Vạt Da Và Phẫu Thuật Tái Tạo (Flaps and Reconstructive Surgery)

390
PART 4 — CONVENTIONAL WORKHORSE FLAPS
FLAP USAGE
The supraclavicular flap can be used for resurfacing the
neck and the lower face. It is especially valuable in cases of
burn injury as it provides a large amount of color-matched
skin for reconstruction. The de-epithelialized flap can be
used for soft tissue fill in cases of Romberg disease as well
as vascularized coverage in cases of Frey’s syndrome after
parotidectomy. Subtotal and total esophageal reconstruc­
tion is also possible with a unilateral supraclavicular flap.
Tubing of the flap for total esophageal reconstruction com­
pares well to other flap options when short lengths of esoph­
agus are needed. The supraclavicular flap is also useful for
reconstruction of intraoral defects, ranging from the floor
of mouth to the tonsillar pillars.
POSTOPERATIVE CARE
GENERAL
Postoperatively, the patient should be monitored to main­
tain normal blood pressure and urine output to ensure
adequate tissue perfusion. Adequate analgesia should be
provided.
RECIPIENT SITE
Pressure on the pedicle of the flap should be avoided. This
is especially true for tunneled flaps. Drain tubes, placed at
the time of surgery, should allow evacuation of blood or
serous fluids that might collect and compress the pedicle.
The head of the bed should be elevated, and twisting
motions of the neck should be avoided in the acute postop­
erative period. Arm activities on the side of the flap should
be limited until the drain is removed.
ESOPHAGEAL RECONSTRUCTION PATIENTS
A Gastrografin swallow, followed by a barium swallow is
performed in patients with esophageal reconstruction at 10
days postoperative to ensure complete healing prior to oral
feeding. A feeding tube is placed at the time of surgery prior
to closure of the neoesophagus and removed if the barium
study shows no leak. Any evidence of leak requires feeding
by feeding tube for an additional 2–3 weeks.
INTRAORAL RECONSTRUCTION PATIENTS
Clear liquid diet may be begun within the first few postop­
erative days. Any evidence of salivary leak in the neck
requires NPO status and reevaluation of the intraoral
closure. Feedings by feeding tube proceed until the leak is
closed.
DONOR SITE
In cases of primary closure, the subcutaneous drain is main­
tained until drainage is <30 cm3 per day. Motion of the arm
is limited until the drains are removed. In cases when a skin
graft is utilized, the bolster is maintained for 5 days and
appropriate skin graft care is instituted once removed.
need to be done if the flap is being used as a free tissue
transfer.
FLAP MODIFICATIONS
Any portions of the flap that are tunneled can be safely
de-epithelialized at the primary procedure without affect­
ing flap perfusion. The supraclavicular flap may be com­
pletely de-epithelialized when used for soft tissue fill or
padding. A delay procedure may be performed when the
tissue required extends beyond the deltoid insertion. Pre­
fabrication of the flap can also be performed prior to the
flap transfer when a dual layer reconstruction is needed or
a mucosalized surface is advantageous. In these situations,
a full flap delay should be considered as part of the prefab­
rication process. The volume of skin available with the
supraclavicular flap the can be greatly increased by tissue
expansion. The expander should be placed subfascially
from one of the proposed flap borders.
DONOR SITE CLOSURE AND
MANAGEMENT
The defect over the flap and deltoid can be closed primar­
ily in flaps of ≤7 cm. This can be accomplished with wide
mobilization of the surrounding skin. Care should be taken
with undermining the area of the deltopectoral flap near
the internal mammary perforators. This preserves the del­
topectoral flap as an excellent secondary or salvage flap.
For larger flaps that cannot be closed primarily, skin graft­
ing is recommended. In women, excessive undermining
while mobilization of the chest skin may elevate the breast
compared with the opposite side. This should be discussed
with the patient prior to surgery. Tissue expansion preop­
eratively may preclude the need for a skin graft when
closing the donor site in large flaps. Tissue expansion may
also be used secondarily to remove a skin graft deformity in
this area.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• Consider tubing the flap and performing a secondary
division and inset when tunneling the flap compresses the
pedicle. This is not uncommon in firm irradiated necks.
If tubing is difficult due to flap thickness, consider a
temporary skin substitute on the exposed portions of the
flap for the 7–10 days of delay prior to division and inset.
• Use the Doppler probe and bipolar cautery when dissect­
ing the final few cm of the flap around the pedicle. Do
not skeletonize the supraclavicular vessels when perform­
ing a pedicled flap.
• This is a “cut as you go” flap, and the supraclavicular
pedicle need not be visualized to perform this flap. Once
adequate flap has been elevated to performed the recon­
struction, no further dissection is required.
• Avoided revising dog-ears that are common at the base of
the flap until at least 4 months postoperatively. Debulking
and revising these at the primary procedure can compro­
mise vascularity of the flap.

