Deltopectoral Flap 6o4333

DELTOPECTORAL FLAP Click to edit Master subtitle style

Compiled by: Dr Ambika Bhandari MDS 1st yr

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CONTENTS  Introduction History Anatomy Indications Technique Complications Advantages Disadvantages 7/30/12

INTRODUCTION  The current treatment objective of head and

neck cancer patient is the removal of the tumor and to preserve and restore preoperative activity and quality of life.

However during the excision exposure of vital

structures such as the brain, eye or major neurovascular structures is observed which cannot be left as such.

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Hence, reconstruction is needed, may it be of

the most basic type as the direct suturing.

The choice of the type of reconstruction is

based on various aspects such as the size, the site and suitability

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Surgical options for head and neck reconstruction have been described schematically as a ladder: Direct closure Skin grafting Local flaps Distant flaps Cutaneous and myocutaneous pedicled flaps Microvascular free flaps 7/30/12

A skin flap is basically a tongue of tissue

consisting an entire thickness of skin and variable amount of the underlying subcutaneous tissue.

This flap is used to reconstruct a primary

defect leaving behind a secondary defect which may be closed by direct suturing or a skin graft. If the flap is raised from the ading areas to

the primary defect then it is called as a local flap. 7/30/12

If a flap is raised which involves movement of

the tissue at a distance from the primary defect then it is called a distant flap.

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HISTORY The deltopectoral flap was the workhorse for

intraoral, cheek and neck reconstruction in the 1960s and 1970s.

It was first described by BAKAMJIAN in 1965. It was the first axial pattern skin flap derived

from an outside area for direct reconstruction of head and neck region.

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FLAP DESIGN The skin of the thorax is supplied by a

combination of direct cutaneous vessels and musculocutaneous perforators which reach the skin primarily via the intercostal muscles, pectoralis major and other muscles.

The deltopectoral flap is an axial pattern flap

i.e. it is constructed around an arteriovenous system and designed on the anterior superior chest wall.

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The deltopectoral flap is based on the first,

second, and third perforators (sometimes the fourth also) of the internal mammary artery and associated veins.

The distal part of the flap is not considered as

axial pattern as the vascular system of the flap ends at the groove separating the deltoid from the pectoralis major muscle. This flap is based on the midline from which it

es horizontally towards the shoulder. 7/30/12

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The base of the flap is located at 2 cm from

the sternal edge, where the perforators pierce in the intercoastal space.

The plane of raising the flap is between the

deep fascia and the pectoralis major muscle.

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The secondary defect after the flap elevation

shows exposed pectoralis major muscle which may be closed by either direct closure or by placing a skin graft as it is an ideal site for the same .

The skin graft may be placed temporary in

cases where the bridge segment of the deltopectoral flap is returned to its original site after the division of the flap.

Laterally it extends as far as the mid lateral

line of the deltoid muscle. 7/30/12

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PLANNING OF FLAP The deltopectoral flap for planning can be

viewed as a very large transposed flap with a pivot point from which the measurements are made.

The geometry of this flap is typical due to the

presence of slack skin over the anterior axillary fold. broad shoulders and short neck are better for

optimal flap.

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The lower border of the flap is longer than the

upper border so any tension during the placement of the flap is transferred to the short upper border, in order to avoid this, the measurements are taken from the medial point of the upper border. ( McGregor & Jackson 1970)

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TECHNIQUE Patient is draped and painted, placed in

supine position.

Arm may be adducted or abducted as per the

surgeons convenience. Land marks sternal edge infraclavicular line deltopectoral groove nipple.

Flap is marked diagnally upward with its base 7/30/12 over second third and fourth coastal

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Upper incision starts 2cm distal to the sternal

edge, follows the infraclavicular line beyond the deltopectoral groove onto the anterior shoulder.

The lower incision parallels the upper incision

extending to the line of the anterior axillary fold above the fifth thoracic intercoastal space ( a few cms above the undisplaced nipple) The distal incision is placed through the skin

and subcutaneous tisssues including fascia over the deltoid muscle. 7/30/12

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Elevation proceeds from distal to proximal. Fascia overlying the muscle is included in the

flap.

The dissection then proceeds rapidly through

a relatively bloodless plane across the deltoid, the deltopectoral groove and onto the pectoralis major muscle.

The dissection is continued until the

perforators are seen emerging through the pectoralis major muscles. 7/30/12

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Rotational transfer- can resurface the entire

adjacent skin of the neck in cancer cases where skin of neck is involved.

Subcutaneous transfer – this is done

subcutaneously with the flap pedicle deepithilialized leaving the distal portion like an island flap. Such a flap is used for covering high cervical defects.

Bridging over the neck- the pedicle is tubed

and the distal part is used for reconstruction. 7/30/12

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For intraoral reconstruction the tubed flap is

approximated to the mucosa and muscle edges of the defect.

Then at the second stage when the tube is

divided and the proximal divided portions of the flap are inset, it is done 2 to 3 weeks after the initial procedure.

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COMPLICATIONS Infection of the flap. Necrosis may have many reasons as tension

on the flap, trauma to the vessels during raising or due to faulty flap design i.e. straight line extensions to the shoulder or ‘L’ shaped extension oh to the upper arm.

Extensions of this flap are not recommended. Late sequel as fistula and strictures.

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INDICATIONS Reconstruction after head and neck tumor

excision.

pharyngo cutaneous and orocutaneos fistula

closure. Reconstruction of large cutaneous cervical

defects.  postburn head and neck reconstruction  perioral reconstruction after ballistic trauma Hypo pharyngeal reconstruction. 7/30/12

CONTRAINDICATIONS Prior chest wall surgery or injury eg radical

mastectomy, pacemaker

Prior cardiac surgery with use of internal

thoracic artery for by . Not much reliable in post radiation patients.

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ADVANTAGES The deltopectoral flap does not require prior

delay of any kind this being the major advantage.

The flap design can be modified in the area by

choosing only one perforator vessel system generally second one is used.

Less donor site morbidity is seen. Accurately replaces the components of the

recipient site. 7/30/12

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DISADVANTAGES Limited reach is the only disadvantage of this

flap.

Patients with anemia, advanced

atherosclerosis, diabetes etc may experience flap faliure due to compromised blood supply. In such cases a delay of 7 to 10 days is preferrable.

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THANK YOU. Click to edit Master subtitle style

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