Seminar Presentation On PMMC By Dr Abdul Qahar Qureshi

transcript

Good morning

PRESENTED BY :-

Dr .Abdul Qahar Qureshi

GUIDED BY :- DR. D.G. Adwani (Prof & H.O.D) DR. M.V. Naphade(Prof & Guide)

ANATOMY OF PECTORAL REGION

a. Pectoralis Major

b. Pectoralis Minor

c. Serratus Anterior

d. Subclavious

MUSCLES OF PECTORAL REGION

Pectoralis Major Muscle • The pectoralis major muscle

is a broad, flat, fan shaped muscle that covers:

– The pectoralis minor

– Subclavius,

– Serratus anterior, and

– Intercostal muscles on the anterior thoracic wall

Gray’s Anatomy:The anatomical basis of clinical practice

Origin:• Origin From:

– Anterior surface of medial half of clavicle.

– Half the breadth of anterior surface of manubrium and sternum upto 6th costal cartilages.

– Second to sixth costal cartilages.

– Aponeurosis of the external oblique muscle of abdomen.

B.D.chaurasia:Human Anatomy,Volume 1,Upper Limb & Thorax

Insertion:

• Insertion into:

-It is inserted by a bilaminar tendon on the lateral lip of the bicipital groove .

-The two laminae are

continous with each other inferiorly.

Nerve Supply:• Medial and lateral pectoral

nerves.- (terminal branches from the cords of

the Brachial plexus (C5-8 & T1)

- Nerve to subclavius (a branch from upper trunk of the Brachial plexus)

- long thoracic nerve (nerve roots from C5-6-7 of the Brachial plexus)

Action:

1.Acting as a whole the muscle causes: a} Adduction and b} Medial rotation of the shoulder (arm)2.Clavicular part produces a}Flexion of the arm3.Sternocostal part is used in a}Extension of flexed arm against

resistance b}Climbing

Blood Supply:• Thoracoacromial - 2nd part of

axillary artery

• Lateral thoracic - 2nd part of axillary artery

• Superior thoracic artery- 1st part of axillary artery.

• Subscapular - 3rd part of axillary artery

Cephalic vein

Thoracoacromial vessel

Lateral Pectoral nerve

Lymphatics

• Deep relations of pectoralis major muscle

Deep to the pectoralis major muscle is its vascular pedicle, the pectoralis minor muscle, the costal cartilages, and inferiorly the costal attachments of the external oblique muscle.

Johan Fagan :OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY

Pectoralis major: sternocostal head

Pectoralis major: clavicular head

Pectoral branch of thoraco-acromial artery

Lateral thoracic artery

Pectoralis minor

Deep relations of pectoralis major muscle

Pectoralis Minor Muscle

• Pectoralis minor is a thin, triangular muscle lying posterior (deep) to pectoralis major.

• Its fibres ascend laterally under cover of pectoralis major, converging in a flat tendon.

• Part or all of the tendon may cross the coracoid process into the coraco-acromial ligament, or even beyond to the coracohumeral ligament, thereby gaining attachment to the humerus.

Pectoralis Minor Muscle • Origin - upper margins and outer surfaces of the third to fifth ribs, near costal cartilages• Insertion -Medial border and upper surface of coracoid process of scapula• Nerve supply - Medial and lateral pectoral nerves• Action -Stabilizes scapula by drawing it forwards around the chest wall (Protraction).

Serratus anterior

• Origin : -Half way of the anterior part of rib 1-8

• Insertion: -Costal surface of scapula along its medial border.

