Grabb’s Encyclopedia of Flaps Head and Neck

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a more proximal point than its usual one just at the medial side of the deltopectoral groove, thereby permitting its
preservation in the use of an extended flap.
A subcutaneous transfer through the dissected neck with the flap pedicle deepithelialized, simulating an island
flap, may be used for covering a high cervical and parotid area defect (Fig. 127.9). This technique eliminates the
need for division of the pedicle in a second stage and may bring welcome protection to the dissected neck as
well as contour augmentation.
Bridging over the neck, with the pedicle tubed and with an intervening span of intact cervical skin from the donor
area, is a more commonly employed method for transfer to locations on the head (Fig. 127.10). Additionally,
splitting the flap end (Fig. 127.11), folding it to provide two layers (Fig. 127.12), and deepithelializing the folded
edge, if necessary (Fig. 127.13), are auxiliary maneuvers that may be used under special circumstances.
The bridging over the neck technique is employable also for intraoral defects, but with a two-directional instead
of the one-directional method of tubing the pedicle (Fig. 127.14). As in the case of cervical flaps, entry is made
through a portal high in the neck, usually created at the time of resecting intraoral cancer. The distal portion of
the flap is dressed into the defect, after which the intermediate short segment within the portal of entry is entubed
(skin side facing inward), and the remainder is tubed in ordinary fashion (skin facing outward). The entry, when a
segment of mandible has not been resected, is deep for defects of the floor of the mouth, tongue, or oropharynx
(Fig. 127.15) and superficial to it for defects of the cheek and maxillary area (Fig. 127.16). Needless to say, this
reversal in direction from the skin-inward to the skin-outward type of tubing demands meticulous care to avoid a
possible strangulation of the blood supply to its distal end.
Whether it is tubed in one or two directions, the pedicle is always available for secondary use by upward waltzing
if there is a need for additional tissue to improve on, or to complete, the reconstruction (Fig. 127.16).
Finally, there are varied and numerous possibilities of using the flap simultaneously with its twin from the
opposite side (Fig. 127.17), with a temporal forehead flap from the same side (12) or with the pectoralis major
musculocutaneous flap from the same side (Fig. 127.18).
FIGURE 127.8 Rotation transfer of the open flap to cover one side of the neck denuded of its skin in radical neck
dissection.

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FIGURE 127.9 Subcutaneous transfer of the flap with deepithelialized pedicle. A: Defect resulting from radical
parotidectomy, mandibulectomy, and radical neck dissection for advanced recurrent cancer. B: The repair. C:
The result.
FIGURE 127.10 Transfer to orbitonasal skin defect with tubing of the pedicle.

FIGURE 127.11 Split in the end of the flap over the face.
FIGURE 127.12 Folded end of the flap to provide two layers for a total lower lip reconstruction.
FIGURE 127.13 Deepithelialization of folded edge of flap in closing a through-and-through defect in the cheek.
CLINICAL RESULTS
Of the first 53 flaps I used in the early period of flap development at the Roswell Park Memorial Institute, 41
were completely successful. Of the remaining 12 flaps, seven suffered minor losses of no particular
consequence, each progressing to a satisfactory outcome either with healing by secondary intention or with
a minor readjustment when dividing the pedicle in a second stage. Only five flaps sustained more than a

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minimal loss, ranging up to a distal third of the flap. Two such losses
were caused by the hanging weight of the pedicle against the hard edge of a mandibular rib graft over
which the flap had been wrapped. Another occurred in a diabetic and arteriosclerotic patient in whom
hematoma formation and infection caused the loss in a “trial” delay that consisted of undermining the entire
area of the flap. It is interesting to note that in none of the patients did the amount of loss prevent the
completion of an intended reconstruction, which involved the use of additional stages with the remaining
portion of the flap.
FIGURE 127.14 The two-directional method of tubing the pedicle as seen in transfer to the oropharynx in a
patient in whom a segment of the mandible had to be sacrificed.
FIGURE 127.15 Two-directional tubing of the pedicle in passage on deep side of mandible into the oral
cavity. A: External view. B: Intraoral view.

FIGURE 127.16 Two-directional tubing of pedicle in passage superficial to the mandible into a defect of
radical orbitomaxillary resection. A: Flap in the defect. B: Appearance after healing. C: Waltzing the
pedicle. Tubed pedicle divided from its base on the chest and ready for use in restoring the palatal defect.
D: The end result.
FIGURE 127.17 Deltopectoral twin flaps.

FIGURE 127.18 Deltopectoral and pectoralis major musculocutaneous flaps simultaneously raised from the
same side.
SUMMARY
The deltopectoral flap is a well-established technique for reconstruction of head and neck defects.
References
1. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin
flap. Plast Reconstr Surg 1965;36:173.
2. Bakamjian VY, Cuff NK, Bales HW. Versatility of the deltopectoral flap in reconstructions following head
and neck cancer surgery. In: Transactions of the fourth international congress of plastic and reconstructive
surgeons, 1967: Amsterdam: Excerpta Medica, 1969;808-815.
3. Bakamjian VY. The reconstructive use of flaps in cancer surgery of the head and neck. In: Saad MN,
Lichtveld P, eds. Reviews in plastic surgery: general plastic and reconstructive surgery. Amsterdam:
Excerpta Medica, 1974.
4. Bakamjian VY, Cervino L, Miller S, Henz VR. The concept of cure and palliation by surgery in advanced
cancer of the head and neck. Am J Surg 1973;126:482.
5. Bakamjian VY, Long M, Rigg B. Experience with the medially based deltopectoral flap in reconstructive
surgery of the head and neck. Br J Plast Surg 1971;24:174.
6. Bakamjian VY. The deltopectoral flap. In: Grabb WC, Myers MB, eds. Skin flaps. Boston: Little, Brown,
1975.
7. Bakamjian VY, Poole M. Maxillofacial and palatal reconstructions with the deltopectoral flap. Br J Plast
Surg 1977;30:17.
8. Bakamjian VY, Dhooge PL. The contralateral deltopectoral flap in repeat resections for recurrent cancer of

the head and neck. Chir Plast (Ber.) 1979;4:243.
9. Bakamjian VY, Ciano M. The reconstructive role in cancer surgery of the head and neck. Ann Chir Plast
1982;27:133.
10. McGregor IA, Jackson IT. The extended role of the deltopectoral flap. Br J Plast Surg 1970;23:173.
11. McGregor IA, Reid WH. Simultaneous temporal and deltopectoral flaps for full-thickness defects of the
cheek. Plast Reconstr Surg 1970;45:326.
12. Krizek TJ, Robson MC. Split flap in head and neck reconstruction. Am J Surg 1973;126:488.
13. Leonard AG. Reconstruction of the chest wall using a deepithelialized “turn over” deltopectoral flap. Br J
Plast Surg 1980;33:187.
14. Konno A, Towaga K, Izuka K. Primary reconstruction after total or extended total maxillectomy for
maxillary cancer. Plast Reconstr Surg 1981;67:440.
15. McGregor IA, Morgan RG. Axial and random pattern flaps. Br J Plast Surg 1973;26:202.
16. Daniel RK, Cunningham DM, Taylor GI. The deltopectoral flap: an anatomical and hemodynamic
approach. Plast Reconstr Surg 1975;55:275.

Chapter 128
Deltopectoral Skin Flap As A Free Skin Flap Using The Internal
Mammary Vessels, Revisited: Further Refinement in Flap Design,
Fabrication, and Clinical Usage
K. SASAKI
M. NOZAKI
T. HONDA
K. MORIOKA
Y. KIKUCHI
T. HUANG
EDITORIAL COMMENT
This chapter shows how anatomic analysis can be used to make a previously difficult free flap anastomosis
more reliable.
The deltopectoral skin flap described by Bakamjian (1) in 1965 is an axial flap; therefore, it can be harvested as
a free skin flap for distant transfer by means of a microsurgical technique (2, 3). This skin flap was useful for
facial resurfacing because of excellent color and texture match. Shortness of the vascular pedicle and smallness
of the vessel caliber, on the other hand, render flap revascularization technically difficult. The method is further
plagued by problems attributable to bulkiness of the skin flap and morbidities associated with donor-site
deformity. These problems have been ameliorated by extending the pedicle to the internal mammary vessel and
defatting the flap.
INDICATIONS
Between 1985 and 1998 at our hospital, a total of 27 patients underwent reconstruction of head and neck
deformities due to various causes, using a free deltopectoral skin flap. There were 14 men and 13 women.
The youngest patient was 11 years old, and the oldest was 66 years of age; the average age of this group
was 36 years. Twelve patients had burn deformities of the face. A large facial hemangioma was seen in
seven individuals. The flap was often used to reconstruct defects consequential to cancer extirpation. The
indications and the number of patients with head and neck deformities managed with a free deltopectoral
flap were as follows: burn contracture, n = 12; hemangioma, n = 7; malignant tumors, n = 4; pigmented
nevus, n = 1; neurofibroma, n = 1; epidermal nevus, n = 1; and silicone granuloma, n = 1. Although the flap
was sufficient to cover any defect around the face and the neck, it was never used to reconstruct the upper
eyelid deformity. Resurfacing of the facial defect, however, did not follow the concept of facial aesthetic
units. The distribution of the 31 recipient sites was as follows: frontal scalp forehead, n = 5; orbital area, n =
1; nose, n = 1; cheek, n = 13; mouth, n = 2; and chin/neck, n = 9. For three patients, the defect involved
more than one area of the face.
ANATOMY
The lateral edge of the flap is bound by a line drawn 2 to 3 cm beyond the deltopectoral sulcus, alias

