectoralis major muscle to its anatomical position without jeopardizing the vascular anastomoses. The patient was satisfied with the increased projection of the breasts.

DISCUSSION

Changing the plane from sub-pectoral to pre-pectoral remains the best treatment option for patients experiencing BAD. In combination with an acellular dermal matrix, this would have been a good option for our patient. However, when choosing to perform autologous breast reconstruction instead, our recommendation would be to always place the flap in the pre-pectoral plane to avoid BAD.

CONCLUSION

The report shows that the plane of a flap can be successfully changed without jeopardizing the pedicle of the flap.

Wooden Breast in Commercial Broilers Associated with Mortality, Dorsal Recumbency, and Pulmonary Disease

Occurrence of mortality, wooden breast, and pulmonary disease in broiler chickens during the last 16 days of production in a teaching flock of 4000 commercial broilers was determined. A new syndrome was identified, in which broilers fell over for an unknown reason and were unable to right themselves (dorsal recumbency). Birds affected by dorsal recumbency were alert and responsive and showed no clinical signs except for occasional mild to moderate dyspnea. When turned over, they resumed normal behavior. Mortality (14 culls; 49 dead) during the last 16 days of production accounted for 1.6% of the flock and 36% of total mortality. Among these, 71% were heavy males, 70% had wooden breast, and 71% had pulmonary congestion and edema. Gross lesions of concurrent wooden breast and pulmonary disease occurred in 68% of the mortality, including 21 of 22 dead birds found on their backs. These findings indicate that wooden breast is associated with mortality prior to processing as a result of pulmonary disease in heavy male broilers. When birds with wooden breast fall onto their backs for unknown reason(s), they are unable to right themselves. If not found and turned over, they may not survive. Based on these findings, wooden breast is likely greater than just a problem with meat quality and should be considered an animal well-being issue.

The Pectoralis Major Island Flap: Short Scar Modified Muscle-Sparing Harvesting Technique Improves Aesthetic Outcome in Reconstructive Head and Neck Surgery

BACKGROUND

Pectoralis major flap reconstruction is often associated with large unappealing scars in head-neck surgery. We recently established an alternative harvesting technique that improves aesthetic outcome.

OBJECTIVES

The objective of this study was to demonstrate a modified surgical technique that harvests the pectoralis major muscle as an island flap and focuses on minimizing incision lines and applying a muscle-sparing approach.

METHODS

A retrospective analysis covering the period 2008-2018 was conducted. Patients who underwent pectoralis major island flap reconstruction for fistula prophylaxis after salvage laryngectomy at the Medical University of Innsbruck were included. Flap harvesting was performed subcutaneously using two small incision lines, thereby sparing the clavicular and upper sternocostal aspects of the pectoralis muscle.

RESULTS

Twenty-three patients with squamous cell carcinoma of the larynx (n = 19) or pharynx (n = 4) underwent salvage laryngectomy and consecutive reconstruction using a pectoralis major island flap and our muscle-sparing technique. Mean overall operation time was 147 ± 48.6 min. The majority (70%) of patients had an uneventful course of recovery and showed satisfying aesthetic results and low donor site morbidity as compared to traditional harvesting techniques. Six (26%) patients had major complications that required surgical revision. Three (13%) cases were complicated with fistulas.

CONCLUSION

The pectoralis major island flap is shown to be reliable in otolaryngeal surgery. This surgical technique minimizes scarring and preserves thoracic wall architecture by taking a less invasive approach, thereby improving aesthetic outcome and reducing overall patient morbidity.

The effect of lateral pectoral nerve sparing technique and radiotherapy on the pectoralis major muscle applied with modified radical mastectomy

BACKGROUND/OBJECTIVE

The aim of this study was to evaluate with electromyography (EMG) the effect of lateral pectoral nerve sparing technique (LPNST) and radiotherapy (RT) on the lateral pectoral nerve (LPN) in patients applied with modified radical mastectomy (MRM).

METHODS

The study included 66 patients who underwent MRM surgery. The patients were separated into 2 groups as those applied with LPNST and those who underwent standard surgery (Control group). Within these 2 groups, patients were again separated as those who received or did not receive RT. The EMG evaluations were made by a neurology specialist blinded to the patient groups.

RESULTS

The mean age of the patients was 53.3 ± 10.6 years. Standard surgery was applied to 33 (50%) patients and LPNST to 33 (50%) patients, RT was applied to 32 (48.5%) patients and not to 34 (51.5%) patients. In the EMG evaluation, latency was 2.1 ms (1.4-3.2) in the LPNST and 3.7 ms (1.9-12.4) in the control (p <0.001) and amplitude values were 9650 mV (3120-36900) in the LPNST and 4780 mV (510-12.4) in the control (p <0.001). The latency values in the Control receiving and not receiving RT were 4.0 ms (1.9-12.4) and 2.6 ms (1.9-6.2) respectively (p <0.05). The latency values of the patients receiving and not receiving RT in the LPNST were 2.2 ms (1.8-3.2) and 2.0 ms (1.4-2.4) respectively (p <0.05). In the Control and LPNST Group, no significant difference was determined between receiving and not receiving RT groups in respect of amplitude values (p >0.05).