•Action: -Pull scapula to chest wall /lift up the ribsB.D.chaurasia:Human Anatomy,Volume 1,Upper Limb & Thorax

Subclavious•Origin: -1st costal cartilage

• Insertion: -inferior surface of clavicle

•Action: -steadies the clavicle during the movements of shoulder joint

Lymphatic drainage :

Axillary lymph nodes:

-Divided into 6 groups:

1. Anterior group 2. Posterior group 3. Lateral group 4. Central group 5. Apical group6. Subclavian lymph trunk

Node & Vessel Locations:

1. Anterior group – at the lower border of pectoralis minor - drainage parallel the lateral thoracic vein.2. Posterior group – anterior to subscapularis muscle.- drainage parallel the subscapular vein.3. Lateral group - at the lower border of teres major- drainage parallel medial side of axillary vein.4. Central group - the outer border of 1st rib5. Apical group – at the apex of the axilla6. Subclavian lymph trunk

Lymph drainage :-Anterior, posterior and lateral groups drain into the central group and then into the apical group.-Apical group drains into the subclavian lymph trunk

Axillary artery : Divided into 3 parts:

First part :Supreme thoracic artery.

Second part :1.Thoraco-acromial trunk

Acromial branch Pectoral branch Clavicular branch Deltoid branch

2. Lateral thoracic artery.

Third part :Subscapular arteryAnterior circumflex humeral arteryPosterior circumflex humeral artery

Axillary Artery: divided into three parts

Part 1 (proximal) one branch

Part 2 (intermediate) two branches.

Part 3 (distal) three branches.

Subclavian A.

Brachial A.

Superior thoracic artery

• From the anterior surface of the first part of the axillary artery

• Upper regions of the medial and anterior axillary walls

Axillary Artery: First PartFrom lateral border of 1st rib to medial border of Pectoralis Major M.

Named Branch:Supreme Thoracic A. (to external thoracic body wall)Supplies blood to first and second intercostal spaces

Thoraco-acromial artery

• From the anterior surface of the second part of the axillary artery

• Pierces the clavipectoral fascia• Four branches

– Pectoral• Pierces the clavipectoral fascia

– Deltoid• Accompanies the cephalic vein

– Clavicular – Acromial

Lateral Thoracic Artery

• Posterior to the inferior margin of pectoralis minor

• Supplies the medial and anterior walls

• Supplies breast

Axillary Artery: Second partDeep to the pectoralis minor M.

Thoracoacromial trunk

Branches to: Clavicular area Pectoralis region Acromion of Scapula Deltoid Muscle.

Lateral Thoracic ArteryBbr. to Serratus Ant. M.

Subscapular artery

• Largest branch of the axillary artery• To the posterior wall of the axilla in

the posterior scapular region• From the posterior surface of the

third part of the axillary artery• Follows inferior margin of the

subscapular artery

Subscapular artery

• Circumflex Scapular Artery– Enters the infraspinous fossa

• Thoracodorsal Artery– Follows the lateral border of the scapula

to the inferior angle– Vascular supply of the posterior and

medial walls of the axilla

Anterior Circumflex Humeral Artery

• Small compared to the posterior circumflex humeral artery

• Passes anterior to the surgical neck of the humerus

Posterior Circumflex Humeral Artery

• From the lateral surface of the third part of the axillary artery

• Leaves the quadrangular space with the axillary nerve

Axillary Artery: third partLateral border of Pectoralis minor M. to lateral border of Teres major M.

Subscapular A.: Branches:

Circumflex scapular A. (to multiple muscles associated with the scapula)

Thoracodorsal A. (to Latissimus dorsi M.)

Posterior circumflex humeral A.

Anterior circumflex humeral A.

Supreme thoracic A.

Thoracoacromial A.

Lateral thoracic A.

Subscapular A.

Ant. Circumflex humoral A.

Post. Circumflex humoral A.

