Management of intrathoracic defects.

Most intrathoracic transpositions involve the serratus anterior, pectoralis major, and latissimus dorsi muscles. These muscles provide an adequate mass and length of muscle for coverage of most structures in the mediastinum and have a single, dominant vascular axis. Winging of the scapula can occur with the harvest of the serratus anterior unless this is prevented by the maintenance of the upper two or three muscle slips as described previously. Even if winging does occur, we believe it to be a reasonable price to pay for control of the ongoing infection. Transposition of the latissimus dorsi and pectoralis major produce little if any significant cosmetic or functional defect in these ill patients. These muscles are transposed to assist in sealing of fistulas and to bolster vascular or visceral repair. We do not think that complete soft-tissue obliteration of the pleural cavity is necessary, and we continue to use the Clagett method of antibiotic-solution filling of the chest cavity at closure. In the irradiated patient with poor healing potential, intrathoracic muscle flaps may provide a means to salvage situations previously considered unsalvageable when the flaps are combined with sound principles of infection control; when used prophylactically, the flaps may prevent those same situations.