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Deltopectoral Flap


Introduction

The deltopectoral flap (DP), introduced by Bakamjian in 1965, dramatically changed how defects in the head and neck were reconstructed. For instance, reconstruction following total laryngopharyngectomy was accomplished using a combination of local skin flaps (Wookey procedure); delayed pedicle flaps from the back, chest, or abdomen; or split-thickness skin grafts fashioned over a stent. These procedures frequently failed as a result of poor skin graft survival, severe strictures, fistulas, and infection. The delayed flaps took many months until inset, by which time the cancer had often recurred. The DP provides healthy, reliable, nonradiated skin to rebuild various defects and quickly became the most popular flap until the pectoralis major myocutaneous flap was introduced by Ariyan in 1979.

The DP is a cutaneous flap based on the first four skin perforators from the internal mammary artery (IMA); ( Fig. 169.1 ). These perforators vascularize a skin paddle that extends from the IMA, just lateral to the sternum, to the deltopectoral groove. Skin beyond the deltopectoral groove, overlying the deltoid, can be harvested, but the vascularity of this distal portion is supplied from deltoid perforators from the thoracoacromial trunk and the anterior circumflex artery and vein and is not completely reliable as a nondelayed flap. A flap 20 cm in length and 10 cm in width can reliably be raised and used with a high likelihood of success.

Fig. 169.1, A, Outline of incisions for the DP. IMAs are represented by semicircles. B, Drawing of the blood supply of the DP.

Despite the evolution of regional and free-tissue options for reconstruction of defects in the head and neck over the last 50 years, the DP remains an important and versatile option for oral and pharyngeal reconstruction and for resurfacing the neck.

Key Operative Learning Points

  • The DP flap is based on the first to fourth perforators from the IMA.

  • The DP flap is a fasciocutaneous rotational flap that can be used for external skin coverage, carotid coverage, reconstruction of the pharynx, and repair of pharyngocutaneous fistulas.

  • The skin paddle is reliable when it is medial to the deltopectoral groove. The vascular supply beyond that point is based on a variable blood supply. For longer flaps, the distal portion should be raised in a delayed fashion.

  • Although classically a two-stage reconstruction, an island DP flap can be completed in a single stage with primary closure of the skin of the chest wall.

Preoperative Period

History

  • 1.

    History of present illness

    • a.

      Pharyngoesophageal defects following total laryngectomy

    • b.

      Exposed skin defects of the neck requiring coverage with vascularized tissue

    • c.

      Exposed vessels, particularly the carotid artery following surgical resection

    • d.

      Coverage of a chronic wound

    • e.

      Intraoral defects requiring reconstruction with a skin paddle

    • f.

      Lack of recipient vessels in the neck for free tissue transfer

  • 2.

    Past medical history

    • a.

      Prior head and neck treatment:

      • 1)

        Prior history of radiation to the chest or neck

    • b.

      Comorbid medical illnesses—cardiac, renal, pulmonary or neurologic (e.g., stroke)—that would significantly elevate perioperative risks

    • c.

      Surgical history:

      • 1)

        Prior surgery of the upper chest

      • 2)

        Scars that suggest the IMA perforators may have been injured

      • 3)

        Prior cardiac surgery that may have sacrificed the IMA

      • 4)

        Prior pectoralis myocutaneous flap where the incision transected the IMA perforators

    • d.

      Family history: Bleeding disorders are important to identify prior to operative intervention.

  • 3.

    Medications

    • a.

      Antiplatelet drugs

    • b.

      Herbal products (increased risk of bleeding)

    • c.

      Alcohol (consider risk of withdrawal)

    • d.

      Allergies to antibiotics

  • 4.

    Mental and social status

    • a.

      Ability to give consent

    • b.

      Social support structure

    • c.

      Willingness and ability to undergo a two-stage operation should secondary division of the pedicle be required (staged DP)

Physical Examination

  • Examination of the proposed donor site

    • Signs of prior surgery or injury to the IMA

    • Pacemaker/defibrillator

    • Central venous catheter port for chemotherapy

    • Radiation changes of the skin

    • Identify any cutaneous precancerous/malignant lesions on the planned skin paddle.

  • Identification of potential alternative reconstructive donor sites using a cutaneous flap

    • Similar evaluation as above for pectoralis major myocutaneous flap

    • Allen test of both forearms for possible radial forearm free flap

    • Examination of thigh skin for possible anterolateral thigh free flap

Imaging

  • No specific imaging is required prior to elevation of this flap.

Indications

  • Typical

    • Repair of cutaneous defects of the neck

    • Coverage of exposed carotid artery or chronic wound infection

    • Coverage of other rotational or free tissue flaps

    • Pharyngocutaneous fistula (prevention or treatment)

  • Less common

    • Reconstruction of the soft palate

    • Reconstruction of the buccal mucosa

    • Closure of defects in the hard palate

    • Reconstruction of the nasopharynx

    • Reconstruction of the pharynx (1 or 2 stages)

Contraindications

  • Defects that are unable to be reached by the flap (anything rostral to the zygoma is generally very difficult to reach)

  • Patients with prior incisions that violate the IMA perforators

  • History of cardiac surgery with ipsilateral harvest of the IMA

Preoperative Preparation

  • No specific preoperative preparation is required beyond that used for surgical ablation.

  • If the reconstruction is being performed secondarily, then the patient should have a routine preoperative evaluation to ensure that their condition is optimized for surgical intervention. This includes a cardiopulmonary examination and a complete blood count (CBC).

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