CHAPTER 33 — Supraclavicular Artery Flap
391
RECIPIENT SITE
Intraoral skin paddles will show atrophy of their skin
appendages waiting contact with saliva for a long time. The
skin will remain intact and serve its function as lining
without problems long term. External skin paddles contour
and stretch well based on stresses applied to the reconstruc­
tion. Color and texture match are usually excellent.
DONOR SITE
A long scar extending over the shoulder should be expected.
In the long term, there is no functional morbidity associated
with this and as the scar phase over time, cosmesis can be
acceptable.
CONCLUSIONS
The supraclavicular artery island flap demonstrates a signifi­
cant advantage in technical ease, operative time, and patient
cost compared with traditional regional/microsurgical free-
flap techniques with similar outcomes, versatility, and mor­
bidity. The supraclavicular artery flap is applicable across all
patient populations, especially those whose medical comor­
bidities limit more complex reconstructions. The supracla­
vicular flap has evolved to be an acceptable alternative for
the reconstruction of skin and intraoral defects, cervical
esophageal defects, neck contractures after burns, general
facial resurfacing, restoration of facial contour deformities,
and chest wall applications such as tracheal-stomal recon­
struction. Its main advantage is its thin well-vascularized
nature with good facial color match and a donor site that
can close primarily with minimal morbidity.
OUTCOMES
GENERAL
It is anticipated that a properly executed flap should survive
completely and its donor site should heal uneventfully.
UNTOWARD OUTCOMES
GENERAL
The incidence of flap failure is small. Common complica­
tions include donor and recipient wound dehiscence, sali­
vary leak, and partial flap loss.
RECIPIENT SITE
The loss of a portion of the distal flap can occur when the
flap design exceeds the angiosome of the supraclavicular
artery. When used a pedicle flap, debridement and further
flap dissection and advancement should be considered.
When ischemia is suspected at the initial procedure by clini­
cal exam or laser angiography, a delay should be considered
(Video 33.1).
DONOR SITE
With primary closure a noticeable scar will be present. Due
to tension and motion of this area, it is not uncommon for
the scar to spread. Certain patients may be susceptible to
keloids on the chest wall. The skin graft to donor site has
poor aesthetics. Secondary surgeries can be performed to
remove the skin graft.
LONG-TERM OUTCOMES
GENERAL
This thin fasciocutaneous flap will nicely contour to the
underlying substructures over time and provide functional
closure for previously mucosalized surfaces. Dog-ears
created by flap rotation may also resolve over time.

392
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 33.4  The 6 cm operative defect after resection of cheek
skin and underlying parotid. The modified neck dissection removed
lymph nodes from levels II to IV.
Figure 33.5  Operative plan and flap design. The large dotted
triangle denotes the SCM anterior, clavicle inferior, and trapezius
posterior. The dotted line bisecting the triangle is the external
jugular vein. “Xs” denote Doppler points within the triangle. Note
the mid-axis of the flap bisects the deltoid and its insertion into the
humerus.
Figure 33.6  Transillumination of the flap during elevation helps
visualize the axial pedicle and protect it.
A 69-year-old man with a squamous cell carcinoma of the left
cheek requiring resection of cheek skin and underlying parotid
duct. He also had a modified neck dissection through a separate
neck incision. The posterior triangle of the neck was not dis-
sected and patient had comorbidities precluding the use of a
free flap. Because of this, a supraclavicular flap was performed.
CASE 33.1  Cheek Skin Defect Reconstructed with a Pedicled Supraclavicular Skin Flap
Figure 33.7  Dissection of the proximal flap stops when adequate
flap length has been attained.

Figure 33.8  In this case, a pedicled flap was used to avoid com­
pression of the pedicle and further dissection of the neck. The
exposed raw surface was covered with Biobrane on pedicle,
Integra at the base. Donor site was closed primarily with wide
subcutaneous undermining.
Figure 33.9  At 2 weeks, testing the blood supply with a tourni­
quet prior to division of the pedicle. Normal color is maintained so
the pedicle was divided. If white or purple, further delay of the
division would be required.
Figure 33.10  After division and inset. Some of the pedicle was
returned to the supraclavicular area for best aesthetics.
Figure 33.11  At a 5-month follow-up of the supraclavicular flap
donor site with acceptable aesthetics.
Figure 33.12  At a 5-month follow-up of cheek result, 4 months
after adjuvant XRT.
CASE 33.1  Cheek Skin Defect Reconstructed with a Pedicled Supraclavicular Skin
Flap—cont’d

394
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 33.15  After inset of the flap. The donor and recipient sites
were connected and the flap was directly inset into the neck,
adding tissue to the contracted neck. The flap was passed via
subcutaneous tunnel to the intraoral defect. The intervening flap
between neck and intraoral skin paddles was de-epithelialized.
A 60-year-old woman with previous intraoral squamous cell
cancer treated with surgery and postoperative XRT. She recurred
and needed intraoral lining of the floor of mouth. Her neck was
scarred and tight from previous surgery and XRT. A supraclavicu-
lar artery flap was planned to both reconstruct the defect and
release the neck tightness.
CASE 33.2  Intraoral Cheek Lining Defect Reconstructed with a Pedicled Supraclavicular Flap
Figure 33.13  After intraoral resection and neck dissection.
Planned flap is marked. The dotted lines denote the triangle and
the “X” marks the Doppler point.
Figure 33.14  The flap is elevated and degree of reach
demonstrated.

CHAPTER 33 — Supraclavicular Artery Flap
395
Access further reading online at http://
expertconsult.inkling.com
Expert Commentary 
Michael W. Chu, MD, and Ernest S. Chiu, MD
The supraclavicular artery flap is most often used as a ped-
icled fasciocutaneous flap for head and neck defects, and is
unique because its source vessel is above the clavicles. It
was previously criticized for high incidence of distal tip
necrosis and fell out of favor until better anatomic studies
and understanding of the limitations of the supraclavicular
flap improved success rates and popularized it again.
The supraclavicular artery flap is a thin, pliable flap with
good color and texture match for head and neck defects. It
also avoids microsurgery expertise when used as a pedicled
flap and has minimal donor site morbidity. Even in patients
who have had prior cervical lymphadenectomies or radiation,
the supraclavicular artery is often intact because the thyro-
cervical trunk is not routinely ligated during neck dissections
and is protected by the clavicle bone during radiotherapy.
The limitation of the supraclavicular flap, as with all pedi-
cled flaps, is distal tip perfusion, which is often the part of
the flap that is most critical for successful reconstruction.
Another concern is possible injury of the pedicle from prior
neck dissections and radiation therapy, which is common in
patients who present with head and neck defects. Preopera-
tive imaging should be performed to ensure patency of the
pedicle when there is concern for vascular injury.
Locoregional flap alternatives, such as pectoralis, delto-
pectoral, and trapezius flaps are bulkier and have increased
donor site morbidity. Skin grafts are another option but do
not restore volume or import vascularized tissue to promote
wound healing or provide robust coverage of essential struc-
ture in the neck. Free flap alternatives require prolonged
operative times and hospitalization, microsurgical capabili-
ties, and are challenging in vessel-depleted, radiated necks.
The supraclavicular artery flap avoids many of these issues.
The supraclavicular artery flap is best for defects that
require a thin, pliable flap. The distal tip of the flap is the most
watershed and potentially ischemic. Careful planning must
ensure a flap design, arc of rotation, and inset that does not
exceed the limits of flap perfusion and can be closed primar-
ily. The supraclavicular flap has become our regional flap of
choice.