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Mohrenheim's fossa. The boundary is especially important in individuals for whom a concomitant
defatting/thinning of the skin flap is contemplated at the time of initial flap harvesting. The medial boundary of the
flap is located usually at the sternal edge on the same side. The medial boundary of the flap can be expanded by
3 to 4 cm beyond the ipsilateral parasternal line, especially where a segment of the internal mammary vessel is
included in fabricating a vascular pedicle.
Length and size of the vessel can vary depending on the location of the flap marked over the upper chest and
the distance from the parasternal line. Diameter of the arterial pedicle can be increased from 0.9 to 2.9 mm by
incorporating a segment of the internal mammary artery. Similarly, elongation of the vascular pedicle can be
achieved by removing the skin and the soft tissues surrounding the vessels at the medial edge of the flap (Fig.
128.1).
FLAP DESIGN
The extent of the tissue defect around the recipient site is measured, and the area is traced with a piece of
paper. The pattern of defect is transferred onto the deltopectoral area over the
second and third intercostal spaces. The course of intercostal vessels supplying the area is traced and marked
using a Doppler device.
FIGURE 128.1 Demonstrating the continuation of the medial vessel into the internal mammary vessel. Use of the
latter vessel makes the final anastomosis easier and safer.
OPERATIVE TECHNIQUE
Dissection of the flap is best started from the lateral edge. The incision is carried down to the muscular layer.
The dissection is continued to include the fascial layer of the pectoralis major muscle and the deltoid muscle,
making the fascia a part of the flap. As dissection is continued medially, care is taken not to injure the anterior
perforating branches of the internal mammary vessel. The vessels usually emerge through the pectoralis major
muscle at the second and third intercostal spaces, one finger width lateral to the sternal border. The origin of the
pectoralis major muscle may be divided and retracted laterally to facilitate dissection of the anterior perforating
branches of the internal mammary vessel and to expose the costal cartilage at a point 1.5 to 2 cm from the
sternal border. A small segment of the costal cartilage is removed with a rongeur to expose the internal mammary
vessel/anterior perforating vessel junction. The cartilage is removed carefully to avoid injuring the vessels that
are positioned closely against the inner surface of the cartilage. The sternal and the anterior intercostal branches
are ligated to include a segment of the internal mammary vessel in fabricating the vascular pedicle (Fig. 128.2).
The anterior perforator of the internal mammary artery assumes the course paralleling the long axis of the skin
flap. It extends toward the deltopectoral sulcus, that is, Mohrenheim's fossa, once it comes through the muscle

and enters the skin. In the pectoral area, several vertical rami branch off this artery to form the subdermal
vascular network. The vascular network in the distal end of this flap is expanded by anastomosis between the
anterior perforating artery and the cutaneous branches of the thoracoacromial artery and the deltoid
musculocutaneous arteries (3, 4, 5). That is to say, a skin flap 7 to 10 mm thick can be fabricated safely without
the need for subcutaneous fatty tissues to maintain vascular supplies to the skin flap.
The soft-tissue defect resulting from costal cartilage resection is obliterated by suturing the previously detached
pectoralis major muscle bundle to the cartilage. In instances in which a complete closure of the wound per
primum is not feasible, would distort the nipple areola configuration, or both, a V-to-Y skin flap advancement
technique of wound closure is used. This approach is especially useful in closing the central defect where the
primary closure would otherwise distort the surrounding structures, for example, nipples and chest configuration.
FIGURE 128.2 The medial pectoralis vessels are dissected through the second and third intercostal spaces. A
small segment of cartilage is excised and the vessel traced to the internal mammary vessel.
To close a wound, a triangular skin marking with its base adjacent to the wound length is made in the caudal or
the lateral section of the chest wall. The length of the flap is determined by the extent of skin laxity surrounding
the triangular skin flap. The triangular island skin flap is advanced cephalad or medialward to compensate for the
tissue defect. The V-shaped donor defect is closed primarily into a Y shape— hence, a V-to-Y skin flap
advancement wound closure. Flap revascularization is accomplished by coapting the graft vessels with the facial
artery/vein or the superficial temporal artery/vein under magnification.
CLINICAL RESULTS
The length of follow-up in this group of patients varied between 14 years and 2 months, and 13 months,
with an average of 5 years and 4 months.
The size of nutrient vessels was quite variable. As expected, the caliber of anterior perforating artery and
vein was small. Of seven flaps with the anterior perforators as the nutrient vessels, the arterial size varied
between 0.6 and 1.2 mm, with an average size of 0.9 mm. The vein was similarly quite small. The venous
caliber varied between 1.5 and 3.2 mm, with an average size of 2.3 mm. The length of vascular pedicle was
inconsistent. The longest one was 4.8 cm, and the shortest one was 1.8 cm, with an average length of 3.5
cm. Vascular anastomosis was, as expected, technically difficult. Thrombosis occurred at the anastomotic
site in three instances. The secondary intervention saved two flaps. That is, we encountered a complete
flap necrosis in one individual in this group of patients.
In 20 flaps in which a segment of the internal mammary vessel was included in vascular pedicle fabrication,
the caliber

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of the artery and vein was noticeably larger. The arterial size varied between 1.4 and 3.0 mm, with an
average size of 2.1 mm. The internal mammary vein was noted to vary between 2.0 and 3.8 mm. The
average venous size was 2.9 mm. The shortest vascular pedicle with a segment of internal mammary vessel
included was 3.5 cm, and the longest one was 7.1 cm. Although necrosis of the flap was not seen in this
group of patients, we encountered venous thrombosis in one patient due to torsion of the vascular pedicle
at the anastomotic site. However, a revisional procedure prevented flap necrosis.
Concomitant thinning of the skin flap at the time of initial surgery was carried out in only 15 patients.
However, secondary thinning of the flap was deemed necessary in two of these patients because of
bulkiness of the flap noted in the area of vascular pedicle attachment. In contrast, debulking procedures
were needed in 6 of 10 flaps that had not had the primary intraoperative thinning. On the other hand, we
had encountered partial necrosis of the flap around the tip in four individuals who had intraoperative
thinning procedures. Derangement of subdermal vascular supplies attributable to defatting was thought to
be the cause.
The V-to-Y flap advancement technique of closing the flap donor site defect was used in eight patients. The
appearance of the wound was judged to be cosmetically satisfactory. The appearance of the donor site in
patients who had undergone a conventional method of skin grafting, in contrast, was unsightly.
SUMMARY
Between 1985 and 1998, a total of 27 patients underwent head and neck reconstruction using a
deltopectoral skin flap, alias dictus a Bakamjian flap, fabricated as a free flap and transferred by means of a
microsurgical technique. We have instituted several technical refinements in flap fabrication. A segment of
the internal mammary artery and vein was incorporated in the fabrication of the flap's vascular pedicle. A
more than twofold increase in the vessel size and the vascular pedicle length rendered flap
revascularization technically easier. The frequency of secondary flap debulking was similarly drastically
reduced by incorporating the maneuver of thinning of the skin flap before transfer. Furthermore, the use of
V-to-Y technique of wound closure simplified the closure of the flap donor defect. The outcome was
considered to be much better than that with the conventional technique of primary closure with concomitant
skin grafting.
References
1. Bakamjian VY. A two-stage method of pharyngoesophageal reconstruction with a primary pectoral skin
flap. Plast Reconstr Surg 1965;36:173.
2. Harii K, Ohmori K, Ohmori S. Free deltopectoral skin flap. Br J Plast Surg 1974;27:231.
3. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243.
4. Daniel RK, Cunningham DM, Taylor GI. The deltopectoral flap: an anatomical and hemodynamic
approach. Plast Reconstr Surg 1975; 55:275.
5. Palmer JH, Taylor GI. The vascular territories of the anterior chest wall. Br J Plast Surg 1986;39:287.

(Trang không có chữ)

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Chapter 129
Deltoscapular Skin Flap
C. J. SMITH
The deltoscapular flap, perceived by several independent observers as a mirror image of the Bakamjian
deltopectoral flap (1), has been used for reconstruction of a posterior neck and back defect (2), an occipital
defect (3), and defects of the lateral and anterolateral neck (4).
INDICATIONS
This flap is useful as an adjunct to the head and neck surgeon's armamentarium, but because of its
anatomic position, it does not equal the deltopectoral flap in versatility. In addition, the thickness of the skin
of the back limits the mobility of the flap and prohibits tubing of the proximal portion.
The primary advantages of this flap are (a) the location of its base inferior to the posterior neck skin, which
commonly receives radiation in cases of head and neck cancer and which constitutes the base of the
classic shoulder flap (5); (b) its arc of rotation, which extends to difficult-to-reach occipital and posterior
neck wounds; and (c) its use as an additional source of tissue when other methods have failed or are not
feasible (3, 4). The flap can be used simultaneously with or subsequent to the use of an ipsilateral
deltopectoral flap by designing the superior limb to superimpose the distal limb of the deltopectoral flap.
ANATOMY
The blood supply is from the perforating branches of the posterior intercostal arteries (2, 3, 4) and, if not
elevated extensively from the trapezius muscle, also from musculocutaneous branches of the descending branch
of the transverse cervical artery (2, 4). It has not been unequivocally demonstrated clinically or in the laboratory
that this mirror image of the deltopectoral flap is a true axial flap capable of transposition without delay.
FIGURE 129.1 Outline of deltoscapular flap with arm elevated in anatomic position. Undermining extends only to
lateral border of neck for transfer to anterolateral side of neck. Inferior incision can be back-cut for greater reach.
(From Smith, ref. 4, with permission.)

