Surgical configurations of the pectoralis major flap for reconstruction of sternoclavicular defects: a systematic review and new classification of described techniques.

OBJECTIVES: The pectoralis major flap has been considered the workhorse flap for chest and sternoclavicular defect reconstruction. There have been many configurations of the pectoralis major flap reported in the literature for use in reconstruction sternoclavicular defects either involving bone, soft tissue elements, or both. This study reviews the different configurations of the pectoralis major flap for sternoclavicular defect reconstruction and provides the first ever classification for these techniques. We also provide an algorithm for the selection of these flap variants for sternoclavicular defect reconstruction. METHODS: EMBASE, Cochrane library, Ovid medicine and PubMed databases were searched from its inception to August of 2019. We included all studies describing surgical management of sternoclavicular defects. The studies were reviewed, and the different configurations of the pectoralis major flap used for sternoclavicular defect reconstruction were cataloged. We then proposed a new classification system for these procedures. RESULTS: The study included 6 articles published in the English language that provided a descriptive procedure for the use of pectoralis major flap in the reconstruction of sternoclavicular defects. The procedures were classified into three broad categories. In Type 1, the whole pectoris muscle is used. In Type 2, the pectoralis muscle is split and either advanced medially (type 2a) or rotated (type 2b) to fill the defect. In type 3, the clavicular portion of the pectoralis is islandized on a pedicle, either the thoracoacromial artery (type 3a) or the deltoid branch of the thoracoacromial artery (type 3b). CONCLUSION: There are multiple configurations of the pectoralis flap reported in the English language literature for the reconstruction of sternoclavicular defects. Our classification system, the Opoku Classification will help surgeons select the appropriate configuration of the pectoralis major flap for sternoclavicular joint defect reconstruction based on size of defect, the status of the vascular anatomy, and acceptability of upper extremity disability. It will also help facilitate communication when describing the different configurations of the pectoralis major flap for reconstruction of sternoclavicular joint defects.

The novel use of cryopreserved human allograft in extensive Hurley stage III hidradenitis suppurativa.

INTRODUCTION: HS is a debilitating dermatologic condition in which apocrine sweat glands become occluded, leading to severe inflammation. Treatment usually ranges from conservative management to surgical intervention with the goal of treating existing lesions while reducing the rate of recurrence, progression, and scarring. Depending on the surface area involved, autologous skin grafting may be difficult when donor sites are limited due to the extent of disease, previous surgery, or scarring. This case report examines the efficacy of cryopreserved human allograft as a surgical treatment of extensive HS. CASE REPORT: A 37-year-old man presented with severe, refractory Hurley stage III HS in which cryopreserved human allograft was used to aid in wound contracture and granulation tissue formation. In addition, its use improved contour deformities and served as a bridge to autologous skin grafting, minimizing donor site size and morbidity. CONCLUSIONS: While autologous skin grafting is necessary for final wound closure, the use of cryopreserved human allograft provides biologic wound management that aids as a bridge to autologous skin grafting. As such, the authors advocate its use as a tissue scaffold in the management of severe, extensive HS and other dermatologic conditions requiring skin excision.

Pilonidal disease of the anterior perineum: an unusual presentation and review of current practice guidelines.

INTRODUCTION: Pilonidal disease is a common condition of the gluteal cleft region, but involvement of the anterior perineum is rarely reported. Surgical options for gluteal cleft disease include simple fistulotomy, excisional procedures with primary closure (ie, Bascom cleft lift, Karydakis and Limberg flaps), or excision with secondary healing. The Bascom cleft lift described here is an excisional procedure involving a rotational flap with an off-midline closure. Deep tissue is salvaged allowing for proper contouring of the gluteal cleft, resulting in a cosmetically pleasing result. CASE REPORT: A 20-year-old man with recurrent pilonidal abscesses of the gluteal cleft underwent a Bascom cleft lift procedure for definitive care of his disease. During the procedure, involvement of the anterior perineum was found. Given the location of the pits relative to the flap, the anterior perineal disease was treated only with removal of hair from within the pits and clipping the hair of the perineum. CONCLUSION: While this case highlights the current standard of care and surgical options for pilonidal disease, the ideal surgical options for rare cases of pilonidal disease of the anterior perineum remain to be determined.