CHAPTER 33 — Supraclavicular Artery Flap 395.e1
FURTHER READING
Anand AG, Tran EJ, Hasney CP, et al. Oropharyngeal reconstruction
using the supraclavicular artery island flap: a new flap alternative.
Plast Reconstr Surg 2012;129(2):438–41.
Chiu ES, Liu PH, Baratelli R, et al. Circumferential pharyngoesopha­
geal reconstruction with a supraclavicular artery island flap. Plast
Reconstr Surg 2010;125(1):161–6.
Chiu ES, Liu PH, Friedlander PL. Supraclavicular artery island flap for
head and neck oncologic reconstruction: indications, complications,
and outcomes. Plast Reconstr Surg 2009;124(1):115–23.
Cordova A, Pirrello R, D’Arpa S, et al. Vascular anatomy of the supra­
clavicular area revisited: feasibility of the free supraclavicular perfora­
tor flap. Plast Reconstr Surg 2008;122(5):1399–409.
Di Benedetto G, Aquinati A, Balercia P, et al. Supraclavicular island
fascial flap in the treatment of progressive hemifacial atrophy. Plast
Reconstr Surg 2008;121(5):247e–50e.
Dulguerov P, Quinodoz D, Cosendai G. Prevention of Frey syndrome
during parotidectomy. Arch Otolaryngol Head Neck Surg
1999;125:833–9.
Epps MT, Cannon CL, Wright MJ, et al. Aesthetic restoration of paroti­
dectomy contour deformity using the supraclavicular artery island
flap. Plast Reconstr Surg 2011;127(5):1925–31.
Guo L, Pribaz JJ. Preexpanded ultra-thin supraclavicular flaps for (full-)
face reconstruction with reduced donor-site morbidity and without
the need for microsurgery (Discussion). Plast Reconstr Surg 2005;
115:1845–7.
Guo L, Pribaz JJ. Clinical flap prefabrication. Plast Reconstr Surg
2009;124(6S):e340–50.
Harii K, Ebihara S, Ono I, et al. Pharyngoesophageal reconstruction
using a fabricated forearm free flap. Plast Reconstr Surg 1985;75:46.
Moustoukas M, Chan JW, Friedlander PL, et al. Sternal wound coverage
using the supraclavicular artery island flap. Plast Reconstr Surg
2012;129(3):585e–6e.
Orgill DP, Ogawa R. Current methods of burn reconstruction. Plast
Reconstr Surg 2013;131(5):827e–36e.
Pallua N, Machens HG, Rennekampff O, et al. The fasciocutaneous
supraclavicular artery island flap for releasing postburn mentosternal
contractures. Plast Reconstr Surg 1997;99:1878–85.
Pallua N, Magnus NE. The tunneled supraclavicular island flap: an
optimized technique for head and neck re-construction. Plast Recon­
str Surg 2000;105:842–54.
Pallua N, von Heimburg D. Pre-expanded ultra-thin supraclavicular
flaps for full face reconstruction with reduced donor-site morbidity
and without the need for microsurgery. Plast Reconstr Surg
2005;115:1837–45.
Persichetti P, Aveta A, Segreto F. Combined use of acellular dermal
matrix and supraclavicular artery island flap for oropharyngeal
reconstruction. Plast Reconstr Surg 2013;131(4):641e–2e.
Reece GP, Schusterman MA, Miller MJ, et al. Morbidity and functional
outcome of free jejunal transfer reconstruction for circumferential
defects of the pharynx and cervical esophagus. Plast Reconstr Surg
1995;96:1307.
Song B, Zhao J, Guo S, et al. Repair of facial scars by the free expanded
deltopectoral flap. Plast Reconstr Surg 2013;131(2):200e–8e.
Topalan M, Guven E, Demirtas Y. Hemifacial resurfacing with prefab­
ricated induced expanded supraclavicular skin flap. Plast Reconstr
Surg 2010;125(5):1429–38.
Vinh VQ, Van Anh T, Ogawa R, et al. Anatomical and clinical studies
of the supraclavicular flap: analysis of 103 flaps used to reconstruct
neck scar contractures. Plast Reconstr Surg 2009;123(5):1471–80.
Yu P, Robb GL. Pharyngoesophageal reconstruction with the anterolat­
eral thigh flap: a clinical and functional outcomes study. Plast Recon­
str Surg 2005;116:1845.
Zan T, Haizhou L, Gu B, et al. Surgical treatment of facial soft-tissue
deformities in postburn patients: a proposed classification based
on a retrospective study. Plast Reconstr Surg 2013;132(6):
1001e–14e.