FLAP DESIGN AND DIMENSIONS
The dimensions of this flap are essentially the same as those of the deltopectoral flap, beginning adjacent to the
midline of the back, spanning three to four intercostal spaces from the first thoracic vertebra, and extending
laterally across the back onto the posterolateral shoulder (Fig. 129.1). The pivot point is at the most medial
aspect of the inferior limb incision, which can be slightly back-cut to increase the reach of the flap. The arc
extends to the occipital scalp, the auricular region, and the lateral or anterolateral neck.
FIGURE 129.2 A: Pharyngocutaneous fistula was prepared by excision of excess surrounding skin and rotation
of local flap as internal lining. Delayed deltoscapular flap extends well onto upper third of upper extremity just
prior to transfer. B: Distally tubed deltoscapular flap at 2 weeks is shown healing well without necrosis. Initial
drainage beneath flap was promptly controlled by pressure dressings for 7 days. C: Transferred segment of
deltoscapular flap heals to right deltopectoral flap anteriorly. (From Smith, ref. 4, with permission.)
The deltoscapular flap is designed to avoid the occipital and nuchal region of patients who have received
extensive radiation to the head and neck. The superior aspect of the limb is placed at the level of the spine of the
seventh cervical or first thoracic vertebra and is extended laterally onto the deltoid region and upper extremity
(Fig. 129.1). When a deltopectoral flap has been used previously, the superior part of the limb curves gently
downward onto the upper extremity to join the distal incision of the deltopectoral flap (see Fig. 129.2).
As recommended for the shoulder flap (6), the proposed incision lines must be marked preoperatively on the skin
while the patient is sitting because of the distortion of the skin relative to the bony landmarks when the patient is
in a lateral decubitus position.
OPERATIVE TECHNIQUE
The inferior incision is always started as far medial as the fourth or fifth thoracic vertebral spine and may even be
back-cut, if necessary, to improve mobility of the flap. The flap is gradually tapered while distally incorporating
the thinner, more pliable skin of the deltoid region and upper extremity. Undermining usually need not be carried
farther medial than the lateral aspect of the neck. It is hypothesized that this permits incorporation of anastomotic
branches of the dorsal scapular artery in addition to the posterior perforating arteries.
Undermining is more difficult than with the deltopectoral flap because of the rigidity of the skin of the back and
the tight adherence of the deep fascia to the muscles. As the undermining proceeds from inferior to superior,
care must be taken not to undermine deep to the deltoid muscle. By limiting the undermining to a vertical line that
extends from the lateral margin of the neck, the flap may extend well onto the posterior aspect of the upper
extremity. Thus, the length and

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pliability necessary to reach the anterolateral side of the neck are obtained without excessive tension (Fig.
129.2).
By delaying the flap in multiple stages and limiting medial undermining to a vertical line at the lateral border of the
neck, a length comparable with the deltopectoral flap may be obtained. In the initial stage, superior and inferior
incisions are made, which are followed in 10 to 14 days by undermining. Ten to 14 days later, the distal end is
incised. The flap may be transferred in 2 to 3 days, when viability is ascertained (Fig. 129.2). As suggested for
the shoulder flap (7), undermining the distal end in long flaps as a separate procedure may be wise and is
recommended. Because of the unknown qualities of this flap and the circumstances in which it was used (after
necrosis of a deltopectoral flap), meticulous, although perhaps excessive, care and delay have been the rule.
CLINICAL RESULTS
The disadvantages of this flap are awkward postoperative positioning of the patient, inflexibility of the
proximal pedicle of thick back skin that reduces the length of the arc of rotation, and an apparent (but
unestablished) necessity for delay. The flap has been used successfully without delay (2), but was simply
transposed as a broadly based, obliquely designed flap with a large dog-ear to an adjacent defect on the
back and inferior posterior neck. On the other hand, it has been recommended that a delay be performed
for flaps that are to be interpolated to more distant defects (3, 4).
SUMMARY
The deltoscapular flap is geometrically a mirror image of the deltopectoral flap and is based on perforating
cutaneous branches of the posterior intercostal arteries. Its use has been limited to major reconstructive
problems of the head and neck when more conventional methods have not been applicable. Application has
been limited by the development of reliable musculocutaneous and free flaps, but it remains a useful
alternative flap for unusual circumstances.
References
1. Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin
flap. Plast Reconstr Surg 1965;36:122.
2. Doldan FG, Shatkin S. The deltoscapular flap. Plast Reconstr Surg 1975;55:708.
3. Harashina T, Nakajima T, Maruyama Y. Deltovertebral flap to cover a large scalp defect. Plast Reconstr
Surg 1977;59:851.
4. Smith CJ. The deltoscapular flap. Arch Otolaryngol 1978;104:390.
5. Mutter TD. Cases of deformity from burns, relieved by operation. Am J Med Sci 1842;4:66.
6. Zovickian A. Pharyngeal fistulas, repair and prevention, using mastoid-occiput based shoulder flaps. Plast
Reconstr Surg 1957;19:355.

7. Chretien PB, Ketcham AS, Hage RC, Gretner HR. Extended shoulder flap and its use in reconstruction of
the defects of head and neck. Am J Surg 1969;118:752.

Chapter 130
Dorsal Scapular Island Flap
C. ANGRIGIANI
EDITORIAL COMMENT
This is a difficult dissection, although a useful umbrella. Flap does have a high failure rate and complication
rate.
The dorsal scapular island flap is raised from the back and can be transferred as an island vascular flap to the
anterior part of the thorax, the face, or the cranial vault without disruption of trapezius muscle function; therefore,
there is no morbidity of shoulder joint motion (1). The flap is irrigated by the cutaneous branch of the superficial
branch of the dorsal scapular artery, which is consistently present (2) (Fig. 130.1). It can be elevated with
vascularized bone (the medial border of the scapula).
INDICATIONS
The procedure is indicated for resurfacing of the neck, the face, or the anterior thorax whenever a
microsurgical free-tissue transfer is not indicated or cannot be carried out. It is also indicated for mandibular
reconstruction as a salvage procedure when free vascularized bone graft cannot be performed.
ANATOMY
The dorsal scapular artery originates from the posterior scapular artery as a deep branch or as a direct branch of
the subclavian artery (3, 4). It runs posteriorly and almost horizontally, deep or through the branches of the
brachial plexus. The artery then courses under the trapezius, the omohyoid, and levator scapulae muscles on top
of the rib cage. During its course, it gives off branches to these muscles. At the medial angle of the scapula, the
dorsal scapular artery gives off a superficial branch that pierces the rhomboid muscle and runs under the deep
surface of the lower part of the trapezius; it then gives off one or two cutaneous branches that pierce this muscle
and reach the skin.
The anatomic course of this artery must be differentiated from the superficial branch of the posterior scapular
artery, which is the main pedicle of the trapezius muscle (5). The dorsal scapular artery runs deep to the levator
scapular and the omohyoid muscle; it is not related to the trapezius main pedicle. This is not a conventional
lower trapezius flap, which is irrigated by the descending branch of the superficial branch of the posterior
scapular artery. The traditional lower trapezius flap disrupts the main vascular pedicle of the trapezius muscle
and impairs its function.
The dorsal scapular flap utilizes a double perforator, as the pedicle pierces two muscles before reaching the
skin: the rhomboideus and the trapezius (Fig. 130.2).
The main trunk of the dorsal scapular artery divides into two branches when it reaches the angle of the scapula:
the superficial (which irrigates the dorsal scapular flap) and the deep branch (which irrigates the medial border of
the scapular bone).
FLAP DESIGN AND DIMENSIONS

The skin projection of the medial border of the scapula, the superomedial angle of the scapula, and the tip of the
scapula are marked with the patient in a standing position and the arms at the sides of the body; the spinous
processes of the vertebrae are also marked. A line is drawn between the spine of the scapula and the spinous
process of the tenth thoracic vertebra, which indicates approximately the lateral border of the trapezius muscle. A
point is marked 2 cm medial to the lateral border of the trapezius muscle at the level of the middle of the scapula.
This point represents the emergence of the cutaneous perforator through the trapezius muscle, and it must be
included in the flap design. A 20-cm-long skin paddle oriented in any direction can be safely designed.
OPERATIVE TECHNIQUE
The patient is placed in a prone decubitus position. The procedure is prepared with the skin infiltrated with 1%
lidocaine (Xylocaine) along the flap margins already marked. The skin is incised, and dissection is performed
above the deep fascia. The lateral border of the trapezius muscle is identified and retracted superiorly, in order
to observe its deep surface, where the superficial branch of the dorsal scapular artery is easily seen. The skin
island is dissected, and the perforator is now observed on the surface of the muscle; it is then dissected free
from the muscle. The vascular pedicle is liberated from the muscle belly, and dissection continues up to the point
where the pedicle pierces the rhomboideus muscle; the pedicle is dissected in depth through this muscle, and
the main trunk of the dorsal scapular artery is exposed. The deep branch to the scapular bone is ligated and
sectioned, unless a bone segment is included in the flap.
FIGURE 130.1 The flap is supplied by the cutaneous branch of the superficial branch of the dorsal scapular
artery. This is a consistent vessel.
A long retractor is placed, pulling up the trapezius, the omohyoid, and the levator scapula muscles and creating a
tunnel. The muscle branches to these muscles are coagulated and sectioned. A cannula is passed through this
tunnel up to the supraclavicular skin, which is incised. The flap is passed to the anterior incision. The donor site
of the back is closed, and the patient is turned to a dorsal decubitus position. The flap is inset into the anterior
thorax, the face, or the neck (Fig. 130.3).
CLINICAL RESULTS
The DSAP flap was used in 42 cases in our clinical series (25 female and 17 male patients). Patient ages

ranged from 9 to 65 years. The flap was used as a single skin and subcutaneous tissue flap in 36 cases. In
seven cases, it was utilized as compound soft tissue and vascularized bone (using the medial part of the
scapula bone); four of these cases were mandibular reconstructions, one case was a clavicle
pseudoarthrosis, and a sixth case was a superior maxillary reconstruction.
FIGURE 130.2 The dorsal scapular flap vascular pedicle pierces two muscles before reaching the skin: the
rhomboideus and the trapezius.
FIGURE 130.3 After transposing the flap anteriorly, the arc of rotation allows for inset into the anterior
thorax, the face, or the neck.
The skin flaps were used for anterior chest-wall resurfacing after release of burn scar contraction in 6
cases, for neck resurfacing (partial or total) in 18 cases, for cranial-vault reconstruction in 4 cases, and for
cheek reconstruction in 8 cases.
There were three complete flap losses and four partial tissue losses suffered at the distal part, which
eventually healed. The complete failures were related to technical errors during flap elevation in two cases;
in one case, the flap could not be carried out as planned due to absence of the skin branch of the dorsal

scapular artery. The direct cutaneous branch of the great intercostal (third space) was used as the vascular
pedicle of the skin island, which was transferred as a free flap.
SUMMARY
The dorsal scapular flap represents an additional way to transfer an island flap from the medial part of the
back (corresponding to the area of the traditional lower trapezius musculocutaneous flap) to the anterior
thoracic wall, the neck, the face, or the cranial vault.
References
1. Angrigiani C, Grilli D, Karanas YL, Longaker M. The dorsal scapular island flap: an alternative for head,
neck, and chest reconstruction. Plast Reconstr Surg 2003;111:67.
2. Weiglein AH, Hass F, Pierer G, et al. Anatomic basis of the lower trapezius musculocutaneous flap. Surg
Radiol Anat 1996;18:257.
3. Huelke DF. A study of the transverse cervical and dorsal scapular arteries. Anat Rec 1958;103:233.
4. Daseler EH, Anson BJ. Surgical anatomy of the subclavian artery and its branches. Surg Gynecol Obstet
1959;108:149.
5. Salmon M. Les artères des muscles du tronc. Paris: Masson, 1933.

