See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/236919422

Reconstruction of the face and neck with different types of pre-expanded

anterior chest flaps: A comprehensive strategy for multiple techniques

Article  in  Journal of Plastic Reconstructive & Aesthetic Surgery · May 2013

DOI: 10.1016/j.bjps.2013.04.028 · Source: PubMed

CITATIONS READS

20 114

8 authors, including:

Tao Zan Kai Liu

Shanghai Jiao Tong University the ninth hospital Shanghai Jiao Tong University School of Medicine
51 PUBLICATIONS   267 CITATIONS    82 PUBLICATIONS   953 CITATIONS   

SEE PROFILE SEE PROFILE

Yun Xie Qingfeng Li

Shanghai Jiao Tong University Shanghai Jiao Tong University
49 PUBLICATIONS   424 CITATIONS    237 PUBLICATIONS   1,665 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

High dose of BMP-2 impair bone regeneration View project

bone graft prefabrication View project

All content following this page was uploaded by Yun Xie on 05 July 2018.

The user has requested enhancement of the downloaded file.

Journal of Plastic, Reconstructive & Aesthetic Surgery (2013) 66, 1074e1081

Reconstruction of the face and neck with

different types of pre-expanded anterior
chest flaps: A comprehensive strategy for
multiple techniques
Tao Zan a, Haizhou Li a, Zijing Du, Bin Gu, Kai Liu, Feng Xie,
Yun Xie, QingFeng Li*

Department of Plastic and Reconstructive Surgery, The Ninth Hospital, Medical School of Shanghai Jiao
tong University, Shanghai 200011, China

Received 11 February 2013; accepted 1 April 2013

KEYWORDS Summary Background: For large defects or deformities of the face and neck, the anterior
Face and neck chest area appears to be an excellent donor site that provides well-matched skin colour and
reconstruction; texture. Many flap techniques based on the anterior chest area have been reported; however,
Surgical flap; there are few reports that focus on a treatment strategy for these different flap techniques.
Perforator flap; Methods: A retrospective study was performed to propose a treatment algorithm. A total of 69
Prefabricated flap; cases were reviewed from May 2005 to July 2011, in which different types of anterior chest
Tissue expansion flaps were performed for face and neck reconstruction. The reconstructive procedures, the
defect characteristics and the complications were collected and analysed.
Results: Thirty-three pedicled thoracic branch of the supraclavicular artery flaps (the pedicled
TBSA flap), 11 pedicled internal mammary artery perforator flaps (the pedicled IMAP flap), 8 free
internal mammary artery perforator flaps (the free IMAP flap), 4 supercharged TBSA flaps, 17
prefabricated flaps and 3 supercharged prefabricated flaps were performed. The applications
of six types of pre-expanded anterior chest flaps were described in an algorithmic approach.
Conclusions: A treatment strategy for face and neck reconstruction using six anterior chest flap
techniques is proposed. It recommended a personalised flap planning according to the charac-
teristics of deformities/defects and the regionally dominant vessels of the anterior chest area.
ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

* Corresponding author. Tel./fax: þ86 21 63089567.

E-mail addresses: drliqingfeng@yahoo.cn, dr.liqingfeng@shsmu.edu.cn (QingFengLi).
a
Tao Zan and Haizhou Li contributed equally to the acquisition, analysis and treatment of data and should be viewed as co-first authors.

1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjps.2013.04.028
Strategy of face and neck reconstruction with anterior chest flaps 1075

The face is irreplaceable for the representation of one’s

identity and the expression of one’s feelings. Burn injuries,
surgical ablation and trauma often lead to full-thickness
soft-tissue defects in the face and neck.1,2 These defects
may severely impact the appearance and function of the
face, causing long-term mental suffering and gravely
impacting physical and psychosocial status.3 Besides, ideal
donor sites for face and neck reconstruction are often
damaged to some extent as a result of the accident.
Therefore, the aesthetic and functional reconstructions of
the face and neck are still the important challenges for
plastic and reconstructive surgeons.
In some patients, the anterior chest soft tissue that is
protected by the patient’s clothing may remain relatively
intact, and this area can provide the skin matched in
colour, texture and thickness to that of the face and neck.
In such cases, an individual flap design based on this region
should be taken into consideration for cervico-facial
reconstruction. Different types of flaps can be used from
this area, including pedicled perforator flaps,4e6 muscu-
locutaneous flaps,7e9 ‘super-thin flaps’,10 prefabricated
flaps11,12 and free flaps.13 These flap techniques are adop-
ted ad libitum or according to each surgeon’s preference,
and no algorithm has been well established that might
improve the aesthetic and functional outcomes while min-
imising costs and complications.
The authors reviewed all the cases from May 2005 to July
2011 in which different anterior chest flaps were performed
to propose an algorithm for face and neck reconstruction
according to the characteristics of deformities/defects and
the regionally dominant vessels of the anterior chest area. Figure 1 Vascular anatomy of the anterior chest area: per-
forators from the supraclavicular artery (①), the internal
mammary artery (②), the thoracoacromial artery (③) and the
Patients and methods lateral thoracic artery (④).

