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Three patients who developed mediastinal sepsis and sternal dehiscence after coronary artery bypass grafting were treated by closure of the wound using bilateral pectoralis major muscle flaps. Excellent cosmetic and functional results were obtained and morbidity was reduced.
A variety of approaches have been employed for the reconstruction of head and neck defects and most of the techniques involve the use of arterialized vascular flaps alone, or in conjunction with other regional or local tissues. We frequently use a pectoralis major myocutaneous (PMMC) flap in our hospital in addition to other pedicled or free tissue transfers. A PMMC flap is a reliable flap with acceptable complications, needs a small learning curve, takes less time, and does not require additional investment (i.e. microscopes, loops etc). The disadvantages of the PMMC flap is that it has a restricted arc of rotation, gives a cosmetically unacceptable bulk in the neck, it is difficult in females and causes significant shoulder dysfunction. We have made a small improvization in the flap-raising technique which is helpful for the surgeon. This involves utilization of intestinal clamps to hold and cut the pectoralis major muscle.
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The development of sarcoplasmic reticulum membranes was studied in vivo and in tissue culture in chicken pectoralis muscle cells. The concentration of the calcium- and magnesium-activated ATPase measured by selective labeling of the enzyme with [32P]ATP in whole muscle homogenates was found to increase in developing chicken pectoralis muscle in vivo from 0.01 nmol/mg of protein in 12-day embryos to 0.3 to 0.4 nmol/mg of protein in 1-month-old chicks, where it constitutes about 3% of the total protein content of muscle. In cultured muscle cells the concentration of calcium-sensitive phosphoprotein increased from 0.015 nmol/mg of protein at 2 days to 0.04 to 0.05 nmol/mg of protein after 5 days of culture. This amount represents about 0.5% of the protein content of the muscle cells. The accumulation of Ca2+ transport ATPase began during fusion and continued with a linear rate during 8 days of culture. The density of 75 A intramembranous particles seen by freeze-etch electron microscopy on fracture faces of sarcoplasmic reticulum membranes is about 4,000/mum2 in adult chick pectoralis muscle but only 400/mum2 in cultured muscle cells in rough proportion to the concentration of Ca2+-sensitive phosphoprotein. The Ca2+, Na+, and K+ concentration of the medium and addition of ouabain, caffeine, or the calcium ionophores A23187 and X537A sharply influence the concentration of calcium transport ATPase in cultured muscle cells, parallel with their effect upon cell fusion and growth. These observations are consistent with the proposition that the gene expression leading to the accumulation of Ca2+ transport ATPase during development in culture may be regulated by intracellular ion concentrations.
The occurrence of a bronchopleural fistula continues to constitute a major therapeutic challenge for the thoracic surgeon. Successful closure of the fistula requires that the associated empyema cavity be obliterated. We describe a patient in whom the entire pectoralis major muscle was transposed into the thorax to obliterate the cavity as well as close the bronchopleural fistula.
Musculocutaneous flaps, allowing one stage reconstructions and reducing the stay in hospital and rehabilitation period, have revolutionised modern plastic surgery. Muscle flaps are a good alternative to provide adequate coverage of tissue losses but with limited scarring. The authors report their 5 year clinical experience in the reconstruction of oral cavity and chest wall defects using the pectoralis major as muscle or musculocutaneous flap. The preliminary data of an angiographic study, confirming the segmentation of the pectoralis major muscle into two subunits, each provided with its own vascular supply (mainly the clavicular and the sternocostal segment), are also presented. The short and long-term results confirm the excellent viability and versatility of the pectoralis major musculocutaneous and muscle flap. In particular the complications rate is so low that this procedure can be considered safe and reliable.
INTRODUCTION: Three ruptures of the pectoralis major are reported. The mechanism of injury was excessive external rotation with high muscular tension. Rupture of muscle often occurs at the humeral insertion or musculotendinous junction. MATERIAL AND METHODS: In the three cases, surgical repair was performed. Suture could be made without excessive tension. Patients were immobilized in a sling for three weeks. Passive exercises were begun at 3 weeks. RESULTS: All patients recovered and had postoperatively the same sport level as before. In late surgical repair the consistent fibrosis makes dissection of the ruptured tendon difficult and it's retraction hinders the suture. DISCUSSION: The symptoms are sometimes initially under evaluated. In limited number of cases the treatment may be delayed: functional disability and strength limitation justify surgical treatment. The results, however, are usually good according to the score of Mc Entire. Surgical repair is recommended in distal ruptures in active patients to restore previous muscle strength and contour.