Chapter 131
Tubed Abdominal and Chest Skin Flaps
M. F. STRANC
W. E. STRANC
EDITORIAL COMMENT
The time-honored techniques of tubed flaps should he studied in light of our present understanding of the
blood supply. In fact, the authors have made an effort to include an axial vessel in the tubed flap, be it
perforating from the epigastric arcade or the internal mammary or axillary vessels. If the axial contributions
are not included in the design, obviously the flaps are subject to the haphazard effects of chance.
Until the early 1970s, abdominal and thoracic tubed skin flaps were some of the main methods of skin transfer.
Advances in our knowledge of the blood supply of the skin (1, 2), subcutaneous tissue, and underlying muscles
(3, 4) have led to the development of much safer and more rapid methods of skin transport, dramatically reducing
the indications for the use of the tubed skin flap.
INDICATIONS
The abdominal tubed skin flap can be used to provide skin cover anywhere in the body, although it requires
several stages and may take months to complete. Chest-tubed flaps, although uncommon in present
practice, may be used for reconstructive surgery of the head and neck following excision for malignancy or
release of burn contractures. This flap was most beneficial to the patient illustrated in Figure 131.4, who
developed high and low esophagocutaneous fistulas following radiotherapy and laryngectomy. Use of the
flap allowed the repair of both without compromising the airway.
The horizontally oriented chest-tubed flap is rarely used since it has been supplanted by the deltopectoral
flap (see Fig. 131.2B). The thoracoabdominal tubed flap is also rarely used at present. The main indication
for this flap is the release of burn contracture where full-thickness skin is needed and only the back is
available as the donor site. A similar flap has been used to close the defect left by a hindquarter amputation
(5).
ANATOMY
Although short tubed skin flaps can be raised in any axis, longer flaps must be raised along the axial patterns of
flow of the vessels supplying the subcutaneous compartment (Fig. 131.1). A standard vertically based abdominal
tubed skin flap is based inferiorly on the superficial epigastric vessels and superiorly on terminal branches of
intercostal vessels (Fig. 131.2A). The horizontally oriented flap is more hazardous because it is raised on a
convex surface and is thus subject to greater tension. It is based on the terminal branches of the segmental
vessels (Fig. 131.2A).
The vertically oriented thoracic tubed flap is based on the thoracoacromial axis above and terminal branches of
the intercostal vessels below. The lower base is situated just medial to the nipple (6) (Fig. 131.2B).
The blood supply of the thoracoabdominal tubed flap is inferiorly based on branches of the superficial epigastric

vessels and superiorly on the posterior perforating branches of the intercostal vessels. It is often necessary to
have an intermediate bridge that carries lateral perforating vessels of the intercostal vessels. The bridge is tubed
as a separate stage.
FLAP DESIGN AND DIMENSIONS
The dimensions of the vertically oriented abdominal tubed flap are 10 cm across its base and 20 cm in length.
Vertically oriented chest tubed flaps share the same general measurements.
OPERATIVE TECHNIQUE
Abdominal Tubed Flap Vertically and Horizontally Oriented
Two parallel incisions are made through the skin and subcutaneous tissues just superficial to the external
oblique aponeurosis. It is important to bevel the edges of the subcutaneous fat so that the tube can be closed
without tension. The donor site can be closed either by wide undermining and suture or by grafting (Fig. 131.3A).
If necessary, the upper end can be extended 5 to 10 cm 2 to 3 weeks after the flap has been raised.
FIGURE 131.1 A: Blood supply of the front of the trunk. B: Blood supply of the back of the trunk.
Three weeks after the flap has been tubed, when it is healed and soft, the upper end is transferred onto the
wrist. The inset must be adequate; if necessary, 2 to 3 cm of the flap may be untubed. A return flap from the
carrier site should be used to increase the area of contact (Fig. 131.3B). When the carrier site is healed, the
abdominal end of the tubed flap should be delayed. It is important to divide the superficial epigastric vessels.
Present knowledge of vascular territories allows the successful combination of stages 1 and 2, thus shortening
treatment time (7).
A third stage is carried out 2 or 3 weeks after the first move. The principles of transfer are the same as above,
except that a return flap is not always needed (Fig. 131.3C).
When the recipient site is well healed, the carrier end is detached and the tubed flap is opened and inset (Fig.
131.3D).
The success of the whole procedure depends on several factors: (a) a cooperative patient; (b) accurate planning
of all stages; (c) use of a pattern of the defect to plan the size of the tubed flap; (d) planning all moves in reverse,
thus checking that the patient has the necessary joint mobility to maintain the required positions; and (e)
recording plans carefully for future reference.

FIGURE 131.2 A: Vertically and horizontally oriented abdominal tubed flaps. B: Vertically and horizontally
oriented anterior chest tubed flaps.
Chest-tubed Flap: Vertically Oriented
Two parallel incisions are made down to and including the pectoral fascia. The thoracoacromial axis above must
be preserved. This flap is not usually used in women because of the presence of breast tissue. The donor site
requires grafting (Fig. 131.4).
CLINICAL RESULTS
The average failure rate for abdominal tubed flaps is 15%. The longer the tubed flap, the higher the failure
rate. Tubed flaps under 20 cm have a failure rate of 6%; those over 25 cm have a failure rate of 22% (8).
The failure rate for thoracic tubed flaps is 5%.

FIGURE 131.3 A: Preparation of flap. B: Flap to carrier site. Note in (2) that a return flap from the carrier
site is elevated to increase the total surface area. C: Flap to recipient site. D: Spreading and insetting of
tubed flap.
FIGURE 131.4 A: Patient with high and low esophagocutaneous fistulas and prepared vertical tubed flap.
B: Fistulas closed and tubed flap kept clear of airway. C: Final result.
SUMMARY
Tubed skin flaps from either the chest or the abdomen are not used as frequently as in the past. They have
been supplanted by faster, more reliable flaps. There are a few occasions, however, when tubed skin flaps
are still indicated.
REFERENCES
1. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast Surg 1973;26:202.
2. Daniel RK. Toward an anatomical and hemodynamic classification of skin flaps. Plast Reconstr Surg
1975;56:330.
3. McCraw J, Dibbell D, Carraway J. Experimental definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:212.
4. McCraw J, Dibbell D, Carraway J. Clinical definition of independent myocutaneous vascular territories.
Plast Reconstr Surg 1977;60:341.
5. Didolkar MS, Baffi RR, Bakamjian VY. Use of a tubed thoracoepigastric flap to cover the defect from a
hindquarter amputation. Plast Reconstr Surg 1978;61:112.
6. Pollock WJ, Bitseff EL, Ryan RF. Rapid transfer of thoracoacromial flaps to the face and neck. Plast
Reconstr Surg 1972;50:433.
7. Shaw DT. Tubed pedicle construction: the single-pedicle abdominal tube and acromiopectoral flap. Ann

Plast Surg 1980;4:219.
8. Stranc MF, Stranc WE. Tubed skin flaps. In: Grabb WC, Myers B, eds. Skin flaps. Boston: Little, Brown,
1975.

Chapter 132
Latissimus Dorsi Musculocutaneous Flap to The Head, Neck,
Cheek, and Scalp
W. Y. HOFFMAN
R. M. BARTON
L. O. VASCONEZ
The latissimus dorsi muscle, with its long vascular pedicle, can be converted to a flap of considerable length that,
combined with the substantial bulk and reliable vascular supply of the muscle, makes this muscle ideal for major
head and neck reconstruction. Moreover, the length and diameter of the primary vascular supply allow the
fashioning of an excellent free flap.
INDICATIONS
The latissimus dorsi has proved especially useful in resurfacing defects of the cheek and lateral scalp.
Although most of the neck can be reached for coverage by the latissimus dorsi, the pectoralis major is
generally preferred for neck and intraoral reconstruction. The latissimus dorsi is used in these areas when a
great deal of bulk or skin or both are needed (1, 2, 3, 4, 5, 6, 7).
For reestablishing oropharyngeal continuity, the musculocutaneous flap has been used with the skin portion
placed inward and with skin grafts placed on the exposed muscle surface (8). The split flap, with two
musculocutaneous units, has been applied to reconstruction of the pharynx while simultaneously providing
outer skin coverage (9, 10).
The free latissimus dorsi flap was first described for coverage of a chronically infected scalp after multiple
skin grafts had failed (11). Since that time, the free latissimus dorsi has been used as a muscle alone with
skin graft cover (12, 13), as a musculocutaneous flap both for scalp and other head and neck defects (14,
15), and as an osteomusculocutaneous composite transfer to achieve internal and external wound closure
and to restore mandibular continuity (16). Whenever possible, however, the long vascular pedicle of the
muscle should lead to consideration of a pedicled flap rather than a free flap.
ANATOMY
The latissimus dorsi muscle originates from the lower thoracolumbar vertebrae, the thoracolumbar fascia, the
lumbar and sacral vertebrae, and the posterior iliac crest. It inserts into the intertubercular groove of the
humerus, serving to adduct, extend, and internally rotate the arm and to lift and stabilize the pelvis in walking (2,
17).
The blood supply to the muscle comes primarily from the thoracodorsal artery, with secondary contributions from
perforating branches of the lower posterior intercostal arteries. The thoracodorsal artery, arising at a bifurcation
with the circumflex scapular artery, is a terminal branch of the subscapular artery that enters the muscle on the
deep surface 8 to 10 cm from the axillary artery and 2 cm from its free anterior edge. There is a constant branch
to the serratus anterior muscle. The diameter of the most proximal part of the thoracodorsal artery averages 1.5
to 3.0 mm, making it an excellent vessel for microvascular anastomosis.
At the point of entry into the muscle, the thoracodorsal artery splits into a lateral branch that is parallel to and 2
cm from the anterior border of the muscle and a medial branch that runs obliquely near the upper border of the

