Current Global Trends in Prepectoral Breast Reconstruction.

Implant-based breast reconstruction (IBBR) is the most frequently performed procedure for breast reconstruction following mastectomy, which involves the surgical placement of breast implants. The approach to breast reconstruction can be divided into two main categories, namely prepectoral breast reconstruction (PPBR) and subpectoral breast reconstruction (SPBR), based on the implant plan and placement technique. In recent years, there has been a significant surge in the popularity of prepectoral implant-based breast reconstruction, where the implants are positioned above the chest muscle, as opposed to beneath it in the subpectoral approach. However, despite this growing preference, there is a lack of comprehensive data regarding the national trends in the utilization of this technique, thus necessitating further investigation. This narrative review aims to ascertain the current global patterns linked to prepectoral breast reconstruction and elucidate the considerations surrounding patient and implant selection, reconstructive techniques, the utilization of meshes in prepectoral reconstruction, the ensuing outcomes and complications, the ramifications of radiotherapy, and the potential advantages of integrating fat infiltration into the implementation of this technique in breast reconstruction with a focus on published papers in last five years. Conclusion: Prepectoral breast reconstruction has emerged as an appropriate surgical option for individuals seeking breast reconstruction. This development can be attributed to the recent progress made in implant technology, which has significantly enhanced the outcomes of this procedure. Additionally, advancements in mastectomy techniques, autologous fat grafting, and the use of acellular dermal matrices (ADMs) have also played a vital role in improving the aesthetic results of prepectoral breast reconstruction. As a result, the significance and effectiveness of this technique in the field of breast reconstruction have been firmly established, making it an essential component of the overall armamentarium available to plastic surgeons for breast reconstruction purposes.

The use of flaps for management of deep sternal wound complications: A systematic review and meta-analysis.

BACKGROUND: Many options are available for reconstruction after deep sternal wound infections. However, these options have not been critically appraised. The aim of this systematic review and meta-analysis was to assess the existing evidence on sternal rewiring versus flap reconstruction and pectoralis major muscle flaps (PMFs) versus greater omental flaps (GOFs). METHODS: A systematic review and meta-analysis was performed. CENTRAL, MEDLINE and EMBASE were searched. Outcomes of interest included mortality, treatment failure and length of hospital stay (LOS). RESULTS: Fourteen studies were included. Nine studies compared flaps to rewiring, reporting on 618 patients. Patients treated with flaps had significantly lower mortality compared with patient treated with rewiring (Risk ratio [RR] 0.42, 95% confidence interval [CI]: 0.23-0.77, P < 0.01). Flap patients had significantly lower treatment failure compared with those who were treated with rewiring (RR 0.22, 95% CI: 0.14-0.37, P < 0.01). No statistically significant differences were observed in LOS between patients treated with flaps compared those treated with rewiring (standard mean difference -0.84, 95% CI: -1.91 to 0.24, P = 0.13). Five studies compared PMF with GOF, reporting on 599 patients. No statistically significant differences were found in mortality (RR 0.63, 95% CI: 0.24-1.68, P = 0.36), LOS (standard mean difference -14.52, 95% CI: -42.00 to 12.96, P = 0.30) or treatment failure (RR 1.37, 95% CI: 0.31-6.07, P = 0.68) in patients treated with PMF compared with patients treated with GOF. CONCLUSIONS: Flap-based reconstruction demonstrated improved mortality and treatment outcomes compared to sternal rewiring. However, no significant differences were observed in outcomes between the PMF- and GOF-based reconstructions.

The Effect of Different Weight Plate Widths (Bumper vs. Standard) on the Biomechanics of the Bench Press.

ABSTRACT: Fiedler, MJ, Triplett, NT, Hamilton, KC, Needle, AR, and van Werkhoven, H. The effect of different weight plate widths (bumper vs. standard) on the biomechanics of the bench press. J Strength Cond Res 38(4): e143-e149, 2024-Anecdotal evidence suggests that bumper plates impact lifts in powerlifting and weightlifting differently than standard cast iron plates, but whether biomechanical differences exist between lifts using bumper versus standard plates has not been investigated. Eleven resistance-trained subjects performed the bench press at 70, 80, and 90% of their 1 repetition maximum (1RM) while being blinded to whether they were lifting with bumper or standard plates. Motion data were captured by an 8-camera motion capture system, and electromyography (EMG) data were recorded for the anterior deltoid, pectoralis major, and triceps brachii. Repeated-measures analysis of variances showed a significant main weight effect for time under tension (p < 0.001), total work (p < 0.001), and muscle activity through EMG (across all muscles; p < 0.001) and a significant weight × joint interaction effect for average joint moment (p < 0.001) and peak joint moment (p < 0.001). However, there were no significant differences observed between the different weight plates for any of the measures. The main finding of the study suggests that there are no biomechanical differences between using bumper plates compared with standard plates during the bench press lift.

