the mammary artery pectoral flaps of jacques joseph

British Journal of Plastic Surgery (1976), ~9, 370-376

THE MAMMARY ARTERY PECTORAL FLAPS OF JACQUES JOSEPH

By T. GIBSON, D.Sc., F.R.C.S., F.R.S.E. and D. W. ROBINSON, F.R.C.S.

Plastic and Oral Surgery Unit, Canniesbum Hospital, Bearsden, Glasgow

IN the welter of papers which have appeared in recent years on axial pattern flaps used either as pedicled flaps or free flaps, none of the authors seems aware of the writings of Jacques Joseph in this field. In the 193 r edition of his book “Nasenplastik” he added not only “Gesichtsplastik” (facial plastic surgery) and “ein Anhang iiber Mammaplastik” (a supplement on mammaplasty) but “einige weitere Operationen aus dem Gebiete der ausseren Kiirperplastik” (some other operations from the field of plastic surgery of the body). If he had called the book a textbook of plastic surgery it might be better known today. The trainee plastic surgeon, when he has learned Joseph’s intercartilagenous nasal incision and how to use Joseph’s saw, is likely to feel that he has acquired all that

FIG. I. Joseph used this illustration from Manchot (1889) as the justification for his use pectoral flap.

370

of the delto-

THE MAMMARY ARTERY PECTORAL FLAPS OF JACQUES JOSEPH 371

FIG. 2. The unilateral deltopectoral flap used to resurface the chin.

372 BRITISH JOURNAL OF PLASTIC SURGERY

FIG. 3. Bilateral deltopectoral flaps used to reconstruct an extensive lower facial defect. A, Left flap raised and attached. B, Right flap raised to add more substance to the chin.

Joseph has to offer. On the contrary, the 840 page book with its 1,718 illustrations is full of ingenuity and inventiveness and much of what the trainee might think of as modern techniques is to be found between its covers.

In the section on reconstruction of defects of the lower face, Joseph describes the “brachial method” of reconstruction with a Tagliacotian flap from the upper arm. Then the “pectoral method” is illustrated with a representation of the now well known illustration of Manchot (1889) (Fig. I). He goes into no detail “In many cases one can recommended the transfer of one or two large pedicle breast flaps from beneath the clavicle in accordance with the blood supply of the skin (Reference to Manchot)“. Then in half a dozen lines he refers briefly to the unilateral deltopectoral flap (Fig. 2) and the bilateral (although in 2 stages) deltopectoral flap (Fig. 3).

His most intriguing case is shown in Figures 4 and 5. The patient had extensive burns scars of her neck. These were excised in April 1930 and 2 pectoral flaps, I on each side, were raised as shown, apparently based on the 3rd and 4th perforating branches of the internal mammary artery, and passing well round into the axilla. The left flap was 8 x 30 cm and the right IO x 30 cm. The secondary defect was closed directly; this was in effect a mastopexy which proved to be just too high on the right side and Joseph had to lower it by inserting some skin from the axilla. The pectoral flaps survived except for a small area over the chin which was later replaced by an arm flap.

Although Penn and Penn (1973) described a similar flap, they delayed and tubed it. It took a brave, if not altogether foolhardy, man to raise in 1930 not I but 2 flaps based


FIG. 4. Reconstruction of neck following excision of an extensive burns scar. A, The defect. B, The left flap 8 x 30 cm outlined; C (see over), raised; D, rotated into position. Secondary defect closed

directly.

29/4--c


FIG. 5. A and B, Pre- and postoperative appearance. An arm flap had been used to build out the chin.

29/4--G*


on that allegedly avascular area, the midline, and with each base on the same part of the midline.

This flap might in certain cases be preferable to the classical deltopectoral flap particularly in women where the secondary defect could be closed directly leaving scars which are readily covered by clothing.

As far as we know a definitive biography of Jacques Joseph is still to be written but vignettes have been written by Safian (1970) and Natvig (1971). His writings are perhaps memorial enough.

REFERENCES

JOSEPH, J. (1931). “Nasenplastik und sonstige Gesichtsplastik nebst einem Anhang iiber Mammaplastik und einige weitere Operationen aus dem Gebiete der iiusseren KBrper- plastik.” Leipzig: Verlag von Curt Kabitzsch.

MANCH;, C. (1889). “Die Hautarterien des menschlichen Koerpers.” Leipzig: F. C. W.

NATVIG, P. (1971). Character and personality of Jacques Joseph. Plastic andReconstructive Surgery, 47, 452.

hNN, J. and PENN, J. G. (1973). The zigzag pectoro-subaxillary flap. Plastic and Recon- structive Surgery, 51, 27.

SAFIAN, J. (1970). Personal recollections of Jacques Joseph. Plastic and Reconstructive SurgerY, 46, 173.

the mammary artery pectoral flaps of jacques joseph

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