396
INTRODUCTION
The pectoralis major myocutaneous flap for reconstruction
was first described in 1968.1 Its application in the head and
neck region, however, was not reported until Ariyan’s pub­
lication in 1979.2 The reliability and versatility of this flap
were subsequently confirmed by many other reports.3,4
During the 1980s and early 1990s, before the era of the
microvascular free tissue transfer, the pectoralis major myo­
cutaneous flap had been considered as the workhorse
reconstruction option following tumor extirpation in the
head and neck region. Even in recent years, in institutes
where microvascular free tissue transfer is not available, the
pectoralis major myocutaneous flap remains to be one of
the primary reconstruction options.5,6
Pectoralis Major Flap
William Ignace Wei  |  Chan Yu Wai
34 
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION B  —  LOCAL AND FREE FLAPS IN THE CHEST
Figure 34.1  Pectoralis major flap.
Pectoralis major
Deltoid
Trapezius
Sternocleidomastoid
Internal
mammary
artery (IMA)
Lateral thoracic
artery
Pectoral branch of
thoracoacromial artery
Subclavian artery
Axillary artery
Lateral pectoral nerve
Medial pectoral
nerve
Pectoralis minor
Thoracoacromial artery
Brachial plexus
Perforating
branches
of IMA
Anterior cutaneous
branches of
intercostal nerves
Deltoid branch of
thoracoacromial artery
Thoracodorsal nerve
Long thoracic nerve
Clavicular branch of
thoracoacromial artery
Acromial branch of
thoracoacromial artery
Pectoral branch of
lateral thoracic artery

Intercostal arteries

(perforating
branches)

CHAPTER 34 — Pectoralis Major Flap
397
fascia. It has four branches: acromial, humeral, clavicular,
and pectoral.
Dominant to the Clavicular Head:  clavicular branch of the
thoracoacromial artery
Length: 1 cm (range 0.5–1.5 cm)
Diameter: 2 mm (range 1.5–2.5 mm)
The clavicular artery is the relatively smaller branch of
the thoracoacromial axis. It comes out of the groove
between the clavicular and sternocostal heads of the pec­
toralis major muscle and runs on the undersurface of the
clavicular head of the muscle, which it supplies. It also
supplies the subclavius muscle and soft tissue around the
clavicle.
The clavicular artery is the branch that is most frequently
subjected to anatomic variations. From a cadaveric dissec­
tion study, 62% of the clavicular arteries arose together with
the pectoral and the deltoid branches, forming a trifurca­
tion from the thoracoacromial axis. In the remaining cases,
the clavicular arteries might arise from the axillary artery,
the thoracoacromial trunk proximal to the main bifurca­
tion, the pectoral artery, the deltoid artery, and the acromial
artery.7
Dominant to the Sternocostal Head:  pectoral branch of the
thoracoacromial artery
Length: 4.5 cm (range 3–5.5 cm)
Diameter: 2 mm (range 1.5–2.5 mm)
The pectoral artery is one of the dominant branches of
the thoracoacromial artery. It pierces the clavipectoral fascia
medial to the tendon of the pectoralis minor muscle and
comes out at the groove between the clavicular and the
sternocostal heads of the pectoralis major muscle. It then
runs in a cephalocaudal direction on the undersurface
of the muscle plastered to it by its fascial envelope. The
vessel communicates with the intercostal branches of the
internal mammary artery and also the lateral thoracic artery.
It gives off muscular branches to supply almost exclusively
the sternocostal portion of the muscle, as well as multiple
cutaneous perforating arteries to supply virtually the entire
ipsilateral chest wall.
Minor:  pectoral branch of the lateral thoracic artery
Length: 3.5 cm (range 3–4 cm)
Diameter: 2 mm (range 1.5–2.5 mm)
The pectoral branch of lateral thoracic artery emerges
below the clavicle and pierces the clavipectoral fascia lateral
to the tendon of the pectoralis minor muscle, passing along
its lateral border for 4–5 cm before running on the under­
surface of the pectoralis major muscle, 3–4 cm lateral to the
pectoral branch of the thoracoacromial artery. It anastomo­
ses with the internal thoracic, subscapular, intercostal arter­
ies and the pectoral branch of the thoracoacromial artery.
In females, the lateral thoracic arteries also give off branches,
which pass around the lateral border of the pectoralis major
muscle supplying the breast.
Figure 34.2  Postmortem specimen of the left pectoralis major myo­
cutaneous flap showing the groove (arrow) between the clavicular (C)
and sternocostal (S) heads. The skin island (Skin) is attached to the
muscle.
FLAP ANATOMY (see Ch. 11 and Figs 11.1,
11.2, 11.3, 11.5, 11.8 and 11.9)
The pectoralis major muscle is a thick, fan-shaped muscle,
situated on the upper chest that provides adduction and
internal rotation of the arm (Fig. 34.1). It has four sites of
origin: first, the anterior surface of the medial half of the
clavicle; second, the lateral half of the anterior surface of
the manubrium and the sternum extending inferiorly to
where the 6th or 7th costal cartilages are attached; third,
the costal cartilage from the 2nd to the 6th rib; and fourth,
the aponeurosis of the external oblique muscle. From this
wide origin, the muscle fibers converge laterally toward the
insertion. Those fibers arising from the clavicular portion
pass obliquely downward and laterally and are separated
from the sternocostal portion by a groove; the fibers from
the sternocostal head pass laterally and upward (Fig. 34.2).
They join to form a 5 cm flat tendon, which is inserted into
the crest of the greater tubercle of the humerus.
The pectoralis muscle along with its tendon provides the
natural look of the anterior axillary fold. The pectoralis
minor muscle, which originates on the anterior surface
of the 3rd–5th ribs and inserts on the coracoid process of
the scapula, lies deep to the pectoralis major muscle. It
functions in drawing the scapula downward and forward.
The anterior serratus muscle, and the intercostal muscles
are present deep to the pectoralis muscles. Superiorly,
the pectoralis muscle borders the deltoid muscle. The
skin of the anterior chest is pliable and matches that of
the face. In females, the breast occupies a large portion
of the subcutaneous tissue overlying the pectoralis major
muscle.
ARTERIAL SUPPLY OF THE FLAP (Fig. 34.1 and
Figs 11.1, 11.2, 11.3 and 11.5)
The thoracoacromial arterial trunk arises from the second
part of the axillary artery and pierces the clavipectoral