Pectoralis Major Muscle Flap Utilization in Salvage Esophagectomy Including Great Vessel Resection Reconstructed by Prosthetic Grafts.

BACKGROUND: Salvage surgery is a therapeutic option for recurrent or residual esophageal cancer after definitive chemoradiation therapy. This report aimed to describe the procedure of reconstruction after salvage esophagectomy involving great vessel resection using prosthetic grafts, a pectoralis major muscle (PM) flap, and free jejunal transfer, if required. To the best of our knowledge, no previous report has described the reconstruction of the defect after combined esophageal and great vessel resection. PATIENTS AND METHODS: From January 2017 to December 2022, 4 patients underwent salvage esophagectomy with excision of the great vessels and reconstruction with prosthetic grafts, as well as a PM flap placement in a single center. We retrospectively investigated the patients' clinical data. The patients were all men, with a median age of 70 (range, 67-77) years. Regarding neoadjuvant therapy, 2 patients received chemoradiation therapy, 1 patient received radiotherapy only due to drug-induced pneumonia, and 1 patient received chemotherapy with adjuvant radiotherapy. RESULTS: Alimentary tract reconstruction was performed by free jejunal transfer in 2 cases, direct suture in 1 case, and stomach roll in 1 case. In all cases, a vascular bypass was established before tumor resection. We created mediastinal tracheostoma in 2 cases. A PM flap was inserted to cover the prosthetic grafts and approximate the tracheal mucosa. With regard to major complications, leakage from the jejunal esophageal anastomotic site was observed in 2 cases. The leakage improved with conservative treatment without graft removal or replacement in both cases. CONCLUSIONS: In cases of locally recurrent or residual tumors after definitive chemoradiation therapy, salvage esophagectomy along with great vessel resection, followed by reconstruction using prosthetic grafts, PM flaps, and free jejunal transfer, if necessary, is a useful option.

Malnutrition and pectoralis muscle index in medical intensive care unit patients: A matched cohort study.

BACKGROUND: Muscle assessment is an important component of nutrition assessment. The Global Leadership Initiative on Malnutrition (GLIM) consortium recently underscored the need for more objective muscle assessment methods in clinical settings. Various assessment techniques are available; however, many have limitations in clinical populations. Computed tomography (CT) scans, obtained for diagnostic reasons, could serve multiple purposes, including muscle measurement for nutrition assessment. Although CT scans of the chest are commonly performed clinically, there is little research surrounding the utility of pectoralis muscle measurements in nutrition assessment. The primary aim was to determine whether CT-derived measures of pectoralis major cross-sectional area (PMA) and quality (defined as mean pectoralis major Hounsfield units [PMHU]) could be used to identify malnutrition in patients who are mechanically ventilated in an intensive care unit (ICU). A secondary aim was to evaluate the relationship between these measures and clinical outcomes in this population. METHODS: A retrospective analysis was conducted on 33 pairs of age- and sex-matched adult patients who are being mechanically ventilated in the ICU. Patients were grouped by nutrition status. Analyses were performed to determine differences in PMA and mean PMHU between groups. Associations between muscle and clinical outcomes were also investigated. RESULTS: Compared with nonmalnourished controls, malnourished patients had a significantly lower PMA (P = 0.001) and pectoralis major (PM) index (PMA/height in m2; P = 0.001). No associations were drawn between PM measures and clinical outcomes. CONCLUSION: These findings regarding CT PM measures lay the groundwork for actualizing the GLIM call to action to validate quantitative, objective muscle assessment methods in clinical settings.

Flap management following orthotopic heart transplantation: A single institution's review of 66 sternal wound complications.