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muscle. This anatomic formation constitutes the basis for the “split” flap with two musculocutaneous units on a
single pedicle and has been found in 85% to 95% of cadavers studied (9, 10, 18).
The secondary blood supply, originating in the intercostal vessels that also nourish the ribs, is important in head
and neck reconstruction and forms the basis for the osteomusculocutaneous flap that carries viable rib with the
muscle based only on the thoracodorsal vessels (16, 19, 20).
Musculocutaneous perforators are widely distributed over the entire muscle surface and supply the overlying
skin. Inclusion of the thoracolumbar fascia will provide blood to skin down to the iliac crest if the proximal
musculocutaneous perforators are also preserved. This “extended,” or musculofascial, flap is not completely
reliable, and some authors recommend delaying this flap by ligating the posterior perforating vessels (3, 5, 7,
21).
FLAP DESIGN AND DIMENSIONS
Planning backward from the expected defect ensures that the skin island is placed sufficiently inferior on the
muscle (Fig. 132.1). Small island flaps may be excluded from any direct musculocutaneous perforators and may
not survive. Using a Doppler probe to locate perforators has been reported, but this is difficult to perform
accurately. The largest flap reported is 20 × 30 cm. The donor defect may be closed primarily if the skin island is
smaller than 8 to 10 cm.
FIGURE 132.1 This diagram shows the partial arc of rotation that can be extended with a distal fascial portion of
the flap. The arterial configuration and the secondary pedicles are shown.
OPERATIVE TECHNIQUE
Muscle and Musculocutaneous Flap
An incision is made just beyond the free edge of the muscle to expose the vascular pedicle. The incision is
carried posteriorly to join the incised skin island, which is sutured to the muscle fascia early in the procedure to
avoid shearing any musculocutaneous perforators. The pedicle can be dissected up to the axillary vessels,
dividing the circumflex scapular vessels if necessary. The nerve also may be divided to cause later atrophy of

the muscle that will create better contour. The muscle is dissected superficial to the serratus anterior and the
scapula. If a transfer of vascularized rib is planned, the perforators to that rib are preserved; otherwise, all the
posterior vessels are divided.
After detaching the origin of the muscle, the flap is tunneled with the attached skin island under the pectoralis
major muscle and over the clavicle. If necessary, the base of the muscle and pedicle are thinned to prevent
pressure on the vessels, and the muscle then is brought either subcutaneously or over the neck skin to the
cheek or scalp, fitting nicely into the defect left after removal of the sternocleidomastoid muscle in radical neck
dissections.
Free-flap Technique
The technique for a free flap is similar to that of a muscle flap, except that the insertion of the muscle is divided
as well. The dissection under the muscle is best done in a retrograde fashion to identify the vascular supply as
early as possible. The donor vessels are divided close to the axillary vessels only after the recipient defect and
vessels have been prepared. For head and neck reconstruction, the superficial temporal and the fascial vessels
are used most frequently as the recipient vessels.
CLINICAL RESULTS
One of the main problems with the latissimus dorsi for head and neck reconstruction is its location and the
difficulty in positioning the patient for simultaneous resection and flap elevation. This can be overcome by
lateral decubitus positioning for lateral lesions or by closing most of the posterior wound before beginning
resection.
The functional deficit is minimal, except in certain athletic endeavors (swimming, climbing) and in patients
who have some pelvic or hip instability.
Temporary brachial plexus palsy has been reported in up to 10% of patients, because of manipulation and
hyperextension or abduction of the arm during the operation. The flap itself is extremely reliable. Any tissue
loss is usually caused by compression of the pedicle or technical difficulty with a microvascular anastomosis
(22).
SUMMARY
With a pivot point in the axilla, the latissimus dorsi muscle and musculocutaneous flap can reach not only
the anterior or posterior neck but also the chin, cheek, and lateral scalp. Other areas that are not within
reach can be closed with a free flap.
References
1. Quillen CG, Shearin JC, Georgiade NG. Use of the latissimus dorsi myocutaneous island flap for
reconstruction in the head and neck area. Plast Reconstr Surg 1978;62:113.
2. Mathes SJ, Nahai F. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979;369-
392.
3. Quillen CG. Latissimus dorsi myocutaneous flaps in head and neck reconstruction. Plast Reconstr Surg

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1979;63:664.
4. Krishna BV, Green MF. Extended role of latissimus dorsi myocutaneous flap in reconstruction of the neck.
Br J Plast Surg 1980;33:233.
5. Maxwell GP, Leonard LG, Manson PN, Hoopes JE. Craniofacial coverage using the latissimus dorsi
myocutaneous flap. Ann Plast Surg 1980; 4:410.
6. Morris RL, Given KS, McCabe JS. Repair of head and neck defects with the latissimus dorsi
myocutaneous flap. Am Surg 1981;47:167.
7. Barton FE, Spicer TE, Byrd HS. Head and neck reconstruction with the latissimus dorsi myocutaneous
flap: anatomic observations and report of 60 cases. Plast Reconstr Surg 1983;71:199.
8. Watson JS, Lendrum J. One-stage pharyngeal reconstruction using a compound latissimus dorsi island
flap. Br J Plast Surg 1981;34:87.
9. Tobin GR, Spratt JS, Bland KI, Weiner LJ. One-stage pharyngoesophageal and oral mucocutaneous
reconstruction with two segments of one musculocutaneous flap. Am J Surg 1982;144:489.
10. Tobin GR, Moberg AW, Dubou RH, et al. The split latissimus dorsi myocutaneous flap. Ann Plast Surg
1981;7:272.
11. Maxwell GP, Stueber K, Hoopes JE. A free latissimus dorsi myocutaneous flap. Plast Reconstr Surg
1978;62:462.
12. Mathes SJ, Vasconez LO, Rosenblum ML. Management of the difficult scalp and intracranial wound. Clin
Plast Surg 1981;8:327.
13. Alpert BS, Buncke HJ, Mathes SJ. Surgical treatment of the totally avulsed scalp. Clin Plast Surg
1982;9:145.
14. Maxwell GP. Experience with 13 latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg
1979;64:1.
15. Maxwell GP. Musculocutaneous free flaps. Clin Plast Surg 1980;7:111.
16. Schmidt DR, Robson MC. One-stage composite reconstruction using the latissimus dorsi myo-
osteocutaneous free flap. Am J Surg 1982;144:470.
17. Bartlett SP, May JW, Jr., Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the
primary neurovascular pedicle. Plast Reconstr Surg 1981;67:631.
18. Tobin GR, Schusterman MA, Peterson GH, et al. The intramuscular neurovascular anatomy of the

latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637.
19. Schlenker JD, Indresano AT, Raine T, et al. A new flap in the dog containing a vascularized rib graft and
the latissimus dorsi myocutaneous flap. J Surg Res 1980;29:172.
20. Schlenker JD, Robson MC, Parsons RW. Methods and results of reconstruction with free flaps following
resection of squamous cell carcinoma of the head and neck. Ann Plast Surg 1981;6:362.
21. Bostwick J, Nahai F, Wallace JG, Vasconez LO. Sixty latissimus dorsi flaps. Plast Reconstr Surg
1979;63:31.
22. Vasconez LO, McCraw JB, Hall EJ. Complications of musculocutaneous flaps. Clin Plast Surg
1980;7:123.

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Chapter 133
Trapezius Muscle and Musculocutaneous Flaps
K. F. HAGAN
S. J. MATHES
EDITORIAL COMMENT
The editors caution the reader to use this flap only when the transverse cervical artery is known to be
intact. The transverse cervical artery often is ablated during a radical neck dissection; therefore, the major
source of blood supply to the flap is interrupted.
The trapezius muscle is the basis for muscle and musculocutaneous flaps that are of great usefulness in
reconstructing defects of the head and neck and of the upper back (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12). Its
location makes it frequently the flap of choice for defects of the occipital, parotid, and cervical spine areas. In
addition, it may be used for intraoral and anterior neck coverage. The posterior trapezius musculocutaneous flap
should be considered the flap of choice for defects of the lateral face, posterior scalp and neck, and the upper
third of the posterior trunk.
ANATOMY
Muscle Function
The muscle may be functionally separated into three parts (Fig. 133.1). The upper occipital and cervical part acts
to elevate the shoulder, holding it in normal postural position by slight, continuous, tonic contraction. This action
is not shared with other muscles (although the levator scapulae exerts an upward pull on the scapula, it does not
have the same effect on the shoulder girdle), and hence denervation of the trapezius or functional loss of its
upper fibers will result in the shoulder-drop deformity (13, 14).
The medial fibers, originating from the upper thoracic region, pull the scapula backward toward the midline and
act to square the shoulders. This function is shared with the rhomboid muscles.
The inferior fibers from the lower thoracic region act in concert with the upper fibers to rotate the scapula,
assisting in abduction of the arm above the horizontal plane; however, loss of function of lower fibers alone
usually has minimal effect on arm abduction because the serratus anterior is a more powerful rotator of the
scapula than the trapezius. Therefore, selective loss of the middle and inferior fibers has no significant clinical
sequelae (see Fig. 133.1).
The trapezius is a broad, flat, triangular-shaped muscle that, when combined with its contralateral mate, forms a
trapezium (see Fig. 133.1). It originates medially from the external occipital protuberance, the medial part of the
superior nuchal line of the occipital bone, the ligamentum nuchae, and the spinous processes of the seventh
cervical and all the thoracic vertebrae. The superior portion of the muscle that originates from the occipital and
upper thoracic areas inserts into the posterior aspect of the lateral third of the clavicle
(Figs. 133.1 and 133.2). The middle portion, originating from the lower cervical and upper thoracic areas, inserts
onto the acromion and the superior spine of the scapula. The inferior fibers, originating from the lower thoracic
vertebrae, insert into the base of the spine of the scapula. The muscle overlies the splenius capitis, levator
scapulae, supraspinatus, rhomboidus minor and major, and the upper medial portion of the latissimus dorsi

muscle.
FIGURE 133.1 Trapezius anatomy. The relationship of the three functional portions of the trapezius muscle to
the vascular supply to the trapezius is demonstrated. The location of the anterior and posterior skin islands is
shown.
The vascular supply consists of a dominant pedicle and several minor pedicles (Figs. 133.1, 133.2, 133.3B). The
dominant blood supply originates from the transverse cervical artery and vein, a branch of the subclavian artery
or thyrocervical trunk and associated veins. This vascular pedicle courses between the sternocleidomastoid and
the scalenus muscles, crosses the anterior margin of the trapezius, and enters the deep surface of the muscle at
the base of the neck. It then divides into ascending and descending branches that are the basis for the separate
superior and inferior musculocutaneous flaps. The descending branch courses along the deep surface of the
muscle, between the spine and the scapulae, supplying musculocutaneous perforators to the overlying skin. The
ascending branch, which may occasionally arise as a separate branch from the thyrocervical trunk, courses
laterally on the deep surface of the superior portion of the muscle, giving perforating vessels to the overlying skin
just posterior to the clavicle. The average length of this dominant pedicle is 4 cm, with an average diameter of
1.8 mm.
FIGURE 133.2 Trapezius muscle, anterior view. The anterior portion is inserted into the clavicle. The anterior
skin island flap, based on the anterior branch of the transverse cervical artery, is illustrated with its arc of
rotation.
Several minor pedicles also supply this muscle. The largest of these is a branch of the occipital artery (which
arises from the external carotid). It supplies the superomedial portion of the muscle (see Fig. 133.1). This branch
is the basis for McCraw's technique for augmenting the Mutter flap with the upper portion of the trapezius (9). It is

