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Deltopectoral Flap and Cervicodeltopectoral Fasciocutaneous Flaps For Head and Neck Reconstruction
Deltopectoral Flap and Cervicodeltopectoral Fasciocutaneous Flaps For Head and Neck Reconstruction
The blood vessels to the fasciocutaneous The DP flap that is located medial to the
flap run in a plane superficial to the fascia deltopectoral groove (junction between
that covers the pectoralis major and deltoid pectoralis and deltoid muscles) has a
muscles; hence the importance of raising reliable axial blood supply and can be
these flaps in a plane deep to the deltoid transferred with a high probability of
and pectoral fasciae. survival.
Figure 3: Perforator branch of IMA 3
Figure 4a: 1st angiosome: yellow; 2nd
angiosome: blue; 3rd angiosome: red
Three angiosomes (arterial/vascular terri-
tories) are included when extending a DP
flap laterally over the deltoid (Figure 4a):
• 1st Angiosome: IMA perforators ex-
tend from the lateral border of the
sternum up to close to the deltopectoral
groove (This area also receives some
blood supply from musculocutaneous
perforators arising from the pectoralis
major muscle)
• 2nd Angiosome: A small, but variable
region of skin below the clavicle and
medial to the deltopectoral groove is
supplied by the thoracoacromial artery
via a small direct cutaneous artery Figure 4b: Typical outline of a DP flap
• 3rd Angiosome: The area over the del- (yellow); deltopectoral groove (blue);
toid muscle is supplied by musculo- lateral extension of flap (red); incision to
cutaneous perforators arising from the gain additional length (green); axis of
deltoid branch of the thoracoacromial rotation (red star)
artery and the anterior circumflex
humeral artery More dominant supply vessels to the 2nd
and 3rd angiosomes increase the risk of
As one moves laterally and away from the necrosis in the 3rd/distal angiosome once
IMA source-perforators the pressure these supply vessels are divided and the
gradient diminishes. Taylor 4 showed with flap becomes dependent only on the ves-
the angiosome concept that the blood sels from the 1st angiosome. The further
supply of the main angiosome and adjacent laterally the flap is raised the more random
angiosome (2nd angiosome) is reliable, but and unreliable the vascular supply and the
that an additional angiosome, such as that less reliable the flap becomes. If very large
over the deltoid muscle, is at risk of under- deltoid perforators are therefore encoun-
going ischaemic necrosis. Once a DP flap tered when elevating the distal part of the
is extended lateral to the deltopectoral flap, one should be more inclined to delay
groove, its reliability is therefore diminish- the flap as delaying or supercharging the
ed (Figure 4b).
2
flap lateral to the deltopectoral groove im- Advantages
proves survival of its distal part (see later).
• Provides large area of skin cover
Deltopectoral Flap (Figure 4) • Better colour and texture match com-
pared to free tissue transfer flaps from
The DP flap has largely been supplanted distant sites
by the pectoralis major, free tissue trans- • Less bulky than pectoralis major flap
fer and, to a lesser extent, latissimus dorsi • Technical simplicity
flaps. It may however be useful in specific
situations when other options are unavaila- Disadvantages
ble or have been exhausted e.g. recon-
struction of cervical skin defects; skin • Limited arc of rotation
cover of an exposed carotid artery (Figures • Fasciocutaneous pedicle limits the
5a, b); closure of a pharyngocutaneous fis- reach of the flap
tula; or (staged) hypopharynx reconstruct- • Unsightly donor defect especially if
tion (very rarely). Contraindications inclu- skin graft is required (Figure 6)
de an internal mammary artery that has
previously been used for coronary artery
bypass surgery; and prior trauma or
surgery (mastectomy, pacemaker, pectora-
lis major flap) to the anterior chest wall.
• General anaesthesia
• Paralysis acceptable as there are no
major nerves are in the surgical field
• Supine position with padding/bag un-
der the shoulders
• Prepare and drape the anterior chest
wall, shoulder and neck
• Prepare and drape the thigh for a possi-
ble skin graft
3
Flap elevation (Figure 8)
4
ioned as an island flap by separating Closure of donor defect
the skin off the pedicle in a subcu-
taneous plane • Small donor sites can be closed prima-
rily by undermining the surrounding
skin and inserting a suction or pencil
drain (Figure 9c)
• Larger donor sites are covered with a
split thickness skin graft (Figure 6)
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subsequently divide the pedicle and return
a the proximal portion of the flap to the
chest wall donor defect after 3-6 weeks
(Figure 15).
Tissue expanders
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Figure 16a: Cervical skin defect; flap has
been based on the 1st 3 perforators
Figure 16d: Fully elevated cervicodelto-
pectoral flap
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A DP flap can be converted into an island j-u-
flap based on one or two perforating bran- yYcm714mFGwhHZeNpw&bvm=bv.6
ches of the internal mammary artery. It 0444564,d.bGQ&cad=rja
may then be used as a pedicled or a free 4. Taylor GI, Palmer JH. The vascular
microvascular tissue transfer flap. This in- territories (angiosomes) of the body:
creases its versatility, provides a variety of experimental study and clinical appli-
axes of rotation and additional length 3. cations. Br J Plast Surg. 1987; 40(2);
IAMP flaps are discussed in a separate 113-41
chapter. 5. Lore JM. General purpose flaps. In:
Lore JM, ed. An Atlas of Head and
Summary Neck Surgery. 3rd ed. Philadelphia, Pa:
WB Saunders Co. 1988:344-57
• The most important part of the DP flap 6. Balakrishnan C. Closure of orocuta
for reconstruction is invariably its dis- nous fistula using a pedicled expanded
tal tip; it is this area that may become deltopectoral flap Can J Plast Surg.
ischaemic and undergo necrosis 2008; 16(3): 178–80
• The DP flap was the workhorse of head 7. Portnoy, WM, Arena S. Deltopectoral
and neck reconstruction during the island flap. Otolaryngol Head Neck
1970’s and 80’s but has since been Surg 1994;111:63-9
replaced by microvascular free flaps
• Although the DP flap may be 1st choice Other flaps described in The Open
in some situations of external defects in Access Atlas of Otolaryngology Head &
the neck, tubed DP flap to reconstruct Neck Operative Surgery
internal pharyngoesophageal defects
has become obsolete in modern head • Pectoralis major flap
and neck surgery • Buccinator myomucosal flap
• Buccal fat pad flap
References • Nasolabial flap
• Temporalis muscle flap
1. Bakamjian,VY. A two-stage method • Paramedian forehead flap
for pharyngoesophageal reconstruction • Upper and lower trapezius flaps
with a primary pectoral skin flap. Plast • Cervicofacial flaps
Reconstr Surg. 1965;36:173 • Submental artery island flap
2. Gedge DR, Holton LH, Silverman RP, • Supraclavicular flap
Singh NK, Nahabedian MY. Internal • Latissimus dorsi flap
mammary perforators: a cadaver study.
• Local flaps for facial reconstruction
J Recon Microsurg. 2005;21(4):239-42
• Radial free forearm flap
3. Schellekens PPA. Proefschrift: Internal
Mammary Artery Perforator flap: 2012 • Free fibula flap
http://www.google.co.za/url?sa=t&rct= • Rectus abdominis flap
j&q=&esrc=s&source=web&cd=2&ve • Anterolateral free thigh flap
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• Thoracodorsal artery scapular tip
(TDAST) flap
• Principles and technique of
microvascular anastomosis for free
tissue transfer flaps in head and neck
reconstructive surgery
Author
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