398
PART 4 — CONVENTIONAL WORKHORSE FLAPS
The venous drainage of the pectoralis major muscle is
located on the undersurface of the muscle. They may
form one or two venules and accompany the pectoral
branch of the acromio-thoracic arterial trunk. They subse­
quently drain into the axillary vein. The venous drainage
of the overlying skin is toward the subdermal plexus
where the vessels join to form venules that subsequently
run along the arterial perforators from the pectoralis
major muscle.
Secondary:  venules from the periphery of the pectoralis
major muscle also drain into the branches of the internal
thoracic vein.
The cephalic vein, although drains the skin paddle of the
flap, is not included with the flap during harvest.
FLAP INNERVATION
Sensory:  Anterior cutaneous branches of the intercostal
nerves (2nd through 7th) (Figs 34.1 and 11.2, 11.9).
These nerve branches supply the skin over the anterior
chest wall.
Motor:  lateral and medial pectoral nerves (Figs 34.1 and
11.1, 11.2).
The clavicular head of the pectoralis major and the
anteromedial part of the sternal head of the muscle are
supplied by the lateral pectoral nerve, which originates from
the lateral cord of the brachial plexus. It has a constant
course running lateral to the axillary artery and then paral­
lel to the thoracoacromial axis. The nerve courses on the
deep surface of the pectoralis major muscle for a mean of
55 ± 7 mm, and is visible under the muscle fascia.
The medial pectoral nerve originates from the medial
cord of the brachial plexus and supplies the posterolateral
parts of the sternal head of the pectoralis major as well as
the pectoralis minor muscle. It has a more variable course,
but in most cases it travels medial to the axillary artery,
piercing and supplying the pectoralis minor muscle at the
level of the third intercostal space, at a mean of 10.3 cm
from the margin of the sternum. The mean distance between
the entry of the medial and lateral pectoral nerves into the
pectoralis major muscle is 30.7 ± 10 mm.9
FLAP COMPONENTS
In view of the short pedicle, the pectoralis major muscle is
considered a less favorable muscle for free tissue transfer
compared with other available muscle or myocutaneous
flaps.
The pectoralis muscle can be harvested as a pedicled
muscle flap or it can be harvested together with an intact
skin island on the muscle as a pedicled myocutaneous flap.
The latter is the most frequently used modality of the pec­
toralis flap. The muscle flap may also be harvested attaching
to a segment of the costal cartilage or the lateral portion of
the anterior cortex of the sternum. When a skin island is
included, the former becomes the “costomyocutaneous
flap” and the latter, “osteomyocutaneous flap.”
Advantages
• The vascular supply of the pectoralis major muscle is in
general very constant. It is covered by small amount of
Minor Supplying the Sternocostal Portion:  perforating branches
of the internal mammary artery (1st to 6th intercostal space)
Length: 1.5 cm (range 1–2 cm)
Diameter: 0.6 (range 0.5–1 mm)
The internal mammary perforating arterial branches pass
through the 1st to 6th intercostal spaces to enter the deep
surface of the muscle within 1.5–2.0 cm of the sternal
margin.
Minor:  perforating branches of the intercostal arteries
(5th to 7th)
Length: 1.5 cm (range 1–2 cm)
Diameter: 0.6 (range 0.5–1 mm)
The perforating artery branches of 5th to 7th intercostal
arteries pass through the respective intercostal spaces to
enter the deep surface of the muscle 4–6 cm from the
sternal origin. The row of minor segmental pedicles is
located 2–3 cm lateral to the perforators from the internal
mammary artery.
The main arterial supply of the pectoralis major muscle
is from the branches of the acromio-thoracic arterial
trunk. The clavicular branch supplies the clavicular head
while the pectoral branch is the dominant arterial supply
to the sternocostal head of the pectoralis major muscle. In
some female subjects, the lateral thoracic artery can be
fairly prominent and may contribute a significant portion
of the overall blood supply. All these vessels descend on
the undersurface of the pectoralis major muscle. The per­
forators of the pectoralis major muscle then in turn
supply the overlying skin. There are more perforators sup­
plying the skin paddle situated on the lateral aspect of the
muscle.
The cutaneous perforators supplying the skin paddle of
the flap can be divided into three zones:8
1. Laterally, over the lateral aspect/free border of pectoralis
major muscle, where numerous large musculocutaneous
and direct fasciocutaneous perforators concentrate. Ink
injection studies have suggested that skin paddle could
be extended safely beyond the muscle towards the axilla,
provided the deep fascia is included.
2. Intermediately, over the main bulk of the muscle, where
the musculocutaneous perforators are fine and sparse.
3. Medially, at the parasternal region, where the supply is
indirect via the “captured” territory of the internal
mammary artery perforators. This circulation relies on
intact connections between the pectoral branch of the
thoracoacromial artery and the internal mammary artery
system that exist within the sternocostal head of the pec­
toralis muscle.
VENOUS DRAINAGE OF THE FLAP (see Fig. 11.6)
Primary:  vena comitantes accompanying the arteries
Length: 4.5 cm (range 3–5.5 cm)
Diameter: 2.1 mm (range 0.5–5.0 mm)