The purpose of this study was to evaluate whether the characteristic change in breast cancer related to chemotherapeutic response (CR) and the effect of invasion and toxicity in the skin and pectoralis muscle exist on MR imaging after intra-arterial infusion chemotherapy. A total of 11 patients with histologically proven breast cancer underwent MR study before and after chemotherapy. Changes in images and the dynamic curve-after-chemotherapy were evaluated, including time to maximum signal intensity (SI) and the early phase enhance ratio (EPER) in the tumor. In the tumor, changes in the dynamic curve, time to maximum SI, EPER and necrosis did not correlate with CR, but change in SI on T2-weighted images was suggested to do so. Changes in the dynamic curve and images in the pectoralis muscle and in images on the skin were suggested to correlate with CR. In addition, images changed for the worse in many cases of invasion and toxicity in the pectoralis muscle and in some cases of invasion in the skin. In conclusion, tumors had fewer imaging changes correlating with CR after intra-arterial infusion chemotherapy. Changes for the worse in images of the pectoralis muscle and skin may be useful for the evaluation of invasion.
A case of tracheal rupture after a Lewis-Tanner esophagectomy in a patient with carcinoma of the esophagus was complicated by the formation of a tracheoesophageal fistula after initial direct repair. The fistula was successfully treated with a pectoralis major muscle flap moved into the superior mediastinum by a sternotomy and excision of the upper part of the sternum and adjacent costal cartilages.
We retrospectively studied 17 cases of distal pectoralis major muscle rupture to compare the results of repair in acute and chronic injuries and to compare operative and nonoperative treatment. Thirteen patients underwent surgery (six acute injuries [less than 2 weeks after injury] and seven chronic injuries) and four had nonoperative management. The mean age of the patients at injury was 29, and 10 of the 17 injuries were the result of weight lifting. Follow-up ranged from 18 months to 6 years (mean, 28 months). All patients subjectively rated strength, pain, motion, function with strenuous sporting activities, cosmesis, and overall satisfaction. Objectively, patients were examined for range of motion, deformity, atrophy, and strength. Isokinetic strength testing was performed in eight patients: six treated operatively (three acute and three chronic) and two treated nonoperatively. Overall subjective ratings were 96% in the acute group, 93% in the chronic group, and only 51% in the nonoperative group. Isokinetic testing showed that patients operated on for acute injuries had the highest adduction strength (102% of the opposite side) compared with patients with chronic injuries (94%) or nonoperative treatment (71%). There were no statistically significant subjective or objective differences in outcome between the patients treated operatively for acute or chronic injuries, but these patients fared significantly better than patients treated nonoperatively.
SUMMARY: Women presenting with anterior thoracic depression, breast hypoplasia, and subsequent asymmetry are often diagnosed with Poland syndrome regardless of pectoralis involvement, or are placed in the generic category of breast asymmetry or skeletal dysplasias. Recently, though, the term "sunken chest" has been used to describe forms of chest wall depression that previously may have fallen under generic skeletal dysplasias. The authors believe that, combined with hypoplasia of the ipsilateral breast, superior location of the nipple-areola complex compared with the contralateral side, and normal pectoralis muscles, this represents a previously undefined and real condition called anterior thoracic hypoplasia. During the past 4 years, the authors have treated eight women who have presented with a diagnosis of Poland syndrome or pectus excavatum, all of whom share the same characteristics-unilateral sunken anterior chest wall, hypoplasia of the breast, superiorly placed nipple-areola complex, normal pectoralis muscle, and normal sternal position. All of the patients underwent correction of breast asymmetry and unilateral anterior thoracic hypoplasia with augmentation mammaplasty, a method that when tailored for each side yields good aesthetic results. The average age of the patients was 31 years and the average chest size was 34. Cup size, as measured by the patient's standard bra, was a B on the nonaffected side in all patients and an A on the affected side in all patients except one. Of the eight patients, seven had the right anterior chest and breast involved, whereas one patient had involvement on the left. For all of the patients, the nipple and areola of the hypoplastic side were smaller and in a more superior position compared with the contralateral side on visual inspection. In the eight patients, a total of 19 augmentations (15 primary augmentations and four revisions) and one mastopexy were performed. Ten inframammary-fold approaches and nine periareolar approaches were used, and all of the implants were placed in a partial submuscular position, except for two implants placed in a subglandular position that were converted to partial submuscular positions in a secondary setting. In all the women, the sternal head of the pectoralis muscle was present and the pectoralis muscle appeared to be equal in size compared to the contralateral side. Nine different types of implants were used. Average implant fill volume measured 412 cc on the hypoplastic side and 257 cc on the contralateral side. In follow-up, all of the patients were satisfied with their operation and rated their aesthetic outcome as very good to excellent. The authors believe that anterior thoracic hypoplasia is a real, previously misdiagnosed and undescribed condition, and that both chest wall and breast deformities can be corrected safely and with excellent results using proper augmentation planning and implant selection.