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approximately 3 cm long and 1 mm in diameter.
The remaining minor pedicles consist of perforating branches of the posterior intercostal arteries and veins that
enter the muscle along the midline adjacent to the cervical and thoracic vertebral bodies. These are 1 to 2 cm in
length and 0.5 mm in diameter.
FIGURE 133.3 Lateral view. Both anterior and posterior branches of the transverse cervical artery are illustrated.
The arc of rotation is demonstrated.
A musculocutaneous flap based on these vessels alone has not been described, but these vessels have been
used as the vascular basis for a medially based turnover muscle flap for coverage of the cervicothoracic spine,
similar to the medially based pectoralis major flap used for sternal wound coverage (see Chapter 356).
The nerve supply to the trapezius consists of the spinal accessory nerve (cranial nerve XI) that enters the deep
surface of the muscle about 5 cm above the clavicle and direct branches of the ventral rami of the third and
fourth cervical nerves. The accessory nerve is the primary motor nerve, and it must be preserved if the muscle is
to remain functional. Cervical nerves III and IV provide sensory (proprioceptive) fibers. The cutaneous sensory
nerves to the skin overlying the trapezius consist of the branches of the cervical nerves anteriorly and the
intercostal nerves posteriorly. Because these nerves must be cut during flap elevation, a neurosensory flap is not
possible unless these sensory nerves are connected to preserved sensory nerves at the flap recipient site.
The entire cutaneous territory of the trapezius measures 34 × 28 cm, which includes several centimeters
superiorly and inferiorly beyond the muscle fibers. The cutaneous perforators are located throughout the muscle
surface, but the largest and most consistent occur along the medial aspect 2 to 3 cm from the midline. For clinical
purposes, the entire muscular unit is almost never used.
FLAP DESIGN AND DIMENSIONS
Clinically useful flaps consist of two anterior flaps based on either the ascending branch of the transverse
cervical artery or on the occipital perforating branch with a skin paddle located laterally over the shoulder (see
Figs. 133.1, 133.2, 133.3) and a posterior flap based on the descending branch of the dominant artery with a
vertical skin island located between the spine and the scapula (Figs. 133.1 and 133.4).

FIGURE 133.4 Posterior vertical flap. Flap is raised, exposing the latissimus dorsi and rhomboid muscles. Note
descending branch of the transverse cervical vessel supplying the overlying trapezius muscle. Superior portion
of muscle is left intact to prevent shoulder drop. Arc of rotation is shown for the right side flap.
Anterior Transverse Flap
The arc of rotation of the flap will reach the temporal area (see Figs. 133.2 and 133.3) and across to the midline
floor of the mouth and neck when mobilized as an island on the transverse cervical vessels. Even as a pedicle
flap, it will easily reach into the hypopharynx and laryngeal areas (11, 14). An osteocutaneous flap for mandibular
reconstruction may be elevated by preserving the insertion of the trapezius to the acromion and spine of the
scapula and removing the entire acromion and scapular spine en bloc with the muscle (9).
Posterior Vertical Flap
The posterior trapezius musculocutaneous flap was developed in an attempt to avoid the loss of function of the
superior fibers and thus to maintain proper shoulder position (13) (see Fig. 133.4). This musculocutaneous flap
is based on the middle and inferior portion of the trapezius muscle. The posterior muscle is supplied by the
descending branch of the transverse cervical vessels. The skin island is located between the scapula and the
spine; skin island dimensions may be up to 25 × 8 cm, extending as much as 5 cm below the inferior border of
the scapula. It may be raised as a musculocutaneous flap with skin continuity maintained for defects of the upper
thoracic vertebrae (Fig. 133.5). For defects of the lateral face, neck, and shoulder, a skin island is preferred
(Figs. 133.1, 133.4, and 133.6). The arc of rotation of this flap will extend to the shoulder, upper third of the
posterior scalp, and lateral neck (Figs. 133.4 and 133.7). The skin island will easily reach the anterior floor of the
mouth and anterior midline of the neck.
Variations
When bulk alone is needed in the lateral neck, as in parotidectomy defects or hemifacial microsomia patients, the
posterior muscle alone may be transferred to the neck, although the resulting bulk at the base of the neck may
require delayed revision. Other flaps, such as the sternocleidomastoid or platysma, are often preferred for
smaller defects.
The trapezius can be used as a free flap. However, the accessibility and functional expendability of other flaps,
such as the latissimus dorsi muscle, make the trapezius a poor choice for transfer.
OPERATIVE TECHNIQUE
Anterior Transverse Flap
The flap may be raised as a pedicle from 6 to 10 cm wide and 8 to 30 cm long. This is raised from lateral to

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medial, similar to the cervicohumeral flap (see Chapter 134), raising the distal skin in a subfascial plane until the
midportion of the trapezius muscle is reached. At this point, the muscle is transected and raised with the flap,
severing the dominant pedicle from the attached portion of muscle that is supplied only by the occipital
perforating branches. The skin over the lateral third of the clavicle on this flap is unreliable, and a delay may be
helpful.
FIGURE 133.5 Posterior vertical trapezius musculocutaneous flap for posterior neck coverage. A:
Osteoradionecrosis of cervical vertebral column following failure of local flap coverage. B: Design of posterior
trapezius flap with skin intact. C: Flap is rotated to provide coverage of the cervical defect. Skin graft is required
to cover the upper portion of the defect. D: Healed flap, anterior view. E: Healed flap, lateral view. (From
Mathes, Nahai, ref. 13, with permission.)
A more reliable and versatile flap consists of the entire upper portion of the trapezius muscle based on the
dominant anterior ascending branch of the pedicle, the transverse cervical artery (Figs. 133.1, 133.2, 133.3 and
133.8). This flap is raised as a skin island, with the skin paddle centered over the acromion, extending several
centimeters in all directions as needed. The flap may be raised from lateral to medial, but the preferred method is
medial to lateral (9), especially because this step is frequently done in conjunction with a neck dissection.
The skin island is designed and marked, and a skin incision is made from the medial portion of the island to the
upper neck, paralleling the anterior border of the muscle (Fig. 133.8A). Dissection is carried deep to the anterior
border, identifying and preserving the transverse cervical vessel (Fig. 133.8B). The superior fibers of the muscle

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are then removed from their insertions into the lateral third of the clavicle, the acromion, and the upper portion of
the spine of the scapula. The dissection is carried beneath the distal random portion of the skin island in a
subfascial plane. The upper portion of the muscle itself may be left intact, attached to its origin as a muscle
pedicle (Fig. 133.8C), or it may be divided, resulting in a skin and muscle island supported only by the ascending
branch of the transverse cervical vessels (Fig. 133.8D). In the latter case, the accessory nerves to the remaining
muscle may be preserved if the muscle is transected distal to the site of entrance of the nerve.
FIGURE 133.6 Posterior vertical trapezius island musculocutaneous flap for lateral face coverage. A: Defect
following removal of squamous cell carcinoma of the ear, parotid, and zygoma. B: Design of skin island of
vertical trapezius. C: Healed flap. Note that skin grafts cover exposed inferior muscle fibers. D: Final result
following division of muscle flap at base of neck. (From Mathes Nahai, ref. 12, with permission.)

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FIGURE 133.7 Anterior arc of rotation for posterior vertical trapezius musculocutaneous flap.
The donor area usually will require a skin graft. Only the smallest skin island will allow primary closure in this
area.
Posterior Vertical Flap
This flap is best raised from inferior to superior (distal to proximal). Flap elevation begins by dissecting the
extended portion of the skin flap off the upper fibers of the latissimus dorsi (see Fig. 133.4). When the inferior
border of the trapezius is identified, it is elevated with the flap, dividing its vertebral origin. At the level of the
scapula, care must be taken to avoid raising the rhomboid muscles with the flap, which would lead beneath the
scapula. The descending branch of the vascular supply will be visualized on the undersurface. The muscle is
divided at the lateral edge of the skin paddle, taking care to preserve the uppermost fibers between the skull and
clavicle, which are responsible for shoulder elevation.
The donor defect usually may be closed primarily. Nevertheless, muscle bulk at the base of this flap is often
aesthetically objectionable (see Fig. 133.6C); therefore, debulking or division of this muscle pedicle is frequently
necessary. This is done after a delay of 3 to 4 weeks in healthy recipient beds and 6 to 8 weeks in irradiated
wounds.
FIGURE 133.8 Dissection of anterior transverse flap. A: Skin incision is made along the anterior border of
trapezius. The trapezius muscle is exposed along with the transverse cervical vessels. Skin incision is made over
skin paddle. B: Dissection is performed in a subfascial plane over the acromion, dissecting beneath the trapezius
muscle. The posterior descending branch of the transverse cervical artery is ligated. C: The skin island is now
elevated along with the intact superior portion of trapezius muscle. D: The fibers of origin of the superior
trapezius muscle may be completely divided, maintaining only the continuity of the vascular pedicle, if a wider arc
of rotation is desired.
CLINICAL RESULTS
The primary disadvantage of the anterior trapezius flap is the potential shoulder-drop deformity and the
continuity of the donor-site defect with the neck wound of a radical neck dissection.
Complications may arise from errors in planning or technique. The most common planning error in raising
trapezius flaps relates to their blood supply. The dominant pedicle, the transverse cervical artery, is
frequently divided during head and neck procedures or is damaged by local radiation treatment to the neck
area. If doubt exists as to the integrity of this vessel, an arteriogram should be obtained. If an anterior
trapezius flap is based on the occipital perforating branches (augmented Mutter flap), the skin portion is less
reliable and flap delay may be necessary for extension beyond the lateral third of the clavicle.
Technical errors most often occur when elevating the posterior flap. Care must be taken to avoid dissection
beneath the rhomboid muscles. In addition, the spinal accessory nerve to the upper portion of the muscle