For the purpose of this study, the anterior chest flap is
defined as the axial pattern flap designed in the area
bounded superiorly by the clavicle, inferiorly by a hori-
zontal line at the level of the nipple, medially by the
midline and laterally by the anterior axillary line. The skin
and soft tissue of the anterior chest are primarily nourished
by the supraclavicular artery, the internal mammary artery,
the thoracoacromial artery and the lateral thoracic artery
(Figure 1).14 In this study, the anterior chest flaps pedicled
by the thoracic branch of the supraclavicular artery (TBSA)
or the second or third perforator of the internal mammary
artery (IMAP) were performed, because these two vessels
were closer to the recipient site for neck and lower face
reconstruction.
The supraclavicular artery
The supraclavicular artery15 arises from the transverse
cervical artery in a triangle formed by the external jugular
vein, the sternocleidomastoid muscle and the clavicle. It
then proceeds towards the acromioclavicular joint and
supplies the skin and the subcutaneous tissue from the
supraclavicular region to the ventral surface of the deltoid
muscles.16,17 In addition to this conventional supra-
clavicular artery, Ma et al. described one branch, called the
TBSA, which bifurcates nearly 2 cm above the middle of the
clavicle bone, travels above the clavicle bone and extends
to the subclavicular and anterior thoracic regions.5,18
The internal mammary artery
The IMAPs19 emerge into the flap from the intercostal
spaces approximately 1 cm laterally from the sternum and
proceed towards the deltopectoral groove. Among these
perforators, the second and the third perforators typically
have the largest diameters and may be regarded as the
primary nourishing vessels of the flap.20,21
This retrospective study included 69 patients, of whom
49 were male and 20 were female, in whom 76 anterior
chest flaps were designed for face and neck reconstruction.
The ages of the patients at the time of surgery ranged from
4 to 54 years and the average age was 27 years. The causes
of the defects included flame burn injuries in 49 cases,
chemical burn injuries in 9 cases, electrical injury in 7
cases, trauma in one case and giant pigmented nevus in
three cases.
Clinical data, such as the patients’ preoperative and
postoperative photographs, the results of colour Duplex
scanning, the surgical details and the complications, were
collected.
The preoperative evaluation that included colour Duplex
scanning of the anterior chest was routinely performed (GE
1076
Voluson E8, frequency 7.5 MHz, GE Healthcare Austria
GmbH & Co OG, Vienna, Austria). Six different types of flap
techniques (Figure 2) were selected according to the
following points: 1) the patient has sufficient unscarred
anterior chest skin and soft tissue; 2) the dominant blood
vessel confirmed by colour Duplex scanning is preferred as
the pedicle; 3) pedicled flaps have the priority over free
flaps in the reconstruction of the lower face and neck;
and 4) supercharged flaps and prefabricated flaps are per-
formed for the flap design that beyond a single vascular
territory.
Surgical techniques
All the patients of these cases had treatment of soft-tissue
expansion in the first stage to harvest a larger flap and to
reduce the donor-site morbidity. A rectangle tissue
expander was implanted into the anterior chest pocket,
which was created between subcutaneous tissue and the
pectoralis fascia to preserve the perforating blood vessels.
Prefabricated flaps were created as in our previous
study.12 In brief, the descending branch of the lateral
circumflex femoral vessel with the lateral intramuscular
septum was dissected from the rectus femoris and the
vastus lateralis muscles. The motor nerve to the vastus
lateralis was preserved by separating it from the main
vascular pedicle during harvest of the fascial flap. Then,
the vascular carrier was anastomosed with the superior
thyroid artery or the facial artery and their venae com-
itantes. After successful microvascular anastomosis, the
vascular carrier was sutured with the overlying flap, and
the tissue expander was placed beneath the vascular
carrier.
Figure 2 Different flap techniques of the anterior chest area TBSA, thoracic branch of the supraclavicular artery IMAP, anterior
perforators of the internal mammary artery.
T. Zan et al.
In the second stage, after removal of the tissue
expander, the flap was elevated and transferred to cover
the defect in the face and neck. In cases of supercharged
flaps, the second or third IMAP was traced into the pec-
toralis major and ligated for anastomosis with the superfi-
cial temporal artery and vein for middle/upper face
reconstruction or with the facial artery and vein for neck
reconstruction. The donor site was closed in most cases,
and a split-thickness skin graft or pedicled lateral thoracic
flap was also used to cover the donor site.
Results
From May 2005 to July 2011, 69 patients received face and
neck reconstructions, and 76 different anterior chest flaps
were harvested: 33 pedicled TBSA flaps, 11 pedicled IMAP
flaps, 8 free IMAP flaps, 4 supercharged TBSA flaps, 17
prefabricated flaps and 3 supercharged prefabricated flaps.
The average follow-up time was 18 months.
All of the patients had soft-tissue expansion. The volume
of the tissue expanders ranged from 100 to 800 ml (mean
volume, 385 ml). The tissue expanders were inflated with a
mean volume of 1287 ml (ranging from 576 to 2720 ml). The
mean expansion period was 117 days (ranging from 63 to
814 days; three patients had prolonged tissue expansion for
total face reconstruction). Complications related to the
tissue expander included infections in five cases (6.58%,
two of them had undergone earlier flap transfers with no
subsequent complications; the other three flaps were cured
with conservative treatment). Three cases (3.95%) that
suffered expander exposure had also undergone an earlier
flap transfer; expander leakage occurred in three cases
(3.95%), and no expander malposition was observed. Flap
Strategy of face and neck reconstruction with anterior chest flaps 1077