The main objective of this study was to decrease breast shape distortion during pectoralis muscle contraction following submuscular augmentation mammaplasty. We followed 348 patients who had retromuscular augmentation mammoplasty: 251 (72.1%) had polyurethane-covered gel-filled, 97 (27.9%) had textured-silicone gel-filled implants. Among the 348, 46 had surgery following the Regnault technique and 302 had surgery by the below-mentioned technique. Periareolar incision, bipartision of breast parenchyma down to the fascia, undermining of breast base from the fascia downward to the inframammary sulcus or a little below it, detaching of muscle off the thoracic cage, disinsertion of abdomino-costal pectoralis attachments. Full thickness incision of pectoralis muscle on a vertical line on the nipple projection for 2-5 inches. Placing of prosthesis. Drainage. Closure. No objective evaluation was used, only clinical judgments by three observers--the surgeon, a nurse and the patient herself. The results showed a definite decrease of the dynamic deformity among patients in whom the author's technical variation was carried out. This technique allows also, for decreasing the upward pushing of the implant during pectoralis muscle contraction and facilitates stretch of the breast tissue in patients with tighter breast envelopes. Despite lack of precise measurements, conclusions drawn from clinical judgments, taken as objectively as possible, suggest that the use of this technique may offer the solution of an otherwise disturbing collateral effect, frequently seen after this operation.
On the basis of the histochemical activity of succinic dehydrogenase, only two fibre-types are distinguished in pigeon pectoralis major muscle. These are narrow "Red" and broad "White". The histochemical activity of myofibrillar ATPase was studied in these two distinct fibre-types. Both fibre-types showed high activity for the ATPase. "Red" fibres of pigeon pectoralis were not alkali-labile, at incubation pH 9.4, as were the "Type I" fibres of both avian and mammalian muscles. Again unlike "Type I" fibres, the "Red" fibres of pigeon pectoralis lacked the characteristic activation of acid-preincubated ATPase reaction. Pigeon pectoralis "Red" fibres are known to possess some characteristics of fast-twitch fibres (e.g. high fat, considerable phosphorylase, fibrillenstruktur myofibrillar arrangement, focal "en plaque" pattern of nerve endings). It is emphasized, therefore, that the pigeon pectoralis "Red" fibres are not equivalent to "Type I or slow-twitch", muscle fibres, but they are possibly "fast-twitch fatigue resistent or Type II Red" muscle fibres.
The present study evaluated the effect of dietary methionine on breast-meat accretion and protein expression in skeletal muscle of broiler chickens in vivo. All broilers received a common pre-test diet up to 21 d of age, and were subsequently fed either a methionine-deficient (MD) or -adequate (MA) diet (3.1 v. 4.5 g/kg diet) from age 21 to 42 d. Dietary cystine levels were 3.7 v. 3.6 g/kg diet for the MD and MA diet, respectively. Detrimental effects on carcass yield (P=0.004), abdominal fat percentage (P=0.001), and breast-meat weight (P=0.001), yield (P=0.001), and uniformity (P=0.002) were observed and validated in birds fed MD diets. Via tandem MS, a total of 190 individual proteins were identified from pectoralis major (PM) muscle tissue. From the former composite, peptides from three proteins were observed to be present exclusively in breast muscle from those chickens fed the MD diet (pyruvate kinase, myosin alkali light chain-1, ribosomal-protein-L-29). No proteins were observed to be uniquely expressed in chickens fed MA diets. Research is warranted to further explore the possibility of the proteins pyruate kinase, myosin alkali light chain-1, or ribosomal protein L-29, as potential biological indicators of differences in protein expression of PM of chickens in response to a dietary methionine deficiency.