BACKGROUND: Sternotomy wound complications are more frequent after orthotopic heart transplantation (OHT) compared to other cardiac surgeries, primarily due to additional risk factors, including immunosuppression. Flap closure often becomes necessary for definitive treatment, although there is a scarcity of data on the outcomes of sternal wound reconstruction in this specific population. METHODS: A retrospective analysis was conducted on 604 sternal wound reconstructions performed by a single surgeon between 1996 and 2023. Inclusion criteria comprised patients who underwent OHT as their primary cardiac procedure. Surgical interventions involved sternal hardware removal, debridement, and muscle flap closure. RESULTS: The study included 66 patients, with culture-positive wound infection being the most common indication for reconstruction (51.5%). The median duration between transplantation and sternal wound reconstruction was 25 days. Bilateral pectoralis major myocutaneous advancement flaps (n = 63), rectus abdominis flaps (n = 2), or pectoralis major turnover flaps (n = 1) were used. Intraoperative wound cultures revealed positivity in 48 patients (72.7%), with Staphylococcus epidermidis being the most frequently cultured organism (25.0%). The overall complication rate was 31.8%, and two patient deaths were related to sternal wounds, resulting from multiorgan failure following septic shock. The majority of the patients reported excellent long-term functional and esthetic outcomes. CONCLUSIONS: Sternal wounds following OHT pose a significant morbidity risk. Our strategy focuses on immediate and aggressive antibiotic therapy, thorough debridement, and definitive closure with bilateral pectoralis myocutaneous advancement flaps. This approach has demonstrated complication and mortality rates comparable to the general cardiac surgery population, as well as excellent functional and esthetic results.

Whole-transcriptome sequencing reveals a melanin-related ceRNA regulatory network in the breast muscle of Xichuan black-bone chicken.

The economic losses incurred due to reduced muscle pigmentation highlight the crucial role of melanin-based coloration in the meat of black-bone chickens. Melanogenesis in the breast muscle of black-bone chickens is currently poorly understood in terms of molecular mechanisms. This study employed whole-transcriptome sequencing to analyze black and white breast muscle samples from black-bone chickens, leading to the identification of 367 differentially expressed (DE) mRNAs, 48 DElncRNAs, 104 DEcircRNAs, and 112 DEmiRNAs involved in melanin deposition. Based on these findings, a competitive endogenous RNA (ceRNA) network was developed to better understand the complex mechanisms of melanin deposition. Furthermore, our analysis revealed key DEmRNAs (TYR, DCT, EDNRB, MLPH and OCA2) regulated by DEmiRNAs (gga-miR-140-5p, gga-miR-1682, gga-miR-3529, gga-miR-499-3p, novel-m0012-3p, gga-miR-200b-5p, gga-miR-203a, gga-miR-6651-5p, gga-miR-7455-3p, gga-miR-31-5p, miR-140-x, miR-455-x, novel-m0065-3p, gga-miR-29b-1-5p, miR-455-y, novel-m0085-3p, and gga-miR-196-1-3p). These DEmiRNAs competitively interacted with DElncRNAs including MSTRG.2609.2, MSTRG.4185.1, LOC112530666, LOC112533366, LOC771030, LOC107054724, LOC121107411, LOC100859072, LOC101750037, LOC121108550, LOC121109224, LOC121110876, and LOC101749016, as well as DEcircRNAs, such as novel_circ_000158, novel_circ_000623, novel_001518, and novel_circ_003596. The findings from this study provide insight into the mechanisms that regulate lncRNA, circRNA, miRNA, and mRNA expression in chicken melanin deposition.

Spatial transcriptomics reveals alterations in perivascular macrophage lipid metabolism in the onset of Wooden Breast myopathy in broiler chickens.

This study aims to use spatial transcriptomics to characterize the cell-type-specific expression profile associated with the microscopic features observed in Wooden Breast myopathy. 1 cm3 muscle sample was dissected from the cranial part of the right pectoralis major muscle from three randomly sampled broiler chickens at 23 days post-hatch and processed with Visium Spatial Gene Expression kits (10X Genomics), followed by high-resolution imaging and sequencing on the Illumina Nextseq 2000 system. WB classification was based on histopathologic features identified. Sequence reads were aligned to the chicken reference genome (Galgal6) and mapped to histological images. Unsupervised K-means clustering and Seurat integrative analysis differentiated histologic features and their specific gene expression pattern, including lipid laden macrophages (LLM), unaffected myofibers, myositis and vasculature. In particular, LLM exhibited reprogramming of lipid metabolism with up-regulated lipid transporters and genes in peroxisome proliferator-activated receptors pathway, possibly through P. Moreover, overexpression of fatty acid binding protein 5 could enhance fatty acid uptake in adjacent veins. In myositis regions, increased expression of cathepsins may play a role in muscle homeostasis and repair by mediating lysosomal activity and apoptosis. A better knowledge of different cell-type interactions at early stages of WB is essential in developing a comprehensive understanding.