delays were performed in 12 cases (15.79%) to reconstruct
the extensive defects in seven cases and to increase the
blood supply of the TBSA in five cases. No flap necrosis was
caused by the delayed procedure.
The donor sites were closed primarily in 67 cases
(88.16%), covered by split-thickness skin grafts in seven
cases (9.21%) and covered by pedicled lateral thoracic is-
land flaps in two cases (2.63%).
The primary complication of flap transfer was flap ne-
crosis of which tip necrosis occurred in six flaps (7.89%) and
complete necrosis occurred in two flaps (2.63%) that were
cured with a split-thickness skin graft. Donor-site compli-
cation included incision dehiscence in three cases (3.94%)
and partial skin graft necrosis in one case (1.31%). The
distribution of the 76 anterior chest flaps is summarised in
Table 1.
Figure 3 shows the proposed algorithm for skin and soft-
tissue reconstruction of the face and neck with anterior
chest skin: 1) for large defects in the neck, cheek or per-
ioral area, the pedicled TBSA flap (Case 1 and Figure 4) is
preferred if the flap is assessed to have a large diameter
and high peak systolic flow velocity; 2) if no obvious TBSA is
confirmed by colour Duplex scanning, the pedicled IMAP
flap could be adopted if the defect is primarily located on
the neck, chin or lower cheek; 3) the free IMAP flap (Case 2
and Figure 5) could be used for the large defect involving
the upper cheek, the central face or the forehead where a
pedicled anterior chest flap cannot reach; 4) for extensive
defects in the lower face or the neck, which are beyond the
vascular territory of the TBSA, the supercharged TBSA flap
could be used if the TBSA is assessed to be dominant; 5) if
the extensive defect is present on the middle and upper
face or no dominant TBSA is scanned, a prefabricated flap
(Case 3 and Figures 6 and 7) is recommended; and 6) a
supercharged prefabricated flap can be used in the recon-
struction of total or subtotal facial defects.
Discussion
Facial reconstruction with the anterior chest skin and soft
tissue possesses certain advantages. First, the skin and soft
tissue in the anterior chest area provide a matched colour
and texture to that of the face and neck. With the use of
tissue expanders, the anterior chest flap becomes thinner
and can allow for appropriate facial expressions. Second,
the anterior chest skin may survive in many burn patients
after terrible accidents because it is protected by their
clothing. Furthermore, its flat surface, supported by the
ribs and the sternum, enhances the efficiency of the tissue
expansion and facilitates daily care during the long-term
tissue expansion period. Third, the supraclavicular artery
thoracic branch and the IMAP flaps are close to the facial
defects; these two reliable and easily manipulated anterior
chest perforator flaps can be used to reconstruct the
appearance and function of the neck, the cheeks and the
perioral area, which are the common sites of many burn
injuries.
There are variations in the blood supply of the anterior
chest. Ma et al.16 considered the conventional supra-
clavicular artery17 that courses towards the acromial region
to be one branch (the deltoid branch) of the supraclavicular
artery, with the supraclavicular artery dividing into another
branch (the thoracic branch), which goes above the clavicle
bone and extends to the subclavicular and anterior thoracic
regions; this anatomical variation existed in 60% of the 43
cadavers in Ma’s anatomical study.18 The thoracic branch
was used for pedicled flaps with sizes that ranged from 150
to 625 cm2 to recover large skin defects of the face and
neck.5 This blood vessel variation allows the TBSA flap to be
a new and versatile anterior chest flap; therefore, we order
colour Duplex scanning routinely before the first and sec-
ond stages of surgery and give preference to this pedicled
flap if the thoracic branch was confirmed to be dominant by
the scanning.
Our treatment algorithm is primarily based on published
studies and our clinical experience. We regard the versatile
pedicled TBSA flap as a new type of workhorse flap because
the pivot point of the TBSA is approximately 2 cm above the
middle point of the clavicle,18 which is closer to the defects
than the pivot point of the other anterior chest flaps, and,
through ligation of the terminal branches of the transverse
cervical artery, more pedicle length could be obtained.16
The pedicled TBSA flap is able to resurface a large skin
and soft-tissue defect in the cheek, the neck or the perioral
area.5 However, the dominant TBSA does not exist in every