CHAPTER 34 — Pectoralis Major Flap
399
The pectoralis flap can be performed for patients of all
ages and in both sexes, although in female patients, the
factors of distortion of breast form and the relative thick
subcutaneous tissue should be taken into consideration. In
obese patients, the excessive thick subcutaneous tissue may
make the pectoralis major myocutaneous flap unsuitable for
reconstruction of some defects such as intraoral defects or
turning the skin paddle into a tube. For intraoral recon­
struction, the pectoralis major muscle can be harvested
alone and split-thickness skin graft is placed on the muscle
to be transposed to the recipient area for reconstruction
(Fig. 34.4).10
For patients with medical comorbidities such as cardiac
or pulmonary diseases, these should be optimized preop­
eratively, as after harvesting the pectoralis major flap, the
chest wound is significant and this might affect the breath­
ing efforts of some patients. This is evidenced by a signifi­
cant decrease in forced vital capacity in 63.6% of patients
after pectoralis major flap harvest.11 Alternative methods of
wound closure, such as skin graft or local transposition
flaps, might be considered when donor defects are large,
soft tissue and is situated clearly among definite tissue
planes, making its isolation relatively easy.
• The pectoralis major muscle as a pedicled flap is well
vascularized and has abundant perforators to supply its
overlying skin. Thus this muscle flap alone or as a myo­
cutaneous flap can stand some degree of manipulation
and survive under less optimal conditions such as when
transferred to an infected or inflamed tissue bed, includ­
ing the contamination of saliva.
• It is located outside the radiation field of the head and
neck region, thus provides healthy tissue for reconstruc­
tion in an irradiated environment.
• The muscle provides adequate tissue bulk for covering
important structures in the neck and for filling tissue
defects in the chest wall or the neck.
• Harvesting of the flap can be performed with the patient
in supine position. Thus for most operations in the head
and neck region or over the chest wall, the resection and
reconstruction can be carried out with the patient in one
position.
Disadvantages
• Occasionally, the defect that requires coverage is small;
the muscle may be too bulky. This is particularly true
when a myocutaneous flap is used, as the thick subcutane­
ous tissue increases the tissue volume. In a female subject,
the presence of breast tissue adds further to this bulk.
• In a female patient, the harvest of the flap distorts the
form of the breast.
• Loss of the entire muscle results in a minor functional
deficit and loss of the anterior axillary fold, which results
in a suboptimal aesthetic appearance.
• The length of the pedicle limits the degree of rotation of
the flap and the distance that the flap can be transferred
to. For head and neck reconstruction, the highest point
that it can reach safely is the zygomatic arch. For chest
wall reconstruction, it can reach as far as the contralateral
anterior axillary line.
• Due to its limited pedicle length and availability of other
muscle flaps, the role of the pectoralis muscle as a free
flap has been minimal.
• Several motor branches supply the muscle; therefore, if
the flap is to be raised as a functional muscle transfer,
all nerves must be coapted in order to attain maximal
function.
PREOPERATIVE PREPARATION
All patients should be examined before raising the flap, any
scar over the chest wall that might interfere with the design
of the flap should be noted, and then the incision for skin
island modified accordingly. The presence of the pectoralis
major muscle should be checked by asking the patient to
tighten the muscle by adduction of the arm. A patient suf­
fering from Poland syndrome has congenital absence of
pectoralis major muscle (Fig. 34.3). For these patients, an
alternative flap should be used for reconstruction.
For patients with a hairy chest wall, the hair should be
removed to expose the skin so that the marking of incision
for the skin island and the chest wall incisions can be clearly
visualized.
Figure 34.3  A patient with Poland’s syndrome; he has congenital
absence of his right pectoralis major muscle.
Figure 34.4  Thick skin paddle is not harvested with the muscle and
a split-thickness skin graft is placed over the muscle (M) to be used
for intraoral reconstruction. Muscle flap with split-thickness skin graft
insetted in the oral cavity.

400
PART 4 — CONVENTIONAL WORKHORSE FLAPS
possible, the skin island should be designed to lie on the
lateral aspect of the muscle where there are more perfo­
rators, particularly when the skin paddle is small. The
reliable lower limit of the skin island size is 5 cm by 7 cm
situated medial to the nipple. The size of the skin island
can be smaller when it is placed lateral to the nipple.
There may be a role for preoperative localization of the
vessels and the perforators using Doppler ultrasound
studies, particularly when a small skin paddle is used in
order to make sure that it contains at least one sizeable
perforator.
2. Pedicled costomyocutaneous flap: the 5th costal cartilage is
identified during the design of the skin flap and marked.
This will avoid inadvertently detaching the pectoralis
muscle origin from the costal cartilage while harvesting
the flap.
3. Pedicled osteomyocutaneous flap: the outer cortex of the
sternum should be marked at the design of the skin flap.
On harvesting the flap, the periosteum and outer cortex
of the sternum should be lifted together with the pecto­
ralis major muscle.
SPECIAL CONSIDERATIONS
The pectoralis major muscle is composed of the clavicular
and sternocostal heads. After harvesting the myocutaneous
flap, the whole pectoralis major muscle together with the
especially in chronic smokers and in those with preexisting
cardiopulmonary disease.
FLAP DESIGN
ANATOMIC LANDMARKS
Superiorly, the pectoralis major muscle is attached to the
clavicle. Medially the landmark (Fig. 34.5) is the lateral
aspect of the anterior surface of the sternum extending
inferiorly to the insertion of the 6th costal cartilage. The
lateral edge of the muscle can be felt as a ridge extending
from the humerus medially and inferiorly to the upper part
of the external oblique muscle.
A line drawn between the acromion and the xiphoid
cartilage marks the axis of the pedicle of the flap.
GENERAL THOUGHTS ABOUT FLAP DESIGN
1. Pedicled myocutaneous flap: the skin island should be
designed to be placed at the appropriate position on the
anterior chest wall so that when the flap is harvested and
turned, it will reach the defect without tension. The
lower the skin island is situated, the higher it will reach
in the head and neck region. To ensure survival of the
entire skin island, the whole area of the skin island
should be situated on the pectoralis major muscle. If
Figure 34.5  Markings of the incision for the skin island and chest wall to allow exposure of the pectoralis major muscle and preservation of
the deltopectoral flap. Lateral design allows for wider arc of rotation. Subcutaneous tissue over the muscle must be included with the flap.
Sternocleidomastoid muscle
Sternum body
Xiphoid
process
Rectus
abdominis
muscle
Tendinous
intersection
Serratus anterior
muscle
External
oblique
muscle
Linea alba
Semilunar line
Umbilicus
Iliac crest
Pectoralis
major muscle
Deltopectoral
triangle
Trapezius muscle
Deltoid muscle
Sternal head
Clavicular head
Anterior
superior
iliac spine
Deltopectoral flap is preserved. Lateral incision is not made (dotted line)
Skin paddle designed laterally
Skin island designed medially
Subcutaneous tissue, which is included with the flap
1
1
2
3
4
3
2
4