Brachial Plexus

• Anterior rami of C5-C8, T1• Roots, trunks, divisions and cords• Proximal parts of the brachial plexus

are posterior to the subclavian artery• More distal regions of the plexus

surround the axillary artery

• Receives gray rami communicates

• In the posterior triangle of the neck

• Between the anterior and middle scalenes

• Superior and posterior to the subclavian artery

Trunks

• Superior trunk – C5 and C6

• Middle trunk – C7 root

• Inferior trunk – C8 – T1– Lies on rib 1 posterior to the subclavian

artery

Divisions

• Anterior• Posterior• Anterior divisions peripheral nerves

anterior compartments of the arm and forearm

• Posterior divisions peripheral nerves posterior compartments

• Related to the second part of the axillary artery

• Lateral cord– Union of upper and middle trunks– Lateral to the axillary artery (2nd part)

• Medial cord– Continuation of the anterior division of

the inferior trunk– Medial to the axillary artery (2nd part)

• Posterior cord

– Posterior to the axillary artery (2nd part)

– Union of all three posterior divisions

Rupture of the pectoralis major muscle:

The mechanism of injury of a pectoralis major rupture is either due to direct injury or indirect trauma due to extreme muscle tension or a combination of both.

Several studies have reported an increased incidence of injuries because of excessive muscle tension rather than direct trauma.

By far the most common mechanism of injury is the ‘bench press’ during which the arm is abducted and externally rotated and during which the pectoralis major tendon is under maximum tension.

Rupture of the pectoralis major muscle: Most injuries occur as the weight is lowered down to the

chest.

The muscle normally helps to ‘brake’ the motion, preventing the weight from falling on the chest.

If this eccentric contraction is uncoordinated either as a result of muscle fatigue or weakness, the individual tries to favour that side and allows the weight to slip to one side. This results in sudden eccentric contraction of the pectoralis major, leading to rupture.

Another common mechanism is a severe force applied to a maximally contracted muscle as a consequence of an attempt to break a fall or during a rugby tackle.

There also appears to be a correlation between the mechanism of injury and the site of rupture.

Direct trauma causes tears of the muscle belly, whereas excessive tension or indirect trauma causes avulsion of the humeral insertion or disruption at the musculo-tendinous junction.

R. G. Kakwani et al. International Orthopaedics (SICOT) (2007) 31:159–163.

Rupture of the pectoralis major muscle

THE PECTORALIS MAJOR FLAP • The pectoralis major flap comprises

the pectoralis major muscle, with or without overlying skin, and may include the underlying ribs. It has an axial blood supply, and is based superiorly on the pectoral branch of the thoracoacromial artery.

Fonseca:Oral & maxillofacial surgery Peter ward Booth: Maxillofacial Surgery,

• It is very useful in the head and neck, and can inter alia be used for the following:

Reconstruction of soft tissue defects of the -oropharynx, -oral cavity, -hypopharynx, -skin of the neck to augment pharyngeal repairs following -salvage laryngectomy, -previous chemoradiotherapy, -and to cover carotid or jugular vein blowouts etc. Rib may be included to bridge mandibular defects.

Fonseca:Oral & maxillofacial surgery Peter ward Booth: Maxillofacial Surgery,

Surgical development of the PMMC

• Complete dissection of the recipient tissue bed followed by development of the flap.

• This sequence permits a thorough dissection of the recipient site with accurate measuring of the required skin paddle size

• The skin paddle dimensions can be simply transferred to the donor site, with designation of the skin paddle accordingly.

Eric R. Carlson :Pectoralis major myocutaneous flap.oral maxillofacial surg clin n am (2003);15: 565–575

• If the donor site is dissected before or simultaneously with the recipient bed dissection (by two surgical teams), a skin paddle of inadequate size may be transposed into the recipient tissue bed.

• In the patient undergoing ablative surgery, the tumor is completely removed, and frozen sections are obtained until the results are deemed acceptable by the ablative surgeon.

• During reconstruction on the trauma patient, nonviable tissue is debrided, and scar contracture is completely released at the recipient site before initiating the development of the pectoralis major flap.Eric R. Carlson :Pectoralis major myocutaneous flap.oral maxillofacial surg clin n am (2003);15: 565–575

Medial incision Lateral incision

• The surgeon then determines whether to place a medial or lateral incision connecting the skin paddle to the region approximating the insertion of the muscle at the greater tubercle of the humerus.

