Deltopectoral Flap

The vascular supply to the rib via the periosteum is tenuous and its use for mandibular segmental defects is associated with a high rate of failure. Marginal necrosis of the skin paddle is relatively common, especially if the distal part of the skin paddle extends beyond the underlying muscle (18). The subcutaneous tissue can be bulky, especially in women in whom the incisional scars may be less acceptable. The weight of the flap and the tendency for regional flaps to return to their site of origin result in an inferior migration of flap tissue. This is well tolerated for posteriorly oriented defects; however, reconstruction of anteriorly oriented defects, especially around the mandibular symphysis, may result in neck contracture, jaw contracture, or exposure of underlying plates and bone grafts.

Deltopectoral I

Description J

The deltopectoral flap, originally reported by Bakamjian, is an axial skin flap sup- |

plied by parasternal direct cutaneous perforators (19). The flap is composed of the o fascia overlying the pectoralis major, subcutaneous tissue, and skin (Fig. 5). It is ยง

based along the parasternal area over the first through the fourth intercostal spaces

Deltopectoral Flap

Figure 5 The deltopectoral flap is a medially based flap supplied by the intercostal perforators, predominantly the second intercostal perforator. The flap is raised off the medial aspect of the deltoid muscle and the pectoralis. Extension much beyond the medial aspect of the deltoid muscle places the distal aspect of the flap at risk for necrosis if no delay is used.

Figure 5 The deltopectoral flap is a medially based flap supplied by the intercostal perforators, predominantly the second intercostal perforator. The flap is raised off the medial aspect of the deltoid muscle and the pectoralis. Extension much beyond the medial aspect of the deltoid muscle places the distal aspect of the flap at risk for necrosis if no delay is used.

and extends laterally with equal width toward the shoulder. The flap is usually transferred as a staged transposition flap, but may also be islanded for single-stage transfer or as a free flap (20). The flap can be extended over the tip of the shoulder; however, this extension will encompass a third angiosome and put this distal part at significant risk of necrosis. Surgical delay is effective in augmenting the flap to capture this third angiosome. The delay may be accomplished by simply ligating the thoracoacromial vessels or partially elevating the flap to sever these vessels. Simply performing the skin incisions alone may be effective without cutting the thora-coacromial vessels (21).

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