CHAPTER 34 — Pectoralis Major Flap
401
portion of the muscle that carries the skin island is required
to be harvested and is included as the myocutaneous flap
(Fig. 34.8).
The skin island should be designed according to the
shape of the defect that it aims to reconstruct. The skin
island usually shrinks about 10% after skin incision. The
dimension of shrinkage is more in young patients, and
adjustments in designing the flap should take this into
consideration.
To extend the length of the flap, the skin island may
be placed more distally maintaining some subcutaneous
tissue over a large part of the muscle more proximally. This
helps to maintain a better venous drainage of the flap
(Fig. 34.5).
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
The design is the same for a free and pedicled flap. If a
longer pedicle is required, the skin island can be designed
over the most distal part of muscle.
FLAP DIMENSIONS
Muscle Dimensions
Length: Average 15 cm (range 12–22 cm)
Width: Average 24 cm (range 21–26 cm)
Thickness: Average 1 cm (range 0.8–1.4 cm)
skin paddle is turned upward to the head and neck region.
The muscle lying over the clavicle will produce a prominent
bulge. The bulkiness of the flap at this point has disadvan­
tages; the swelling besides being unsightly, although with
time it will atrophy, limits the mobility of the pedicle. The
vessels running on the muscle bulk may be stretched when
the muscle swells in the early postoperative period. The
muscle bulge also reduces the distance the flap can reach
superiorly (Fig. 34.6).
This can be avoided when only the sternocostal head of
the pectoralis major is used to carry the skin island and
turned upward to the head and neck region. As blood
supply of the clavicular and the sternocostal heads are sepa­
rate,12 the two heads can be separated by dissecting along
the groove between the two heads. The origin of the pecto­
ral branch as the pedicle of the flap can be identified in the
groove and preserved on the deep surface of the sternocos­
tal head. The clavicular head can be divided along the axis
of the pedicle and the muscle fibers will retract, producing
a triangular gap in the muscle to allow the positioning of
the pedicle of the flap when turned upward to the head and
neck area (Fig. 34.7).
With the elimination of the muscle bulk formed by the
clavicular head, the stretching of the pedicle is reduced and
the length of the pedicle is also increased by 4–6 cm. The
mobility of the myocutaneous flap is also enhanced, so that
the tension exerted at the skin paddle is reduced.
In general, the bulk of the pectoralis major is its main
disadvantage. Thus, while lifting the muscle, only the
Figure 34.6  (A) Line drawing showing the bulge of the muscle over the left clavicle. (B) Clavicular head of the pectoralis major muscle is
intact, planned incision is marked by dotted line. (C) Muscle bulge over the clavicle with the intact clavicular head (arrow).
B
C
A
B
C

402
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Figure 34.7  (A) Line drawing showing the pedicle of the pectoralis major muscle sitting in the gap created by dividing the clavicular head
(arrow). (B) Clavicular head incised and muscle fibers retract to give a triangular space for the pedicle (arrow). (C) Pedicle of the myocutaneous
flap (arrow) sits comfortably in the space that developed following incision of the clavicular head.
A
C
B
Figure 34.8  Incision marking on the muscle showing only the
portion of muscle that carries skin island is included in the myocuta­
neous flap (arrows).
Skin Island Dimensions
Length: Average 12 cm (range 7–30 cm), maximum to close
primarily 8 cm
Width: Average 8 cm (range 5–20 cm), maximum to close
primarily 10 cm
Thickness: Average 1.4 cm (range 0.6–2.5 cm)
The location for easiest closure is where the skin paddle
is placed laterally along the natural skin crease.
FLAP MARKINGS
The skin island should be marked and additional incisions
placed to allow the exposure of the pectoralis major muscle.
This incision, when placed parallel to the clavicle and
extending laterally from the skin island, will preserve the
deltopectoral flap territory while at the same time allow
adequate exposure for raising the pectoralis major myocu­
taneous flap (Figs 34.5, 34.9).
PATIENT POSITIONING
The optimal position of the patient for harvesting the pec­
toralis major flap is the supine position. The patient may