must be preserved. Constrictive dressings around the neck must be avoided.
SUMMARY
Trapezius muscle and musculocutaneous flaps are extremely useful for reconstructing defects of the head
and neck, upper posterior thorax, and anterior neck.
References
1. Mutter TD. Case of deformity from burns, relieved by operation. Am J Med Sci 1842;4:66.
2. Zovickian A. Pharyngeal fistulas: repair and prevention using mastoid occiput based shoulder flaps. Plast
Reconstr Surg 1957;19:355.
3. Chretien PB, Ketcham AS, Hoye RC, Gertren HR. Extended shoulder flap and its use in reconstruction of
defect of the head and neck. Am J Surg 1972;118:752.
4. Robson MC. The undelayed Mutter flap in head and neck reconstruction. Am J Surg 1976;132:472.
5. McCraw J, Dibbell D, Carraway J. Experimental definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:212.
6. McCraw J, Dibbell D, Carraway J. Clinical definition of independent myocutaneous vascular territories.
Plast Reconstr Surg 1977;60:341.
7. Demurgasso F. Reconstruction con colgajo osteo cutaneous trapecial en reseccion mandibulares
segmentarias por cancer de cabeza y cuello. Presented at the Premio Anual, Sociedad Argentina de
Patologia de Cabeza y Cuello, Buenos Aires, 1977.
8. Demurgasso F, Piazza M. Trapezius myocutaneous flap in reconstructive surgery of head and neck
cancer: an original technique. Am J Surg 1979;138:533.
9. McCraw JB, Magee WP, Jr., Kalwaic H. Uses of the trapezius and sternocleidomastoid myocutaneous flap
in head and neck surgery. Plast Reconstr Surg 1979;63:49.
10. Bertolti JA. Trapezius musculocutaneous island flap in the repair of major head and neck cancer. Plast
Reconstr Surg 1980;65:16.
11. Mathes SJ, Vasconez LO. Head, neck and truncal reconstruction with the myocutaneous flap: anatomical
and clinical considerations. In: Transactions of the Seventh International congress of Plastic and
Reconstructive Surgeons, 1979. São Paulo, Brazil: Cartgraf, 1980;178-182.
12. Mathes SJ, Nahai F. Muscle flap transposition with functional preservation: technical and clinical
considerations. Plast Reconstr Surg 1980; 66:242.

13. Mathes SJ, Nahai F. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979.
14. Mathes SJ, Nahai F. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982.

Chapter 134
Cervicohumeral Flap
E. A. LUCE
The musculocutaneous “revolution” in reconstructive surgery has allowed refinement of the principle of primary
reconstruction of head and neck defects following extirpative cancer surgery. The cervicohumeral flap was
designed as an extension of the trapezius flap for reconstruction in the midface, oral cavity, neck, and anterior
chest.
INDICATIONS
At present, I limit the use of the cervicohumeral (and trapezius) flap to coverage of anterior cervical defects
or to situations where other alternatives are not available (see Fig. 134.5). In most head and neck cancer
patients, I prefer the modified pectoralis major island flap (1, 2) as the “workhorse” in head and neck
coverage.
ANATOMY
The cervicohumeral flap is based on the posterior shoulder and supraclavicular region, extends across the
acromioclavicular joint, and continues down the lateral aspect of the arm (Fig. 134.1). The axis of rotation, and
presumably the blood supply, is the trapezius muscle (3, 4). The dominant vascular pedicle to the trapezius is the
transverse cervical artery, although branches (probably minor in significance) are contributed by the occipital
artery proximally, the superficial cervical artery in the midportion of the muscle, and branches of the
suprascapular in the distal portion (3).
Beyond the distal insertion of the trapezius, the skin over the deltoid on the lateral proximal arm is supplied by
the posterior circumflex humeral artery. This skin, when included with the trapezius musculocutaneous unit and
with sacrifice of the posterior circumflex humeral artery, is random in blood supply. The skin distal to the insertion
of the deltoid probably is derived from the lateral head of the triceps and the biceps-triceps intermuscular septum
(5).
FLAP DESIGN AND DIMENSIONS
The cervicohumeral flap has been described as reliable when raised undelayed with a length-width ratio of 3:1.
The flap has been centered over the acromioclavicular joint and extended down the anterolateral arm. On
occasion, the flap has been extended to a distance of 30 cm, although not with consistent success.
The wide arc of rotation of the flap (Fig. 134.2) has permitted reconstruction of a wide variety of defects in the
past, including the oral cavity, midface and cheek, temple, and neck (Fig. 134.4); however, the flap has not been
as consistent and reliable as initially anticipated (5) (Fig. 134.3).
OPERATIVE TECHNIQUE
My standard procedure has been to perform a preliminary delay 10 days prior to definitive rotation of the
cervicohumeral flap. This initial delay consists of parallel incisions of the distal 10 to 12 cm of the flap with
subfascial undermining of the included skin. This delay ligates the posterior circumflex humeral artery. Definitive
rotation of the flap requires mobilization proximally to the acromioclavicular joint, including detachment of the
trapezius muscle from the spine of the scapula. The arm donor site has been skin grafted in every case (Figs.

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134.4 and 134.5).
Clearly, if an associated radical neck dissection is necessary, care must be taken to identify the transverse
cervical artery at the base of the neck. In my experience, the course of this artery
varies from patient to patient, and at times I have identified the artery as high as 5 or 6 cm superior to the
clavicle.
FIGURE 134.1 Dominant and minor blood supplies to the trapezius and cervicohumeral flap.
FIGURE 134.2 Arc of rotation of the flap.
CLINICAL RESULTS
I reviewed my experience over a 16-month period with use of the cervicohumeral flap for coverage of head
and neck defects and compared the results to the standard flap in use at that time, the deltopectoral flap.
The location of the lesion, the nature and extent of the resection, the use of radiotherapy, the length of the
flap, and outcome were tabulated. A comparison was made between the cervicohumeral and the
deltopectoral flap when used for similar reconstructive needs.
The cervicohumeral flap was used in 15 patients during the 16-month period for reconstruction of head and
neck defects following cancer resection in patients aged 32 to 91 years. All flaps had prior delay. Ten of the
15 patients had radical neck dissections, and two patients had previous radiotherapy. Necrosis of the
cervicohumeral flap occurred in six patients (40%). Three major sloughs required alternative methods of

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coverage, and three tip sloughs had wound disruption that required advancement reinsertion of the flap.
Age of the patient, location of lesion, or associated radical neck dissection did not influence flap survival.
FIGURE 134.3 Limits of the cervicohumeral flap.
During the same time period, 10 deltopectoral flaps were used for similar reconstruction, and flap necrosis
occurred in two patients.
The determining factor in survival of the cervicohumeral flap was the length of the flap. Extension of the
cervicohumeral flap beyond the distal insertion of the deltoid at the middle or proximal third of the humerus
was associated with a high probability of flap necrosis despite prior delays. Experience has indicated that
proximal mobilization of the trapezius muscle is preferable to distal skin extension (Fig. 134.3).
SUMMARY
The cervicohumeral skin flap can be used to reconstruct various head and neck defects; however, the flap
should not be extended beyond the insertion of the deltoid.
FIGURE 134.4 A: Level IV malignant melanoma of the cheek diagnosed by excisional biopsy. Wide skin
excision, superficial parotidectomy, upper neck dissection. A cervicohumeral flap was mobilized on the right
shoulder. B: Patient 6 months postoperatively. C: Donor site on upper arm and shoulder.

FIGURE 134.5 A: Chondroradionecrosis of the larynx with skin ulceration. Defect after partial laryngectomy
and wide excision of ulcer and surrounding damaged skin. B: Outline of cervicohumeral flap that extends to
the insertion of the deltoid only. C: Result several weeks following retrieval of flap.
References
1. Ariyan S. The pectoralis major myocutaneous flap. Plast Reconstr Surg 1979;63:73.
2. Luce EA, Gottlieb SE. Versatility of a pectoralis major flap in head and neck reconstruction. Movie
presented at the Annual Meetings of the American Society of Plastic and Reconstructive Surgeons, New
Orleans, La., October 1980, and the Society of Head and Neck Surgery, Marco Island, Fla., April 1982.
3. Mathes SJ, Vasconez LO. The cervical humeral flap. Plast Reconstr Surg 1978;61:7.
4. McCraw JB, Magee WP, Kalwaich H. Uses of the trapezius and sternocleidomastoid myocutaneous flaps
in head and neck reconstruction. Plast Reconstr Surg 1979;63:49.
5. Blevins PK, Luce EA. Limitations of the cervical humeral flap in head and neck reconstruction. Plast
Reconstr Surg 1980;66:220.