Revisiting the expanded use of hyperbaric oxygen therapy for treatment of resistant migraines.

There are currently 13 indications approved by the U.S. Food and Drug Administration for use of hyperbaric oxygen therapy. The European Consensus Conference on Hyperbaric Medicine has 28 indications approved for its use. However, neither includes the use of hyperbaric oxygen therapy for neurological conditions such as migraines with aura. Recent research has made the attempt to fully understand the use of hyperbaric therapy in treatment of neurological conditions, but results have so far been inconclusive. We report a 23-year-old female with an 11-year history of migraines with aura who has received inadequate pharmacological treatment for her migraines since she began having them. Migraines have led her to significant loss of function. The patient underwent treatment at 1.5 absolute atmospheres in a hyperbaric chamber Monday through Friday for 1 hour each day for a total of 40 sessions but reported missing a few sessions over the 8-week period. No more than 1 session during a given week was missed and the patient received no other treatments for her migraines throughout this time period. By her 24th treatment, the patient had only experienced a single migraine with aura but without debilitating pain. The patient stated she had never had a migraine with such little intensity prior to initiation of hyperbaric treatment and did not have to take any days off from work or school. Follow-up at the end of her 40-day treatment period revealed a highly-satisfied patient who had only experienced the single episode of a mild migraine during the entire course of treatment. Thus, we believe that further research needs to be done to realize the full potential of hyperbaric oxygen therapy in the treatment of neurological conditions as this case highlights the potential for using hyperbaric oxygen therapy as prophylaxis against attacks in patients with treatment resistant migraines with aura.

Revisiting the musculocutaneous external oblique flap as a versatile alternative in large thoracic wall defects.

BACKGROUND: The external oblique myocutaneous flap has been previously described for reconstruction of chest-thoracic wall defects smaller than 400-500 cm2. However, it is utilized less often than workhorse flaps such as the omental, pectoralis, rectus abdominis, and latissimus dorsi myocutaneous flaps as many plastic surgeons are not aware that the flap can cover larger areas than previously documented. CASE PRESENTATION: We report a 57-year-old female tobacco user who underwent a resection of a grade 3 breast angiosarcoma resulting in a high left chest wall soft tissue defect approximating 900 cm2. The patient underwent an external oblique myocutaneous pedicle flap reconstruction of the defect, most notably in anticipation of postoperative adjuvant radiation therapy. No gross flap complications and or patient impairment were noted. Thirteen months status post flap reconstruction, the patient underwent an aortic valve replacement requiring re-elevation of the same flap for exposure. The flap demonstrated excellent viability during the procedure and postoperatively. CONCLUSION: The pedicled external oblique myocutaneous flap should be considered when reconstructing larger high chest wall defects when other more common flaps used in chest reconstruction may not be indicated. The external oblique myocutaneous flap is an excellent tool in the armamentarium of any reconstructive surgeon; it is a straightforward and versatile flap that can be safely and reliably used in durable reconstruction of defects of the chest wall and covers defects larger than previously described in the literature.

Reconstruction of sternoclavicular defect with completely detached pectoralis major flap.

Sternoclavicular joint infection is very rare. Osteomyelitis is a known complication of septic sternoclavicular joint. Once this condition is diagnosed, aggressive management including antibiotic and surgical debridement is warranted. Patients are often left with sizeable sternoclavicular defects that may need surgical reconstruction. In this report, we describe the use of a completely detached pectoralis major flap for the reconstruction of a large sternoclavicular defect after resection for osteomyelitis. Briefly, after the debridement of the infected sternoclavicular joint, the pectoralis major was detached from its sternoclavicular attachments and further detached from the humeral attachments rendering it completely detached on a vascular pedicle. The muscle was advanced to cover the defect and secured. Patient recovered well without any surgery related complication. She retained good use of the ipsilateral upper extremity. The pectoralis major can be completely detached to provide ample coverage for sternoclavicular joint reconstruction if needed.