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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)

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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) OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY DELTOPECTORAL AND CERVICODELTOPECTORAL FASCIOCUTANEOUS FLAPS FOR HEAD AND NECK RECONSTRUCTION Johan Fagan, Ottie van Zyl Fasciocutaneous flaps raised from the Common carotid artery anterior chest wall below the clavicle are Innominate artery well suited to reconstructing skin defects in Internal mammary artery the head and neck region in terms of prox- imity, skin texture and skin colour. Bakam- jian first described the deltopectoral (DP) flap in 1965 as a head and neck recon- 1 Perforating branches structive option . The DP flap is a pedi- cled axial fasciocutaneous flap based on the internal mammary artery perforator arteries (IMAP) (Figure 1) although the perforator(s) are usually not identified, dissected, nor mobilized. However, if the Superior epigastric artery flap is raised as an island flap with Figure 1: Perforators originate from the complete division of the skin pedicle and internal mammary artery the perforators are dissected out, it be- comes an internal mammary artery perfo- rator flap (IMAP flap); the IMAP flap will be discussed in a separate chapter. 1st rib Surgical anatomy 2nd rib Paired internal mammary (IMA) arteries Perforators arise from the subclavian artery and course inferiorly on the inside of the rib cage ap- proximately 1cm lateral to the sternum (Figure 1). The perforating branches of the IMA emerge about 7mm lateral to the sternum through five or six intercostal spaces; they are 0.25-3.5mm in diameter (Figures 1, 2, 3). The so-called “principal Sternum perforator” traverses the 2nd intercostal space; the mean diameters of this artery and vein are just over 1.8mm 2. The vessels subsequently course laterally to provide blood supply to the pectoralis major mus- Figure 2: Left half of sternum: Perforators cle and overlying skin; the 2nd - 4th perfo- emerge approximately 7mm lateral to ster- rators send branches to the breast. num 2 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 rd • 3 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 4 these supply vessels are divided and the gradient diminishes. Taylor 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 nd laterally the flap is raised the more random angiosome (2 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. Figure 6: Scarring from skin grafts and flap contracture band of the neck Anaesthesia and preparation • 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 Flap design (Figures 4, 7) Figures 5a, b: DP flap used to cover skin defect that caused a carotid blowout • Outline the flap over the anterior chest wall and shoulder (Figure 7) 3 Flap elevation (Figure 8) • Cut through skin and subcutaneous fat and breast tissue onto the (delto)pec- toral fascia • Cut through the (delto)pectoral fascia onto the muscle • Suture the skin edges to the fascia • Leave these sutures long at the distal end of flap and hold onto them when elevating the flap Figure 7: Closing a pharyngocutaneous • Use a scalpel (not diathermy) to elevate defect after laryngectomy (pharyngeal mu- the pectoral fascia off the muscle in st cosa has been closed); positions of the 1 order to protect the suprafascial vascu- three perforators and the deltopectoral lar network groove have been marked on the skin • Elevate the flap from lateral to medial just deep to the (delto)pectoral fascia; • The DP flap was originally based on this exposes the muscle fibres of the st rd the 1 - 3 perforators but is now is two muscles (Figure 8) nd rd generally based only on the 2 and 3 • Branches of the thoracoacromial artery perforators which perforate the pectoralis major • Mark the positions of the intercostal muscle laterally are severed during perforators on the skin in the intercos- elevation tal spaces, 1cm lateral to the sternum • Stop elevating the flap about 2cm • A Doppler probe may be used to define lateral to the sternum so as not to injure their positions more accurately (Figure the perforators 7) • Measure the required length of the flap from the top of the defect in the neck to the point of rotation which is based at the most inferior perforator to be used • Note that the point of rotation of the DP flap is located closer to the upper side of the base of the flap due to the Pectoralis major more lax skin along the inferior border Deltopectoral groove of the flap and along the anterior axil- lary fold Deltoid muscle Limits of DP flap Figure 8: Flap has been elevated in a sub- fascial plane to expose pectoralis major • Above: clavicle (unless cervicodelto- and deltoid muscles pectoral rotation flap is used) • Below: 5th intercostal space Flap Inset • Lateral: deltopectoral groove (exten- sion over the deltoid muscle may • The entire flap may be used to cover require delaying the flap) adjacent defects (Figures 9a, b, c) • The flap may also be tubed and passed over an intact bridge of skin, or fash- 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) Maximising flap survival • Handle the flap atraumatically • Use a scalpel (not diathermy) to raise the flap • Use bipolar cautery for haemostasis Figure 9a: Flap is positioned in its final position to cover the pharyngocutaneous • Avoid injury to the perforating arteries defect; note the back-cut below the 3rd • Avoid tension on the flap during its perforator to increase the length of the flap rotation and inset • If possible, avoid extending the flap beyond the deltopectoral groove • Avoid tracheostomy ties around the neck as they may compress the vascu- lar pedicle Gaining additional length • Cut back over the sternum below and medial to the most inferior perforator (Figures 4, 10) Figure 9b: The skin bridge between the defect and the flap has been divided and elevated to accommodate
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