Procedure:
Pectoralis muscle flap
SPLIT THICKNESS SKIN GRAFT CHEST
VAC PLACEMENT
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left lateral thigh will be used as a donor site in a similar area to her prior graft harvest. then brought back to the operating room and placed supine on the operating room table. SCDs were placed on bilateral lower extremities. arms were outstretched on padded foam arm rests and abducted to less than 90 degrees at the shoulder. underwent general anesthesia. prepped and draped in the usual sterile fashion. Prior to beginning of the procedure wound measurements were taken after the VAC was removed. left chest wall defect measured 6 x 5 x 1.5 cm. There was exposed pectoralis major, pectoralis minor, and ribs with a thin layer of periosteum. The wound bed was clean and started to granulate. An additional 1 cm margin was taken medially of subcutaneous tissue and pectoralis muscle. This was oriented with a single suture anteriorly and a double suture at 12:00 and sent to pathology. Upon inspection of the defect given the fact that the middle third of the pectoralis major muscle had already been taken during the prior resection it seemed appropriate to mobilize the superior third of the muscle and rotate it 90 degrees counterclockwise to fill the vertical defect underlying her open wound. Therefore using cautery the pectoralis major muscle fibers were removed from the sternal attachments as well as the clavicle. The deep side of the muscle was released off of what remained of pectoralis minor as well as the anterior border of the ribs. Care was taken not to damage the pectoralis major pedicle. Dissection proceeded until there was enough rotation in the muscle to allow the medial border of pectoralis major to cover the full extent of the defect. The entire wound bed was then copiously irrigated with 3 L of pulse lavage saline. Metal clips were placed to mark the superior and inferior medial lateral and deep borders of the recurrent tumor bed. Hemostasis was then achieved using electrocautery. The pectoralis muscle was then rotated into position and secured using 3-0 Vicryl sutures. There was not significant tension on the flap. The skin edges were tacked down to the muscle flap circumferentially in a similar fashion. At this point the skin defect requiring grafting measured 5 x 6.5 cm. A 1/14 inch split-thickness skin graft was harvested from the left lateral thigh using a 2 inch dermatome blade. It was meshed at a 1-1.5 ratio and secured to the pectoralis muscle using a running 5-0 chromic suture. Xeroform and a black foam sponge was placed over the graft. The VAC sponge was bridged to the left lateral chest wall and the system was secured at 125 mm of pressure. The left thigh was dressed with Xeroform, Tegaderm and Ace wrap. Anesthesia then performed a serratus block using Exparel