Table 1 Surgical details of 6 different anterior chest flaps.

Flap type No. Average Tip Total Donor-site Reconstructed areas and no. of cases
size/cm necrosis necrosis complication
Pedicled TBSA flap 33 17  11 4 1 1 Perioral area 12; cheek 7; neck 14.
Pedicled IMAP flap 11 18  10 0 0 1 Neck 9; neck and lower cheek 2
Free IMAP flap 8 18  9 0 0 0 Cheek 3; forehead 3; nose and perioral 2
Supercharged TBSA flap 4 20  17 0 0 0 Cheek and perioral area 1; neck and chin 2;
neck 1
Prefabricated flap 17 21  15 1 1 2 Neck 1; nose and perioral area 2; neck, chin
and perioral area 4; cheek and lateral neck 5;
upper two thirds face 2; lower two thirds
face 1; total face 2
Supercharged 3 24  20 1 0 0 Total face 1; lower two thirds face 2
prefabricated flap
Total 76 19  13 6 2 4
1078 T. Zan et al.

Figure 3 Treatment algorithm of face and neck reconstruction with different anterior chest flaps.

Figure 4 Case 1, Reconstruction of the neck with bilateral pedicled TBSA flaps: A 54-year-old man had an electrical injury to the
lower face and neck and suffered a neck contracture that severely impacted his neck movement (left above). A 20  13 cm
expanded flap was harvested from each side of the anterior thoracic region after a 7-month tissue expansion. The intraoperative
photo (right) showed the TBSA (yellow arrow) and its venae comitantes went above the clavicle and nourished the flap. The pedicle
flaps, nourished by the TBSA, were transferred to the lower face and neck through a subcutaneous tunnel after the total removal of
the neck scar. Pictures showed the postoperative views at 1.5-year follow-up (left down). The entire hypertrophic scar was
replaced with matched skin and patient was allowed to resume nearly normal neck movement.
Strategy of face and neck reconstruction with anterior chest flaps 1079

Figure 5 Case 2, Reconstruction of cheek and chin with free IMAP flap: A 20-year-old man complained of scars on the chin and in
both cheek regions after a burn injury suffered 10 years previously. A free IMAP flap was designed on the right anterior thoracic area
after left cheek reconstruction by a pedicled TBSA flap, because no obvious TBSA was probed pre-operatively with a Doppler ul-
trasonography. A 23  12 cm flap was harvested and revascularized to the left facial vessels to resurface the right cheek and chin.
Preoperative views (left) and postoperative views at 16-month follow-up were shown (middle). Intraoperative view (right) showed
the flap design based on second internal mammary artery. Donor site was closed primarily after flap transfer to cover the facial
scars.

