The Split Pectoralis Flap: Combining the Benefits of Pectoralis Major Advancement and Turnover Techniques in One Flap

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We read with great interest the article entitled “The Split Pectoralis Flap: Combining the Benefits of Pectoralis Major Advancement and Turnover Techniques in One Flap” (Plast Reconstr Surg. 2017;139:1474–1477).1 The authors performed a retrospective study in which they evaluated a new technique for the reconstruction of sternal wounds in which the pectoralis major flap was split and harvested as an advancement and turnover flap. The authors treated 11 patient with this technique, with few complications. In our opinion, this technique is very useful, especially to cover the distal part of the sternum. The risk of recurrence is high in these patients, and thus preserving the contralateral muscle flap permits having another choice for a second reconstruction. The advancement of a pectoralis flap does not permit total coverage of the inferior part of the sternum, which is the most common site for dehiscence after sternotomy, and does not fill the dead space.2 In our practice, to overcome this problem, we usually perform a monolateral advancement flap with mobilization of a rectus fascia flap.
Two main points of the article remain doubtful. First, these patients are usually anticoagulated, and thus splitting the muscle fibers can increase the risk of bleeding and hematoma formation, which reaches 20 percent in some clinical series.3 Furthermore, usually the internal mammary vessels are not present because of their use in previous cardiac surgery.
In our practice, we carry out a staged reconstruction,4 consisting of surgical débridement and negative-pressure therapy until negativization of microbiological specimens is achieved. Negative-pressure therapy led to early removal of infective material3,5 and helped to reduce dead space.4 Then, a monolateral advancement pectoralis major flap, including a piece of rectus fascia, is harvested for wound closure. We congratulate the authors on the newly described technique because it led to coverage of the entire sternum and full obliteration of the inferior dead space with reduction of the area for seroma formation and long-term wound stability.
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