The Split Pectoralis Flap: Combining the Benefits of Pectoralis Major Advancement and Turnover Techniques in One Flap

We read with great interest the article entitled “The Split Pectoralis Flap: Combining the Benefits of Pectoralis Major Advancement and Turnover Techniques in One Flap” by Brown et al.1 We agree that the treatment of sternal wounds is a challenge for the plastic surgeon. In addition, these patients have many comorbidities and need well-vascularized tissue to cover the loss of substance. From January of 2003 to date, we have solved 57 cases of poststernotomy mediastinitis. Since 2012, we have used negative-pressure wound therapy on surgical wounds before and after coverage with advancement flaps with pectoral muscles. In our department, we implement a three-step protocol: débridement, negative-pressure wound therapy, and coverage with pectoralis major advancement flaps. We disagree with the statement that the advancement of the pectoralis major offers coverage of only the upper two-thirds of the sternum region. The authors use a split pectoralis flap to cover the lower third of the sternum. We find it very interesting, but in our experience, through the advancement of the chest muscles, we have always been able to offer good coverage of the distal portions of the sternum. In fact, when we need greater coverage in the distal third of the chest, we resort to an approximation of the flaps where one flap is positioned more caudally and one more cranially. If necessary, we have recourse to the humeral insertion detachment of the pectoralis major muscle. The pectoralis major advancement flap is also used in chest malformations such as in the treatment of pectus excavatum. Although today these techniques are used less often, we just want to highlight how the filling of dead spaces has not been a problem in using these techniques even in specific situations.2 In addition, we have always achieved good filling of dead spaces, especially through the use of negative-pressure wound therapy,which offers an easy-to-use solution. In fact, by applying negative-pressure wound therapy for 7 to 10 days, we are able to realize several advantages related to its use3 (e.g., increase in microcirculation, reduction of bacterial charge, and better wound bed preparation). In our series, dehiscence of the surgical wound was the main cause of reoperation. This resulted in an increase of biological risks for the patient and hospitalization costs. In selected cases, we apply the negativepressure wound therapy to −80 mmHg for 7 to 10 days to prevent surgical dehiscence (as we apply in other locations).4 The use of negative-pressure wound therapy has allowed us to reduce the rate of dehiscence of wounds. We would like to ask the authors whether they have considered the use of this resource. We would like to know whether, through the technique proposed, they had problems with closing the superficial planes for the bulky effect because of the turnover of the flap (as indicated by their images).