• The lateral incision is more cosmetic, it is also more technically difficult to close, because one member of the surgical team must retract the breast medially while another member of the team sutures.

• Flap design The flap may be employed either as a muscular or musculocutaneous flap, with or without the 4th or 5th ribs.

• Positioning and draping The patient is placed in a supine position with the chest exposed and prepped up to the midline, and inferiorly to the costal margin. The upper arm is abducted slightly to expose the anterior axillary fold and lateral chest wall.

• Surface markings of vascular pedicle :The surface markings of the vascular pedicle are determined by drawing a line from the shoulder to the xiphisternum and another line vertically from the midpoint of the clavicle to intersect the 1st line

GENERAL CONSIDERATIONSIndications:

• The pectoralis major myocutaneous flap and myofascial flap variation are utilized in a large variety of head and neck reconstructive procedures that can include coverage of mucosal and/or cutaneous defects. The extent of coverage and the reach of the flap are dependent on the anatomy of the patient, modifications of the standard techniques of elevation, and inset. The upper limits are generally considered the zygomatic arch area externally and the superior tonsillar pole internally - patient body habitus may either limit extension short of these landmarks, or permit extension beyond.

• The myofascial flap variation carries no skin paddle and is utilized primarily to close small mucosal defects, to protect major vascular structures, and to support primary mucosal closure in a patient at increased risk of wound breakdown (prior radiation, diabetic, weight loss).

Christiansen & leighton. Pectoralis major myocutaneous flap.Iowa head and neck Protocols 2014.

Contraindications:

• A defect that is too large or outside the potential reach of the reconstructive tissue

• Very obese patients will have a difficult-to-handle and possibly nonviable skin paddle

• Patients with prior chest wall trauma and/or prior chest wall surgery (mastectomy, breast implants, cardiac pacemaker, etc) may have absent, scarred or poorly vascularized pectoralis major muscle.

• Removal of the muscle will affect the strength of the shoulder and arm; this weakness may affect the ability of the patient to work or participate in recreational activities

• Congenital absence of pectoralis muscle (Poland's syndrome)

Christiansen & leighton. Pectoralis major myocutaneous flap.Iowa head and neck Protocols 2014.

Advantages:• This flap offers one-stage reconstruction.• The patient's position need not be changed

intraoperatively.• This flap provides a large cutaneous island that

can be used for defects involving 2 epithelial surfaces.

• The muscular part covers neck structures protecting the carotid artery, especially in patients who have undergone radiation therapy.

Peter ward Booth: Maxillofacial Surgery

Disadvantages:• The flap can conceal recurrences, making follow-

up in the neck area more complicated.• In women, the flap might include breast tissue,

which may lead to breast asymmetry.• In males, hirsute chest skin is placed intraorally.• This flap causes loss of pectoralis muscle function

in arm adduction and/or rotation.• In patients who are overweight, the flap is bulky,

which leads to postoperative contour deformities.

Peter ward Booth: Maxillofacial Surgery

References:Gray’s Anatomy:The anatomical basis of clinical practice,Peter ward Booth: Maxillofacial Surgery,B.D.chaurasia:Human Anatomy,Fonseca:Oral & maxillofacial surgery,Jatin Shah :Head & neck surgery & oncology,Johan Fagan :OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY ,Eric R. Carlson :Pectoralis major myocutaneous flap.oral maxillofacial surg clin n am (2003);15: 565–575,R. G. Kakwani et al.Rupture of the pectoralis major muscle: Surgical treatment in athletes. International Orthopaedics (SICOT) (2007) 31:159–163.Christiansen & leighton. Pectoralis major myocutaneous flap.Iowa head and neck Protocols 2014.

THANK YOU

Seminar Presentation On PMMC By Dr Abdul Qahar Qureshi

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