Complete coverage of a tissue expander by a musculofascial pocket including the sternalis muscle during breast reconstruction

Article information

Arch Plast Surg. 2018;45(1):89-90

Publication date (electronic) : 2017 October 27

doi : https://doi.org/10.5999/aps.2017.00017

Naohiro Ishii^,¹, Yusuke Shimizu ², Jiro Ando ³, Michiko Harao ³, Masaru Takemae ³, Kazuo Kishi ⁴

¹Department of Plastic and Reconstructive Surgery, Tochigi Cancer Center, Tochigi, Japan

²Department of Plastic and Reconstructive Surgery, University of the Ryukyus Hospital, Okinawa, Japan

³Department of Breast Surgery, Tochigi Cancer Center, Tochigi, Japan

⁴Department of Plastic and Reconstructive Surgery, Keio University, Tokyo, Japan

Correspondence: Naohiro Ishii Department of Plastic and Reconstructive Surgery, Tochigi Cancer Center, 4-9- 13, Yohnan, Utsunomiya City, Tochigi 320-0834, Japan Tel: +81-28-658-5151, Fax: +81-28-658-5669 E-mail: ishinao0916@gmail.com

Received 2016 December 31; Revised 2017 April 24; Accepted 2017 May 2.

The sternalis muscle is a vestigial muscle that is vertically long with a rectangular shape, courses parallel or oblique to the long axis of the medial sternocostal part of the pectoralis major, and presents in rare cases (1.3%) [1,2]. It often has a major effect on the insertion of a tissue expander during breast reconstruction; however, there has only been a single report of the sternalis muscle and the pectoralis major muscle being elevated as a lower mastectomy flap, and no reports have been published about repairing intraoperative trauma [3].

A 66-year-old woman underwent immediate breast reconstruction using a tissue expander after total mastectomy. She had a left-sided sternalis muscle that was 3.5 cm wide and 12.0 cm long (Figs. 1, 2). In a musculofascial pocket that included the muscle, a loose adipose connection between the sternalis muscle and the pectoral major muscle collapsed due to the textured surface of the tissue expander to form a caudal lesion that was 5.0 cm long. However, this was successfully repaired using an untied suture technique (Fig. 3).

Fig. 1.

Imaging analysis of the sternalis muscle. (A) Image obtained 6.0 cm distal from the origin in T1-weighted magnetic resonance imaging. (B) Image obtained 9.0 cm distal from the origin in T1-weighted magnetic resonance imaging. (C) Image obtained 8.0 cm distal from the origin in computed tomography. The blue arrow indicates the sternalis muscle.

Fig. 2.

Schematic depiction of the sternalis muscle. The sternalis muscle was 3.5 cm wide and 12.0 cm long, coursed adjacent to the sternum and longitudinally for 8.5 cm of its length, and then coursed slightly obliquely, running lateral to the fascia of the rectus abdominalis muscle. It connected to the medial portion of the pectoralis major muscle via loose adipose connective tissue. SM, sternalis muscle; PM, pectoralis major muscle; FRM, fascia of rectus abdominalis muscle.

Fig. 3.

(A) Repair of the loose adipose connection. The textured surface of the tissue expander filled with saline caused the collapse of the loose adipose connection between the sternalis muscle and pectoralis major muscle, resulting in a caudal lesion that was 5.0 cm long. The tissue expander was subsequently removed and 6 untied sutures were inserted in these muscles. The SV-14 tissue expander (volume, 500 mL; height, 12 cm; width, 14 cm; projection, 7.1 cm) was made by Allergan Inc. (Santa Barbara, CA, USA). (B) Insertion of the tissue expander in the musculofascial pocket. Untied sutures were ligated carefully and both the pectoralis major muscle and the fascia of the serratus anterior muscle were sutured. The tissue expander was subsequently inserted into the musculofascial pocket. The blue arrows indicates the ligated untied sutures. SM, sternalis muscle; PM, pectoralis major muscle; FRM, fascia of rectus abdominalis muscle; TE, tissue expander.

Many plastic surgeons may be unfamiliar with the sternalis muscle; however, they should investigate whether it is present preoperatively via imaging. The merits of the untied suture technique include the certain and safe suturing of both the sternalis muscle, which is often thin, and the pectoralis major muscle without damaging the tissue expander, preventing the recurrence of collapse in this area of connective tissue when inserting it after the ligation of sutures during repair. This technique may be improved by combining it with horizontal mattress sutures.

Notes

No potential conflict of interest relevant to this article was reported.

Patient Consent

The patient provided written informed consent for the publication and the use of their images.

References

1. Schulman MR, Chun JK. The conjoined sternalis-pectoralis muscle flap in immediate tissue expander reconstruction after mastectomy. Ann Plast Surg 2005;55:672–5.

2. Barlow RN. The sternalis muscle in American whites and Negroes. Anat Rec 1934;61:416–26.

3. Alani HA, Balalaa N. Complete tissue expander coverage by musculo-fascial flaps in immediate breast mound reconstruction after mastectomy. J Plast Surg Hand Surg 2013;47:399–404.

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