CONCLUSION

The results of this study demonstrated that electromyographically the latency and amplitude values were better protected in the LPNST group. It was also seen that RT increased the formation of nerve damage in both groups.

Poland syndrome: A proposed classification system and perspectives on diagnosis and treatment

Poland Syndrome (PS) is a rare condition, with an estimated incidence of approximately 1 per 30,000 births and encompasses a wide range of severities of chest and upper arm anomalies. The etiology remains unknown, but genetic involvement is suspected. Few radiological investigations have proven useful in the study PS phenotypes and we propose a reference algorithm for guiding pediatricians. Our experience with 245 PS patients in the last 10 years stimulated a phenotypical classification of PS. The management of the different PS types and a therapeutic algorithm according to the phenotypical features of each PS patient are also proposed.

Efficacy of Partial- Versus Full-Sling Acellular Dermal Matrix Use in Implant-Based Breast Reconstruction: A Head-to-Head Comparison

BACKGROUND

Acellular dermal matrix (ADM), popularly used in tissue expander-based breast reconstruction, is applied either as a partial or full sling, but without any consensus regarding which method of application produces better outcomes. We aimed to compare the outcomes between two patient groups who underwent tissue expander-based breast reconstruction using these techniques.

METHODS

A retrospective review was conducted for consecutive patients who underwent immediate two-stage implant-based breast reconstruction using ADM between January 2013 and June 2016. They were categorized into two cohorts: cohort 1 included patients in whom ADM was applied using the partial-sling technique, insetting it obliquely after releasing the pectoralis major muscle from its costal origin, and cohort 2 included those who underwent a full-sling technique, insetting it transversely after releasing the muscle from its costal and lower sternal origin. Postoperative complications and aesthetic outcomes were compared between the two groups.

RESULTS

We analysed 329 cases (167 in cohort 1 and 162 in cohort 2) with similar baseline characteristics in both cohorts. Reconstruction failure occurred in 2.4% of overall patients. The rates of each and overall acute complications did not differ significantly between the cohorts. Cohort 2 showed significantly lower rates of tissue expander displacement and malposition following the first-stage operation and rippling following the second-stage operation, differences that retained the influences in multivariate analyses. Higher aesthetic scores were obtained in cohort 2.

CONCLUSION

Using the full-sling ADM might reduce unintended migration of prostheses and enable proper tissue expansion, resulting in better overall outcomes without increasing morbidities.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Individual difference in pectoralis major muscle thickness and its effect on single-stage breast reconstruction using a tissue expander

BACKGROUND

In breast reconstruction using a tissue expander (TE), sufficient coverage of the TE with the pectoralis major (PM) muscle, particularly with a musculofascial flap, is highly important for avoiding postoperative complications. In patients in whom the PM is thin, intraoperative trauma often occurs, leading to troublesome repair. The present study aimed to investigate the usefulness of preoperative measurement of PM thickness in planning of breast reconstruction using a TE.

METHODS

In this case-control study, we identified 68 patients (70 breasts) with mammary carcinoma treated with simple mastectomy and TE insertion from April 2014 to December 2016. We measured average PM thickness at two specific points, sternocostal PM distance on the long axis and sternocostal PM area preoperatively using magnetic resonance imaging. Then, we analyzed the difference in PM thickness among individuals and its relationship to intraoperative trauma to the PM or surgical difficulty creating a muscular pocket (delicate PM).

RESULTS

Average PM thickness was significantly larger in younger patients (p = 0.046) and those with larger breasts (p < 0.01). In addition, average PM thickness on the affected side was significantly smaller in patients with delicate PM (12 breasts) (p < 0.01). PM thickness had a significant influence on delicate or firm PM (odds ratio 27.40; 95% confidence interval 2.01-372.00; p = 0.013).

CONCLUSION

These findings demonstrate the usefulness of preoperative measurement of PM thickness in planning of breast reconstruction using a TE. Dissection should be performed more carefully in patients with average PM thickness less than 2.9 mm.