patient, so the preoperative colour Duplex scanning results
are critical. Where it went above the clavicle, the thoracic
branch of the supraclavicular artery was scanned; the
branch of which the systolic peak flow velocity was above
10 cm s1 could be selected as the pedicle.
The IMAP flap is more reliable, with one or two dominant
perforators up to 1.2 mm in diameter, which makes the flap
a good choice for vascular anastomosis for the reconstruc-
tion of the middle- and upper-third of the face, areas
where the pedicled anterior chest flap cannot reach.13,21
However, the recipient region of the pedicled IMAP flap is
relatively restricted, limited to the neck, chin and lower
cheek6,20,21 because of its distant pivot point and short
pedicle length.
For defects that are extremely large and involve the
middle- and upper-third of the face, the use of pre-
fabricated flaps is recommended for two main reasons:
First, the pivot point of the prefabricated flaps is approxi-
mately 7e12 cm higher than the supraclavicular flap, and
the length of the pedicle is approximately 8e16 cm long,12
which helps in the transfer of the flap to recover these large
defects. At this point, we consider the anterior chest pre-
fabricated flap to have the same versatility as the free flap
in facial reconstruction. Second, the vascularisation of the

Figure 6 Case 3, Post-burn hemi-facial reconstruction with anterior chest prefabricated flap22: A 27-year-old man presented with
a hemi-facial scar after a burn injury suffered 10 years previously. The TBSA was not well probed with a Doppler ultrasonography
before the first operation. A prefabricated anterior chest flap was performed. Preoperative views (left) and postoperative views at
13-month follow-up (right) were presented.
1080
Figure 7 Intraoperative view of Case 3: In the first stage, a 6  8.5 cm fascia flap nourished by the descending branch of the
lateral femoral circumflex vessel was dissected and implanted inside a superficial subcutaneous anterior chest pocket. The vessel
carrier was anastomosed with the right superior thyroid vessels. The lateral thigh fascial flap was inset into a subcutaneous pocket
of the anterior chest area and fixed by suture (left). The second stage occurred earlier than planned because of an infection of the
tissue expander. A scar area and of approximately 15  16 cm was removed. (middle and right).
implanted vascular carrier may increase the flap size and
the efficient use of the remaining skin that is either irreg-
ularly shaped or beyond the vascular territory of the TBSA
or the IMAP. In our experience, the pre-expanded TBSA flap
or the IMAP flap could hardly cover the total loss of two
facial aesthetic units because of the restriction of the
vascular territories. Nevertheless, extremely large pre-
fabricated flaps were successfully performed for total
facial reconstruction in our three cases. Besides, for some
obese patients, facial expression is restricted with overly
thick subcutaneous tissue after flap reconstruction. The
vascular carriers could be placed just below the subcu-
taneous tissue to reduce the flap thickness.
Although the donor site can be closed in most cases, an
obvious linear scar cannot be avoided and will cause de-
formations of the breast and an asymmetry in the position
of the nipples, which may have a negative psychological
impact, especially in young females.
Limitations
Our knowledge of the vascular anatomy of the anterior
chest flap is based on our literature review and our own
clinical experience. However, because variations in blood
vessels, such as the supraclavicular artery and the lateral
thoracic artery, exist in this area, future work might focus
on a large-scale and detailed anatomical study.
Disclosure
The authors have no commercial associations or financial
disclosure to report.
Acknowledgements
This work was supported by grants from the National Nat-
ural Science Foundation of China (No: 30925034,81101437),
the National Key Project of Scientific and Technical Sup-
porting Programs Funded by Ministry of Science & Tech-