Chapter 135
Pectoralis Major Muscle and Musculocutaneous Flaps
S. ARIYAN
EDITORIAL COMMENT
This is one of the most significant musculocutaneous flaps for head and neck reconstruction. It is extremely
versatile and has a hardy blood supply. The aesthetic appearance of the donor scar can be minimized by
using the parasternal paddle, allowing for a curving midline scar with a transverse extension. This scar in
women is almost completely hidden by the overlying breast.
The pectoralis major muscle and musculocutaneous flaps are reliable flaps that can be used for various head
and neck defects (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11).
INDICATIONS
The pectoralis major musculocutaneous flap can be used to reconstruct the oropharynx or the defect left
after orbital exenteration or temporal bone resection as well as for mandibular reconstruction. (See Chapter
218 for reconstruction of the esophagus and Chapter 407 for chest wall reconstruction.)
Oropharynx (1, 2, 3, 4, 5, 6)
In most cases, tumors of the floor of the mouth or lateral tongue can be reconstructed by other flaps, such
as the sternocleidomastoid, platysma, nasolabial, or tongue flaps. If the surgical wound is larger than these
flaps can cover, however, more tissue can be provided with the pectoralis major musculocutaneous flap,
with either a single skin paddle, two skin paddles in tandem (Fig. 135.1), or two split-skin paddles side by
side (Fig. 135.2). Previously, reconstructions of the tongue and piriform sinus with forehead flaps or
deltopectoral flaps did not provide sufficient bulk. These cutaneous flaps are relatively thin flaps, and
reconstructions using them often led to a “funnel” that directed fluids toward the laryngeal airway, frequently
leading to aspiration of fluids.
Resection of the lateral floor of the mouth, alveolar ridge, posterior half of the tongue, and piriform sinus
requires sufficient skin and bulk for reconstruction. This can be achieved with a pectoralis major
musculocutaneous flap in one stage. The bulk provided by this flap appears to be sufficient to avoid
aspirations, either by directing fluids past the airway or by diverting fluids to the contralateral normal piriform
sinus, as a result of fullness on the operated side.
Orbital Exenteration
The wound resulting from an orbital exenteration has been reconstructed by a variety of flaps, including
forehead flaps (12) and temporalis muscle flaps (13, 14, 15, 16). The pectoralis major musculocutaneous
flap is particularly useful for reconstruction in this area because it provides bulk and well-vascularized tissue
to fill the cavity, to seal cerebrospinal fluid (CSF) leaks, and to provide greater protection against bacterial
invasion (1, 2, 3).
Temporal Bone Resection
Resections of malignant tumors of the external auditory canal and mastoid can cause significant disability
because of the proximity of the disease to the brain, the major dural sinuses, the carotid artery, and the

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cranial nerves, or because of the surgical treatment necessary to control the malignancy. Adequate tumor
resection often has been compromised because of the complexity of the surgery as well as the difficulty of
the reconstruction. In addition, these wounds often have been complicated by CSF leaks and bacterial
contamination.
Because these cancers are otherwise uniformly fatal, treatment should consist of a radical en bloc resection
of the tumor and temporal bone, together with a full course of postoperative radiation therapy (17, 18).
Although these wounds have been covered with rotation scalp flaps and deltopectoral flaps, the pectoralis
major musculocutaneous flap is ideal for these reconstructions because it provides sufficient bulk and soft
tissue to cover the dura and seal it against CSF leaks and it provides a rich vascularity to permit
uncomplicated healing despite bacterial contamination of the wounds (19).
Mandibular Reconstruction
Bone grafts often fail to reconstruct a mandibular segment because of the poor vascularity in the recipient
bed resulting
from radiation fibrosis or dermal scarring from previous surgical procedures or injuries.
FIGURE 135.1 A: Double skin paddles in tandem to resurface a through-and-through defect. B: The
proximal paddle is used for the chin, and the distal paddle is used for the floor of the mouth. C: The distal
paddle at 2 weeks.

FIGURE 135.2 A: A split pectoralis major muscle with two side-by-side skin paddles. B,C: These were
used to line and resurface a through-and-through defect of the cheek. D: The lining at 3 weeks.
Because I was able to demonstrate that rib grafts would survive on their periosteal blood supply, I then
employed the pectoralis major musculocutaneous flap, incorporating a segment of underlying rib to
reconstruct a jaw (9). Although this extended pectoralis major flap may be used for reconstruction of
segmental resections of the mandible, it does not appear to be suitable for reconstruction of the entire
mandible.
ANATOMY
Although the thoracoacromial artery had been previously described in the literature as running along the
undersurface of the pectoralis minor muscle, fresh cadaver dissections confirmed the consistent presence of this
vessel along the undersurface of the pectoralis major muscle, with a branch from this vessel to the pectoralis
minor. There are additional arteries to the pectoralis major, namely, the lateral thoracic artery to the lateral and
inferior portions of the muscle, the superior thoracic artery to the clavicular portion, and the intercostal
perforators from the internal mammary artery, providing some supply to the sternal portion of the muscle (2, 20,
21, 22).
Nevertheless, the dominant blood supply is the thoracoacromial artery, a branch of the subclavian, which
traverses laterally from the midportion of the clavicle for about 4 cm until it reaches the “axis” from the acromion
to the xiphoid, where it then turns and runs along this line (Fig. 135.3). The thoracoacromial artery is
accompanied along its course by its corresponding vein (or two veins) and by one of the motor nerves to the

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pectoralis major muscle, the lateral pectoral nerve (lateral anterior thoracic nerve) (2).
FIGURE 135.3 The various stages in outlining the pedicle, identifying the axial vessels within the subpectoral
fascia, dissecting the skin paddle with a narrow pedicle of only a portion of the muscle, freeing the neurovascular
“island” pedicle, and transporting the flap to the recipient site.
The pectoralis major muscle could be classified, along with the latissimus dorsi muscle, as a type V muscle—a
single dominant vascular pedicle close to the insertion with additional segmental pedicles (22). Flat muscles
(such as the pectoralis major, latissimus dorsi, and trapezius) have a dominant vascular pedicle traveling along
the undersurface of the muscle. These muscles may be split such that only a portion of the muscle need be
elevated with its underlying vessels to provide a reliable muscular pedicle to transport portions of overlying skin.
FLAP DESIGN AND DIMENSIONS
Prior to outlining the skin paddle, the vascular axis must be drawn across the chest from the tip of the shoulder to
the xiphoid (Fig. 135.3). The thoracoacromial artery and vein exit at a right angle from the midportion of the
clavicle until they reach this axis, at which point they proceed inferomedially along this line. The paddle of skin
(or two paddles), in a size and shape to fit the surgical defect, then can be outlined at the appropriate location on
this vascular axis to provide the length to the muscle pedicle necessary to reach the defect. If additional skin is
desired, or if additional length is necessary for the pedicle to reach a cranial defect, the paddle may be extended
farther beyond the pectoralis major muscle. In these
cases, the underlying rectus fascia must be elevated with the pectoralis major muscle.

FIGURE 135.4 The pectoralis major flap may be outlined medial to a ptotic and atrophic breast in the older
patient. This may be done reliably even after a previous harvesting of a deltopectoral flap. (From Ariyan, ref. 4,
with permission.)
FIGURE 135.5 A: In the younger woman, the skin paddle may be taken from the inframammary area after the
breast is completely elevated off the muscle and returned again. B-D: Clinical example. (Periareolar
depigmentation is vitiligo.) (From Ariyan, Cuono, ref. 5, with permission.)
Use of the pectoralis major musculocutaneous flap may pose some problems on the chests of female patients. In
my experience, most of my female patients have been older, and their breasts have been atrophic and ptotic and
lie laterally when the patient is supine (Fig. 135.4). The skin paddle may therefore be outlined on the medial
aspect of the breast skin over the thin parasternal area, where little breast tissue is incorporated in the skin
paddle (4). The skin is then easily advanced to close the donor defect.
In the younger patient who has fuller breasts, thinner inframammary skin is used on the muscle pedicle to

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prevent distortion of the breast (5). After the inframammary skin incision is made, the breast is completely
elevated off the pectoralis major muscle, as in an augmentation mammaplasty (Fig. 135.5).
OPERATIVE TECHNIQUE
Donor Site
Skin Paddle
There are any number of ways to proceed with the dissection whereby the vascular pedicle is identified early to
avoid any
damage to it during the dissection. The method used most often is to incise along the inferolateral portion of the
skin paddle first. The dermis of the skin paddle is sutured to the muscle fascia with several interrupted sutures
along the entire skin paddle as the dissection proceeds around the paddle.
Once the skin is incised along the inferolateral border of the outline, the muscle fibers are split to enter the
subpectoral space. Care must be taken to enter the space deep to the subpectoral fascia; when the muscle is
dissected from this subpectoral fascia, the vascular pedicle in this fascia is separated from the muscle. To do this
safely, the dissection is carried sharply to the ribs before the loose areolar space can be identified. Once this
space is entered, the pectoralis major muscle may be readily elevated with finger dissection. A large retractor is
now placed to elevate the pectoralis major muscle to identify the thoracoacromial vessels in this fascia. With the
vascular pedicle clearly identified, the remainder of the dissection of the flap may be done with relative ease. The
location of the vessels, relative to the dissection site, is frequently checked to avoid inadvertent damage to the
blood supply.
Muscle Pedicle
After the skin paddle has been dissected fully, the size of the muscle pedicle must be determined to complete the
dissection. This pedicle of muscle may be as wide or as narrow as desired, for it merely transports the skin
paddle with the underlying vasculature. If the sternocleidomastoid muscle has been removed in a neck
dissection, the muscle pedicle of the pectoralis major flap is dissected as wide as the contralateral
sternocleidomastoid appears in that patient so that it may serve to replace the missing sternocleidomastoid (2)
and to restore contour and symmetry to the neck. It is rarely necessary to dissect the entire pectoralis major
muscle.
The muscle pedicle is dissected on each side parallel to the vascular pedicle directly up to the clavicle. This flap
is then freed of all its attachments to the clavicle by resecting approximately 4 to 6 cm of the infraclavicular
portion of the muscle, which is left attached only by its neurovascular pedicle as an “island” flap (2, 3). These
vessels should not be skeletonized during the dissection; they should be left with their adventitial and fascial
attachments intact to prevent spasm or traction damage during the postoperative period.
When the flap is brought up to the neck, the portion of the pedicle that rests over the clavicle is then only the thin
neurovascular bundle, with the muscle stump lying above the clavicle. In this manner, an unsightly bulge of
muscle overlying the clavicle is avoided. Additional length may be provided to the pedicle by transecting the
lateral pectoral nerve that tethers the vascular pedicle at this point. If muscle bulk is important (as in the
replacement of a resected sternocleidomastoid), the nerve may be left intact to allow for less atrophy. Otherwise,
it is best to transect the nerve for additional pedicle length and to allow for muscle atrophy and less bulk with the
passage of time.
Chest Skin
Although the skin above the outlined skin paddle on the chest may be incised to lay open the pectoralis major