The Laminated Nature of the Pectoralis Major Muscle and the Redefinition of the Inframammary Fold: Clinical Implications in Aesthetic and Reconstructive Breast Surgery

The breast is appreciated aesthetically and clinically for its shape, projection, and volume. Surgical techniques have evolved to manipulate the breast skin envelope, soft tissues, and chest wall anatomy, with and without prosthetic devices. The pectoralis major specifically is altered for pocket dissection and implant coverage. Both the aesthetic and reconstructive surgeons are aware of its relationship to the chest wall and the breast soft tissues. Both are able to achieve outstanding outcomes; however, the authors present an alternative appreciation of the pectoralis and its relationship to the breast.

A tecnique to maximise length of pectoralis major muscle myocutaneous flap pedicle in orofacial reconstruction

Introduction Pectoralis muscle flap is one of the most common regional flap used in orofacial reconstruction. Mobilization of pedicle and reach of the skin paddle is a technical consideration. Method Based on the anatomical difference in blood supply to clavicular and sternal head, we elaborate a tecnique to maximise the length of pedicle in maxillofacial reconstruction. Conclusion The proposed technique is reproducible and reliable and possibly increase the indications of usage of the flap.

A salvage maneuver for the caudal part of the pectoralis major muscle in the reconstruction of superior thoracic wall defects: The pectoralis kite flap

The pectoralis major muscle flap is the most commonly used option for chest wall reconstruction. However, its utilization should be avoided in chest wall tumors infiltrating the muscle. This article presents the utilization of the caudal part of the pectoralis major muscle as a pedicled flap in cases requiring the resection of the cranial part of the muscle due to tumor infiltration. Fourteen patients with a mean age of 60.3 years were operated for malignant thoracic wall tumors between 2011 and 2014. All tumors were located on the upper thoracic area with a mean defect size of 16.6 × 12 cm. During tumor resection, the thoracoacromial vessels and pectoral branch were preserved and dissected until reaching the pectoralis muscle. After the resection of the cranial part of the muscle, the caudal part is prepared as a pedicled island flap and used for the coverage of the resultant defect. The mean postoperative follow-up period was 10.9 months. All flaps survived without any partial or total flap loss. A case of local recurrence, two cases of hematoma requiring drainage, and two cases of local wound-healing problems were the encountered complications. The pectoral kite flap is a versatile and reliable option for the coverage of small to medium upper chest wall defects with minimal morbidity, and it gives the reconstructive surgeon the opportunity to use the non-infiltrated caudal part of the pectoralis muscle instead of an unnecessary resection of the whole muscle.

Muscular variations during axillary dissection: a clinical study in fifty patients

AIM

The present study was conducted to detect the musculature variations during axillary dissection for breast cancer surgery.

METHODS

The anatomy of axilla regarding muscular variations was studied in 50 patients who had an axillary dissection for the staging and treatment of invasive primary breast cancer over one year.

RESULTS

In a period of one year, two patients (4%) with axillary arch and one patient (2%) with absent pectoralis major and minor muscles among fifty patients undergoing axillary surgery for breast cancer were identified.

CONCLUSIONS

Axillary arch when present should always be identified and formally divided to allow adequate exposure of axillary contents, in order to achieve a complete lymphatic dissection. Complete absence of pectoralis major and minor muscles precludes the insertion of breast implants and worsens the prognosis of breast cancer.

Effects of tonic immobility (TI) and corticosterone (CORT) on energy status and protein metabolism in pectoralis major muscle of broiler chickens

Tonic immobility (TI), which can be divided into short (STI) or long (LTI) duration, is a character related to fear. Our previous study has demonstrated LTI phenotype and chronic corticosterone (CORT) administration retarded growth of breast muscle in broiler chickens. In order to investigate the mechanism behind the negative effects of LTI and CORT on growth, the level of mRNA transcription of several key genes linked to energy and protein metabolism was measured in muscle. LTI broilers showed lower levels of ATP, energy charge (EC) (p<0.01), and lower muscle glycogen content (p<0.05) but higher level of ADP (p = 0.08) than STI birds. CORT treatment elevated EC level (p<0.05) and reduced liver glycogen content (p<0.05). Real-time PCR results showed that STI chickens had higher mRNA expression of PPAR α (p = 0.06) and AMPK α (p = 0.09) than LTI. CORT significantly down-regulated α-enolase mRNA expression in breast muscle compared to control (p<0.05). Neither TI nor CORT altered gene expression in Akt/mTOR/p70s6k cascade pathway in muscle (p > 0.05). However, western blot results showed that LTI chickens exhibited higher protein content of total Akt (p = 0.05) and phosphorylated Akt (p = 0.06) than STI. CORT treatment decreased the total protein content of Akt (p = 0.09) and p70s6k (p = 0.08). These results suggest that the retardation of muscle growth by LTI and chronic CORT administration parallels a strong alternation in energy status but slight changes of Akt/mTOR/p70s6k cascade, indicating that a decrease in muscle growth induced by LTI and CORT might not be mediated through mTOR-dependent signaling pathways.