Pectoral muscle mass is not a robust prognostic factor for survival after left ventricular assist device (LVAD) implantation.

BACKGROUND: Left ventricular assist devices (LVAD) are an established treatment for end-stage left ventricular heart failure. Parameters are needed to identify the most appropriate patients for LVADs. This study aimed to evaluate pectoral muscle mass and density as prognostic parameters. METHODS: This single-center study included all patients with LVAD implantation between January 2010 and October 2017 and a preoperative chest CT scan. Pectoral muscle mass was assessed using the Pectoralis Muscle Index (PMI, surface area indexed to height, cm2/m2) and pectoral muscle density by Hounsfield Units (HU). Overall mortality was analyzed with Kaplan-Meier survival analysis and 1-year and 3-year mortality with receiver operating characteristic (ROC) curves and Cox regression models. RESULTS: 57 patients (89.5% male, mean age 57.8 years) were included. 64.9% of patients had end-stage left ventricular failure due to ischemic heart disease and 35.1% due to dilated cardiomyopathy. 49.2% of patients had preoperative INTERMACS profile of 1 or 2 and 33.3% received mechanical circulatory support prior to LVAD implantation. Total mean PMI was 4.7 cm2/m2 (± 1.6), overall HU of the major pectoral muscle was 39.0 (± 14.9) and of the minor pectoral muscle 37.1 (± 16.6). Mean follow-up was 2.8 years (± 0.2). Mortality rates were 37.5% at 1 year and 48.0% at 3 years. Neither PMI nor HU were significantly associated with overall mortality at 1-year or 3-year. CONCLUSIONS: The results of our study do not confirm the association between higher pectoral muscle mass and better survival after LVAD implantation previously described in the literature.

Integrated assessment of computed tomography density in pectoralis and erector spinae muscles as a prognostic biomarker for coronavirus disease 2019.

BACKGROUND ＆ AIMS: Muscle quantification using chest computed tomography (CT) is a useful prognostic biomarker for coronavirus disease 2019 (COVID-19). However, no studies have evaluated the clinical course through comprehensive assessment of the pectoralis and erector spinae muscles. Therefore, we compared the impact of the areas and densities of these muscles on COVID-19 infection outcome. METHODS: This multicenter retrospective cohort study was conducted by the COVID-19 Task Force. A total of 1410 patients with COVID-19 were included, and data on the area and density of the pectoralis and erector spinae muscles on chest CT were collected. The impact of each muscle parameter on the clinical outcome of COVID-19 was stratified according to sex. The primary outcome was the percentage of patients with severe disease, including those requiring oxygen supplementation and those who died. Additionally, 167 patients were followed up for changes in muscle parameters at three months and for the clinical characteristics in case of reduced CT density. RESULTS: For both muscles, low density rather than muscle area was associated with COVID-19 severity. Regardless of sex, lower erector spinae muscle density was associated with more severe disease than pectoralis muscle density. The muscles were divided into two groups using the receiver operating characteristic curve of CT density, and the population was classified into four (Group A: high CT density for both muscles, Group B: low CT density for pectoralis and high for erector spinae muscle. Group C: high CT density for pectoralis and low for erector spinae muscle, Group D: low CT density for both muscles). In univariate analysis, Group D patients exhibited worse outcomes than Group A (OR: 2.96, 95% CI: 2.03-4.34 in men; OR: 3.02, 95% CI: 2.66-10.4 in women). Multivariate analysis revealed that men in Group D had a significantly more severe prognosis than those in Group A (OR: 1.82, 95% CI: 1.16-2.87). Moreover, Group D patients tended to have the highest incidence of other complications due to secondary infections and acute kidney injury during the clinical course. Longitudinal analysis of both muscle densities over three months revealed that patients with decreased muscle density over time were more likely to have severe cases than those who did not. CONCLUSIONS: Muscle density, rather than muscle area, predicts the clinical outcomes of COVID-19. Integrated assessment of pectoralis and erector spinae muscle densities demonstrated higher accuracy in predicting the clinical course of COVID-19 than individual assessments.

Common Wrist-Extensor Tendon and Pectoralis Muscle Stiffness in Healthy Recreational Tennis Players.

