Research Article| Volume 65, ISSUE 2, e23-e28, February 2012

Treatment of pectoralis major flap myospasms with botulinum toxin type A in head and neck reconstruction

Published:November 10, 2011DOI:



      Treatment options for muscle spasm complications of the pectoralis major (PM) flap in head and neck reconstruction have hardly been investigated. The authors report their experience using botulinum toxin (BTX-A) injections as a treatment of PM flap myospasm complications in head and neck reconstruction.


      From January 2005 to May 2009, 83 patients underwent PM flap reconstruction. Eleven of them reported muscle twitching as a post-operative complication and are therefore included in this study. As all 11 patients refused a second surgery, they were offered BTX-A injections. This group of patients was followed up at regular intervals with clinical examinations, digital photography, range of motion (ROM) of the neck in different vectors, and neck disability system (NDS) questionnaires.


      After the first BTX-A infiltration, muscle twitching decreased, the ROM values increased and, according to the NDS, patients’ discomfort progressively decreased. Only two of the 11 patients required two additional BTX-A sessions.


      BTX-A infiltration is an effective non-invasive procedure that significantly reduces the PM muscular contraction in head and neck reconstruction.


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        • Ariyan S.
        The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck.
        Plast Reconstr Surg. 1979; 63: 73-81
        • Issing P.R.
        • Kempf H.G.
        • Heppt W.
        • Schonermark M.
        • Lenarz T.
        Reconstructive surgery in the head–neck area with regional and free tissue transfer.
        Laryngorhinootologie. 1996; 75: 476-482
        • Vartanian J.G.
        • Carvalho A.L.
        • Carvalho S.M.
        • Mizobe L.
        • Magrin J.
        • Kowalski L.P.
        Pectoralis major and other myofascial/myocutaneous flaps in head and neck cancer reconstruction: experience with 437 cases at a single institution.
        Head Neck. 2004 Dec; 26: 1018-1023
        • Urken M.L.
        • Biller H.F.
        Pectoralis major.
        in: Urken M.L. Cheney M.L. Sullivan M.J. Biller H.F. Atlas of regional and free flaps for head and neck reconstruction. Raven Press, New York1995: 3-28
        • El-Marakby H.H.
        The reliability of pectoralis major myocutaneous flap in head and neck reconstruction.
        J Egypt Natl Canc Inst. 2006; 18: 41-50
        • Merve A.
        • Mitra I.
        • Swindell R.
        • Homer J.J.
        Shoulder morbidity after pectoralis major flap reconstruction for head and neck cancer.
        Head Neck. 2009 Nov; 31: 1470-1476
        • Shah J.P.
        • Haribhakti V.
        • Loree T.R.
        • Sutaria P.
        Complications of the pectoralis major myocutaneous flap in head and neck reconstruction.
        Am J Surg. 1990; 160: 352-355
        • Mehta S.
        • Sarkar S.
        • Kavarana N.
        • Bhathena H.
        • Mehta A.
        Complications of the pectoralis major myocutaneous flap in the oral cavity: a prospective evaluation of 220 cases.
        Plast Reconstr Surg. 1996; 98: 31-37
        • Hoffman G.W.
        • Elliott L.F.
        The anatomy of the pectoral nerves and its significance to the general and plastic surgeon.
        Ann Surg. 1987; 205: 504-507
        • Moosman D.A.
        Anatomy of the pectoral nerves and their preservation in modified mastectomy.
        Am J Surg. 1980; 139: 883-886
        • Mast B.A.
        Painful pectoralis major myospasm as a result of sternal wound reconstruction: complete resolution with bilateral pectoral neurectomies.
        Plast Reconstr Surg. 1999; 104: 798-800
        • Hao L.
        • Clarke C.P.
        Persistent twitching of the latissimus dorsi muscle after a posterolateral thoracotomy.
        ANZ J Surg. 2002; 72: 680-681
        • Alderson K.
        • Holds J.B.
        • Anderson R.L.
        Botulinum-induced alteration of nerve-muscle interaction in the human orbicularis oculi following treatment for blepharospasm.
        Neurology. 1991; 41: 1800-1805
        • Hoefflin S.M.
        Botox alternatives.
        Plast Reconstr Surg. 1998; 101: 865
        • Wong L.
        Pectoralis major myospasm resulting from a subpectoral implant.
        Plast Reconstr Surg. 2000; 105: 1571-1572
        • Senior M.A.
        • Fourie L.R.
        Botox and the management of pectoral spasm after subpectoral implant insertion.
        Plast Reconstr Surg. 2000; 106: 224-225
        • Richards A.
        • Ritz M.
        • Donahoe S.
        • Southwick G.
        Botox for contraction of pectoral muscles.
        Plast Reconstr Surg. 2001; 108: 270-271
        • Layeeque R.
        • Hochberg J.
        • Siegel E.
        • et al.
        Botulinum toxin infiltration for pain control after mastectomy and expander reconstruction.
        Ann Surg. 2004; 240: 608-613
        • Cattin T.
        • Govender S.
        Botulinum toxin for tethering of breast implant.
        Plast Reconstr Surg. 2005; 116: 686-688
        • Saenz A.
        • Avellanet M.
        • Garreta R.
        Use of botulinum toxin type A on orthopedics: A case report.
        Arch Phys Med Rehabil. 2003; 84: 1085-1086
        • Sinha A.
        • Higginson D.W.
        • Vickers A.
        Use of botulinum A toxin in irreducible shoulder dislocation caused by spasm of pectoralis major.
        J Shoulder Elbow Surg. 1999; 8: 75-76
        • Dessy L.A.
        • Curinga G.
        • Mazzocchi M.
        • Scuderi N.
        Treatment of muscular pseudogynecomastia with botulinum toxin A.
        Aesthetic Plast Surg. 2007; 31: 104-106
        • Figus A.
        • Mazzocchi M.
        • Dessy L.A.
        • Curinga G.
        • Scuderi N.
        Treatment of muscular contraction deformities with botulinum toxin type A after latissimus dorsi flap and sub-pectoral implant breast reconstruction.
        J Plast Reconstr Aesthet Surg. 2009; 62: 869-875
        • Vernon H.
        • Mior S.
        The neck disability index: A study of reliability and validity.
        J Manipulative Physiol Ther. 1991; 14: 409-415
        • Moukarbel R.V.
        • Fung K.
        • Franklin J.H.
        • et al.
        Neck and shoulder disability following reconstruction with the pectoralis major pedicled flap.
        Laryngoscope. 2010; 120: 1129-1134