DELTOPECTORAL FLAP

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Compiled by: Dr Ambika Bhandari MDS 1st yr

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CONTENTS
 Introduction History Anatomy Indications Technique Complications Advantages Disadvantages
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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. the site and suitability 7/30/12 . 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.

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 .

This flap is used to reconstruct a primary If the flap is raised from the adjoining areas to the primary defect then it is called as a local flap. 7/30/12 . defect leaving behind a secondary defect which may be closed by direct suturing or a skin graft.A skin flap is basically a tongue of tissue consisting an entire thickness of skin and variable amount of the underlying subcutaneous tissue.

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.

It was the first axial pattern skin flap derived from an outside area for direct reconstruction of head and neck region.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. 7/30/12 .

it is constructed around an arteriovenous system and designed on the anterior superior chest wall. i. The deltopectoral flap is an axial pattern flap 7/30/12 .e. pectoralis major and other muscles.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.

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The distal part of the flap is not considered as This flap is based on the midline from which it passes horizontally towards the shoulder. axial pattern as the vascular system of the flap ends at the groove separating the deltoid from the pectoralis major muscle. second.The deltopectoral flap is based on the first. 7/30/12 . and third perforators (sometimes the fourth also) of the internal mammary artery and associated veins.

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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 7/30/12 . deep fascia and the pectoralis major muscle.

7/30/12 The skin graft may be placed temporary in Laterally it extends as far as the mid lateral .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 . cases where the bridge segment of the deltopectoral flap is returned to its original site after the division of the flap. line of the deltoid muscle.

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The geometry of this flap is typical due to the broad shoulders and short neck are better for optimal flap. presence of slack skin over the anterior axillary fold. 7/30/12 .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.

in order to avoid this.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. the measurements are taken from the medial point of the upper border. ( McGregor & Jackson 1970) 7/30/12 .

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placed in supine position.TECHNIQUE Patient is draped and painted. Flap is marked diagnally upward with its base 7/30/12 over second third and fourth coastal . Arm may be adducted or abducted as per the surgeons convenience. Land marks sternal edge infraclavicular line deltopectoral groove nipple.

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follows the infraclavicular line beyond the deltopectoral groove onto the anterior shoulder. 7/30/12 .Upper incision starts 2cm distal to the sternal edge. 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.

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Elevation proceeds from distal to proximal. perforators are seen emerging through the pectoralis major muscles. Fascia overlying the muscle is included in the flap. the deltopectoral groove and onto the pectoralis major muscle. 7/30/12 The dissection is continued until the . The dissection then proceeds rapidly through a relatively bloodless plane across the deltoid.

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Rotational transfer. Subcutaneous transfer – this is done subcutaneously with the flap pedicle deepithilialized leaving the distal portion like an island flap. 7/30/12 Bridging over the neck. Such a flap is used for covering high cervical defects. and the distal part is used for reconstruction.can resurface the entire adjacent skin of the neck in cancer cases where skin of neck is involved.the pedicle is tubed .

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it is done 2 to 3 weeks after the initial procedure. Then at the second stage when the tube is divided and the proximal divided portions of the flap are inset. 7/30/12 .For intraoral reconstruction the tubed flap is approximated to the mucosa and muscle edges of the defect.

7/30/12 . Extensions of this flap are not recommended.COMPLICATIONS Infection of the flap. Necrosis may have many reasons as tension on the flap. Late sequel as fistula and strictures. straight line extensions to the shoulder or ‘L’ shaped extension oh to the upper arm.e. trauma to the vessels during raising or due to faulty flap design i.

7/30/12 .  postburn head and neck reconstruction  perioral reconstruction after ballistic trauma Hypo pharyngeal reconstruction.INDICATIONS Reconstruction after head and neck tumor excision. closure. pharyngo cutaneous and orocutaneos fistula Reconstruction of large cutaneous cervical defects.

Not much reliable in post radiation patients.CONTRAINDICATIONS Prior chest wall surgery or injury eg radical mastectomy. 7/30/12 . pacemaker Prior cardiac surgery with use of internal thoracic artery for by pass.

Accurately replaces the components of the recipient site. 7/30/12 .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.

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Patients with anemia. In such cases a delay of 7 to 10 days is preferrable. diabetes etc may experience flap faliure due to compromised blood supply.DISADVANTAGES Limited reach is the only disadvantage of this flap. advanced atherosclerosis. 7/30/12 .

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