CONTEXT: Imbalances in upper-extremity soft tissue stiffness may play a role in the development of shoulder and elbow musculoskeletal injuries in tennis players. Ultrasound shear wave elastography provides quantifiable and specific data regarding muscle stiffness. The purpose of this study was to compare tendon and muscle stiffness in healthy tennis players to nontennis players. DESIGN: Cross-sectional study. METHODS: The shear wave modulus, measured in kilopascals, was obtained for the dominant pectoralis major, pectoralis minor, and common wrist-extensor tendon using 2-dimensional shear wave elastography ultrasound imaging (GE Logiq S8, L9 linear transducer). Independent t test was run to compare age, body mass index, and the activity index score between both groups. Within-day intrarater reliability was assessed using a within-examiner intraclass correlation coefficients (ICC [3, 1]) with 95% confidence intervals. A multivariate general linear model was run to compare the mean differences between the tennis and nontennis players for each of the soft tissues. RESULTS: Twenty-six individuals (13 tennis players and 13 nontennis players) were recruited. Within-day ICCs were very good (ICC > .78 for the pectoralis musculature) and excellent (ICC > .94 for the common wrist extensor). Common extensor tendon stiffness was significantly higher in tennis players compared to nontennis players (mean difference = 114.8 [61.8], confidence interval, -22.8 to 252.5 kPa for the dominant arm [P = .039]). Mean pectoralis major and minor stiffness differences were not significant (P > .214). CONCLUSIONS: Common wrist-extensor stiffness in healthy recreational tennis players is higher than those who do not play tennis. Therefore, clinicians may need to facilitate a greater soft tissue stiffness response with resistance training when rehabilitating recreational tennis players as compared to those not playing tennis. Additional normative data on a larger sample of recreational tennis players should be collected.

MicroRNA expression and oxidative stress markers in pectoral muscle of broiler chickens fed diets supplemented with phytobiotics composition.

Phytobiotic compositions are commercially used in broiler production, mostly to improve general health and the production parameters. Moreover, some of their active substances may change the expression of miRNA in different tissues. Therefore, the purpose of this study was to evaluate the effect of the phytobiotic composition (PBC) containing white mustard, calamus, turmeric, and common ivy on production parameters, oxidative stress markers and expression of selected miRNAs in pectoral muscle of broiler chickens. The experiment was performed on broiler chickens fed the control diet (without PBC), and a diet supplemented with 60 or 100 mg/kg of PBC for 35 days. After the experiment, samples (blood and muscle) were collected for analyses. The analyzed production parameters included: feed conversion ratio, feed intake and body weight. There was no effect on growth performance of broiler chickens but feeding diet supplemented with 60 mg/kg phytobiotics significantly increased the expression of miR-30a-5p, miR-181a-5p, and miR-206, and decreased that of miR-99a-5p, miR-133a-5p, miR-142-5p, and miR-222 in pectoral muscle of chickens. The addition of 100 mg/kg phytobiotics significantly increased miR-99a-5p and miR-181a-5p expression, and caused down-regulation of the expression of miR-26a-5p and miR-30a-5p. Chickens fed diet supplemented with 100 mg/kg PBC had lower level of lipid peroxidation products in blood, while in the muscle tissue it was higher in birds fed a diet with the addition of 60 mg/kg as compared to the control group. The results suggest that this unique composition of phytobiotics does not affect productive traits but can change expression of miRNAs that are crucial for muscle physiology and pathology in broiler chickens. This additive may also protect against the oxidative stress but the effect is dose dependent.

Water properties in intact wooden breast fillets during refrigerated storage.

The wooden breast (WB) condition notably alters moisture content and water holding capacity (WHC) in broiler breast fillets. The purpose of this study was to investigate water properties during refrigerated storage from 4 h to 168 h postmortem using time domain nuclear magnetic resonance (TD-NMR). Water properties measured included mobility (T), proportion (P), and abundance per 100 g of meat (A). Changes in meat quality indicators including compression force, color, pH, cumulative purge loss, and proximate composition were also measured. Compression force and energy of the WB fillets were higher than normal fillets (P < 0.05). Slopes of changes in lightness of the WB and normal fillets were different in skin and bone side (P < 0.05). The slope of the purge loss from the WB fillets was higher than the normal fillets (P < 0.05). Time domain nuclear magnetic resonance analysis showed 4 water populations in intact broiler fillets with transverse relaxation time (T2) constants at approximately 4 to 5 milliseconds (ms) (designated as 2b, corresponding to hydration water or bound water), 40 to 60 ms (designated as 21, corresponding to intra-myofibrillar water or immobilized water), 80 to 210 ms (designated as 22a, corresponding to extra-myofibrillar water or free water with lower mobility) and 210 to 500 ms (designated as 22b, corresponding to extra-myofibrillar water or free water with higher mobility) during early postmortem storage (between 4 h and 72 h postmortem) and only 3 populations (2b, 21, and 22a) after 72 h postmortem. There were interaction effects (P < 0.05) between storage time and WB condition for all water properties except T2b, A2b/100 g, and T22b. The linear change of T21, P21, A21/100 g, T22a, A22a/100 g, P22b, and A22b/100 g in stored WB samples were different from the normal fillets (P < 0.05). During storage, P21 and A21/100 g of the WB fillets exhibited faster linear increases than those of the normal fillets, whereas T21 and T22a of the normal fillets and A22a/100 g, P22b, and A22b/100 g of the WB fillets showed faster linear decreases (P < 0.05). Our data demonstrate that the WB condition affects changes in water properties in broiler fillets during postmortem refrigerated storage.