nology of China (No: 2012BAI11B03) and the Joint Research
T. Zan et al.
Project of Shanghai Municipal Level Hospital for Emerging
Cutting-edge Technology (No: SHDC12010105).
References
1. Ho WS, Ying SY. An epidemiological study of 1063 hospitalized
burn patients in a tertiary burns centre in Hong Kong. Burns: J
Int Soc Burn Injuries 2001;27:119e23.
2. Taira BR, Singer AJ, Thode Jr HC, et al. Burns in the emergency
department: a national perspective. J Emerg Med 2010;39:1e5.
3. Stubbs TK, James LE, Daugherty MB, et al. Psychosocial impact
of childhood face burns: a multicenter, prospective, longitu-
dinal study of 390 children and adolescents. Burns: J Int Soc
Burn Injuries 2011;37:387e94.
4. Xianjie M, Zheng Y, Ai Y, et al. Repair of faciocervical scars by
expanded deltopectoral flap. Ann Plast Surg 2008;61:56e60.
5. Xie F, Wang J, Li Q, et al. Resurfacing large skin defects of the
face and neck with expanded subclavicular flaps pedicled by
the thoracic branch of the supraclavicular artery. Burns 2012
Sep.;38(6):924e30.
6. Andrews BT, McCulloch TM, Funk GF, et al. Deltopectoral flap
revisited in the microvascular era: a single-institution 10-year
experience. Ann Otol Rhinol Laryngol 2006;115:35e40.
7. Cunha-Gomes D, Choudhari C, Kavarana NM. Vascular
compromise of the pectoralis major musculocutaneous flap in
head and neck reconstruction. Ann Plast Surg 2003;51:450e4.
8. Ahmad QG, Navadgi S, Agarwal R, et al. Bipaddle pectoralis
major myocutaneous flap in reconstructing full thickness de-
fects of cheek: a review of 47 cases. J Plast Reconstr Aesthet
Surg 2006;59:166e73.
9. Liu HL, Chan JY, Wei WI. The changing role of pectoralis major
flap in head and neck reconstruction. Eur Arch Otorhinolar-
yngol 2010;267:1759e63.
10. Chin T, Ogawa R, Murakami M, et al. An anatomical study and
clinical cases of ‘super-thin flaps’ with transverse cervical
perforator. Br J Plast Surg 2005;58:550e5.
11. Margulis A, Agam K, Icekson M, et al. The expanded supra-
clavicular flap, prefabricated with thoracoacromial vessels, for
reconstruction of postburn anterior cervical contractures.
Plast Reconstr Surg 2007;119:2072e7 [discussion 2078e2079].
12. Li Q, Zan T, Gu B, et al. Face resurfacing using a cervico-
thoracic skin flap prefabricated by lateral thigh fascial flap and
tissue expander. Microsurgery 2009;29:515e23.
13. Sasaki K, Nozaki M, Honda T, et al. Deltopectoral skin flap as a
free skin flap revisited: further refinement in flap design,
Strategy of face and neck reconstruction with anterior chest flaps
fabrication, and clinical usage. Plast Reconstr Surg 2001;107:
1134e41.
14. Palmer JH, Taylor GI. The vascular territories of the anterior
chest wall. Br J Plast Surg 1986;39:287e99.
15. Pallua N, Machens HG, Rennekampff O, et al. The fasciocuta-
neous supraclavicular artery island flap for releasing postburn
mentosternal contractures. Plast Reconstr Surg 1997;99:
1878e84 [discussion 1885e1876].
16. Vinh VQ, Van Anh T, Ogawa R, et al. Anatomical and clinical
studies of the supraclavicular flap: analysis of 103 flaps used to
reconstruct neck scar contractures. Plast Reconstr Surg 2009;
123:1471e80.
17. Pallua N, Magnus Noah E. The tunneled supraclavicular island
flap: an optimized technique for head and neck reconstruction.
Plast Reconstr Surg 2000;105:842e51 [discussion 852e844].
View publication stats
1081
18. Ma X, Zheng Y, Xia W, et al. An anatomical study with clinical
application of one branch of the supraclavicular artery. Clin
Anat 2009;22:215e20.
19. Bakamjian VYA. Two-Stage method for pharyngoesophageal
reconstruction with a primary pectoral skin flap. Plast Reconstr
Surg 1965;36:173e84.
20. Daniel RK, Cunningham DM, Taylor GI. The deltopectoral flap:
an anatomical and hemodynamic approach. Plast Reconstr
Surg 1975;55:275e82.
21. Vesely MJ, Murray DJ, Novak CB, et al. The internal mammary
artery perforator flap: an anatomical study and a case report.
Ann Plast Surg 2007;58:156e61.
22. Li QF, Zan T, Gu B, et al. Cervicothoracic prefabricated flaps
for reconstruction of face and neck. Zhonghua Zheng Xing Wai
Ke Za Zhi 2008;24:116e9. 115.