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The technique of muscle transposition is a powerful tool in the armamentarium of the thoracic surgeon. Pedicled thoracic myoplasty, a simple and robust technique to bring vascularized tissue into the chest cavity, is performed to address space issues or to buttress closure of the bronchus or esophagus. The ability of the thoracic surgeon to successfully complete these procedures without consultant involvement is important; the myoplasty is often a key or integral component of the planned thoracic operation, or in other cases the need for muscle transposition may present itself unexpectedly.
The use of muscle transposition to treat the persistent intrathoracic space typically occurs in the setting of postsurgical empyema (with or without ongoing parenchymal air leak), or in combination with high-risk anatomic pulmonary resection. In the latter case, the transposed muscle is employed in a prophylactic fashion to minimize postoperative infectious or air leak complications. The muscle flap may also be used as a well-vascularized tissue buttress, applied to bronchial stumps, esophageal anastomoses, or esophageal repairs.
We discuss the technique of harvesting and transposition of the three flaps most commonly used at our institution: latissimus dorsi, pectoralis major, and intercostal muscle. The first two muscles may be used both for space issues and to buttress airway or esophageal closure, whereas the intercostal flap is used primarily for buttressing. Use of the serratus anterior muscle for intrathoracic myoplasty results in a flared or “winged” scapula, poorly tolerated in this typically debilitated patient population, and thus, is rarely employed at our institution.
The additional impact of muscle transposition on the postoperative care of the thoracic surgical patient is negligible. The subcutaneous drain is maintained until drainage is minimal to avoid seroma formation. Early mobility and range of motion of the ipsilateral upper extremity is encouraged, with a gradual increase to full use over 4 to 6 weeks. Most patients report the return of full range of motion and nearly complete strength following large muscle (LD and PM) transposition, with only mild weakness in adduction and medial rotation of the upper extremity.
Intrathoracic muscle transposition is a versatile and easily mastered procedure, applicable to a variety of clinical situations. The use of a muscle flap to buttress an esophageal or bronchial closure can minimize postoperative morbidity, particularly in the difficult or complex case. In the setting of a persistent, infected pleural space, selective intrathoracic myoplasty may lead to eradication of the space with surprisingly minimal impact on upper extremity motion or strength. A basic knowledge of the techniques described above is essential to the busy thoracic surgeon.
Dr. Mitchell reports receiving lecture fees from Covidien.