Chronic heat stress inhibits glycogen synthesis through gga-miR-212-5p/GYS1 axis in the breast muscle of broilers.

Studies have demonstrated that chronic heat stress can accelerate glycolysis, decrease glycogen content in muscle, and affect muscle quality. However, the consequences of chronic heat stress on glycogen synthesis, miRNA expression in pectoralis major (PM) muscle, and its regulatory functions remain unknown. In this study, high-throughput sequencing and cell experiments were used to explore the effects of chronic heat stress on miRNA expression profiles and the regulatory mechanisms of miRNAs in glycogen synthesis under chronic heat stress. In total, 144 cocks were allocated into 3 groups: the normal control (NC) group, the heat stress (HS) group, and the pair-fed (PF) group. In total, 30 differently expressed (DE) miRNAs were screened after excluding the effect of feed intake, which were mainly related to metabolism, signal transduction, cell growth and death. Furthermore, the gga-miR-212-5p/GYS1 axis was predicted to participate in glycogen synthesis through the miRNA-mRNA analysis, and a dual-luciferase reporter test assay confirmed the target relationship. Mechanistically, chronic heat stress up-regulated gga-miR-212-5p, which could inhibit the expression of GYS1 in the PM muscle. Knocking down gga-miR-212-5p alleviates the reduction of glycogen content caused by chronic heat stress; overexpression of gga-miR-212-5p can reduce glycogen content. This study provided another important mechanism for the decreased glycogen contents within the PM muscle of broilers under heat stress, which might contribute to impaired meat quality.

Distal insertion of the clavicular portion of pectoralis major muscle: anatomical study.

PURPOSE: Several descriptions of the anatomy of the pectoralis major (PM) have been published. However, the precise description of its distal humeral insertion, which is involved in traumatic tears, remains controversial. The distal tendon is classically described as being made of two layers, one anterior (ALPM) and one posterior (PLPM), which regroup at their distal edge. The clavicular head (CH) participates in the ALPM according to most authors. However, others describe a more superficial termination in a close relationship with the deltoid humeral insertion. The objective of this anatomical work is to precisely describe the anatomy of the CH and its relationship with the rest of the distal PM tendon and the distal deltoid tendon. MATERIALS: Twenty-three fresh cadaveric specimens were dissected (41 shoulders). The entire PM as well as the deltoid were exposed. Several measurements were collected to establish the relationships between the distal tendon of the CH and the PM, the deltoid and the bony landmarks. RESULTS: In all cases, the CH muscular portion sits on the ALPM but does not participate in the connective structure of the PM distal tendon. The inferolateral part of its distal end gives a thin tendinous portion that inserts lower on the humerus in conjunction with the distal tendon of the deltoid. In 24.4%, this tendon was more difficult to isolate but was always observed. CONCLUSIONS: The distal tendon of the PM only comes from the muscle fibres of its sternal head. The CH fibres do not contribute to this tendon but appear to terminate in a separate tendon fusing with the humeral insertion of the deltoid: the deltopectoral tendon. This could explain the different patterns of tears observed in clinical practice.

Operative technique: Pectoralis major flap with rib.

The osteomyocutaneous pectoralis major flap was first described in 1980 and provides a single stage reconstructive option for poor free flap or pectoralis major flap with reconstruction plate candidates requiring bony reconstruction. The flap provides good functional and cosmetic outcomes in appropriately selected patients. We describe the indications and operative techinique for harvesting this flap in written and video format.