CHAPTER 34 — Pectoralis Major Flap
403
have a sandbag placed behind the shoulder for procedures
in the head and neck region. He can be placed in any posi­
tion that is necessary for the primary procedure; in general
the most common position for surgery of the head and neck
region is the supine position. The flap can be harvested in
the lateral decubitus position with the arm freely mobile but
this is rarely indicated.
ANESTHETIC CONSIDERATIONS
General anesthesia with endotracheal intubation is nor­
mally used for raising the pectoralis muscle or myocutane­
ous flap, as it is generally harvested in a one-stage procedure
together with the resection of the primary pathology. The
flap may also be raised under regional nerve block employed
for mastectomy, such as intercostal nerve block supple­
mented with infraclavicular infiltration to interrupt the
supraclavicular branch of the cervical plexus that provides
sensation to the upper chest wall and subcutaneous infiltra­
tion in the midline to block the nerve supply from the
contralateral side.
TECHNIQUE OF FLAP HARVEST
STERNOCOSTAL HEAD OF THE PECTORALIS
MAJOR MUSCLE
After the incision around the skin island and the lateral
incision, the skin is elevated from the underlying muscle.
Following the elevation of the skin flap laterally, the lateral
border of the pectoralis major muscle is identified, and this
is completely exposed to its insertion inferiorly at the exter­
nal oblique. After the identification of the lateral border of
the pectoralis major muscle, the lateral portion of the
Figure 34.10  Incision of the muscle goes upward until the groove
between the clavicular and the sternocostal portions of the muscle
(arrows).
Figure 34.9  Markings of the pectoralis myocutaneous flap.
muscle is dissected off the chest wall. As there is an avascu­
lar plane between the pectoralis major and pectoralis
minor muscles, it is easy to separate these two muscles. The
vascular pedicle of the pectoralis major muscle is attached
to the undersurface of this muscle and comes up from the
chest wall medial to the medial border of the pectoralis
minor muscle. It can be identified both visually and by pal­
pation of its pulsation. The sternocostal origin of the
muscle is detached and the muscle is divided medial to its
insertion into the humerus. The division of the muscle
goes cephalically until the groove between the clavicular
and the sternocostal heads (Fig. 34.10); the pedicle on the
undersurface of the muscle is safeguarded at all times. The
medial and lateral pectoral nerve that pierce through
the pectoralis minor muscle to supply the pectoralis major
muscle have to be divided to allow elevation of the pectora­
lis major off the chest wall. The lateral pectoral vessel, lying
lateral to the pectoralis minor muscle, is divided so that the
entire sternocostal portion of the pectoralis major muscle
is elevated.
The two heads of the pectoralis major muscle are sepa­
rated by sharp dissection in the groove that separates the
two heads. The groove is deepened until the soft connective
tissue surrounding the vascular pedicle is reached. When
the pectoralis major myocutaneous flap is used to recon­
struct defects on the anterior chest wall, then the pectoralis
major muscle with the skin paddle can be transposed to its
destination (Fig. 34.11).
When the myocutaneous flap has to be transposed to the
head and neck region, then the clavicular head is divided
along the axis of the vascular pedicle until its insertion at
the clavicle. The sternocostal portion of the muscle with its
skin island is then transposed upward; the vascular pedicle
will be sitting in a triangular space created by the edges of

404
PART 4 — CONVENTIONAL WORKHORSE FLAPS
Further dissection proceeds in the submuscular plane with
medial traction on the transected insertion of the clavicular
head. The deltoid artery is identified and ligated. The artery
and the venae comitantes are traced to the thoracoacromial
axis and the pectoral branch to the sternocostal portion of
the pectoralis major muscle is identified and ligated. The
clavicular origin is then separated from the clavicle to com­
plete the flap harvest.
FLAP MODIFICATION/FLAP HANDLING
COSTOMYOCUTANEOUS FLAP
The sternocostal portion of the pectoralis major is not
detached from the 5th costal cartilage. While lifting the
muscle from the chest wall is proceeding cephalically, the
5th intercostal space is identified. Intercostal muscles on
the lateral aspect of the flap are divided just short of the
parietal pleura. A subperiosteal dissection is carried out and
the parietal pleura is separated from the undersurface of
the rib and costal cartilage for the length of the costal car­
tilage that is to be used. Up to 18 cm segment of rib can be
harvested.
The rib cartilage is divided both medial and lateral to
where the pectoralis major muscle is attached and then
reflected upward. The intercostals muscle of the 4th inter­
costals space is also divided and then the 5th costal cartilage
is only attached to the undersurface of the pectoralis major
muscle (Fig. 34.13). The entire costomyocutaneous flap is
now ready to be transposed to the head and neck region for
reconstruction.14 The parietal pleura sometimes is adherent
to the costal cartilage and the blunt dissection may lead to
perforation of the parietal pleura. When the perforation is
small, the lungs are insufflated and the pleural perforation
the split clavicular head following retraction of the divided
muscle fibers (Fig. 34.7).12 In this way the pedicle of the
myocutaneous flap is lengthened as it does not have to arch
over the muscle bulge of the clavicular head. The length of
the vascular pedicle that needs to be isolated should be
enough for it to sit comfortably over the clavicle without
having any bulging or angulation.
In some female patients, the lateral thoracic vessels,
emerging on the lateral border of the pectoralis minor
muscle, may be prominent and contribute significantly to
the blood supply of the pectoralis major muscle.13 This
pedicle can also be preserved by dividing the pectoralis
minor muscle (Fig. 34.12). With this maneuver, all the blood
supply to the muscle can be preserved without compromis­
ing the length of the pedicle.
Despite a good blood supply of the pectoralis major
muscle, its pedicle is short so it is rarely used as a free flap.
CLAVICULAR HEAD OF THE PECTORALIS
MAJOR MUSCLE
The clavicular portion of the muscle can be harvested as a
muscle flap, musculocutaneous flap, or an osseous muscu­
locutaneous flap.
With the patient lying in the supine position, an elliptical
skin island is designed with the long axis parallel to the
clavicle and one to two fingerbreadths inferior to it. The
medial and superior cutaneous margin of the flap is incised,
exposing and preserving the cephalic vein in the deltopec­
toral groove. The supraclavicular nerve may be preserved if
a neurosensory flap is desired. The incision is extended to
expose the anterior lamina of the clavicular head insertion
into the humerus. This is selectively cut. The remaining
inferior cutaneous incision is then completed, exposing the
separation between the clavicular and sternocostal heads.
Figure 34.11  The sternocostal portion of the muscle that carries the
skin paddle is transposed to cover defects on the anterior chest wall.
Figure 34.12  The pectoralis minor muscle is divided between
clamps to preserve the lateral thoracic artery (arrow) supply to the
pectoralis major muscle.

CHAPTER 34 — Pectoralis Major Flap
405
osteotome. The pectoralis muscle now carries the overlying
skin, the muscle insertions, and the underlying segment of
sternum. It is important to insert a few tacking stitches as
required so that the continuity between the skin and the
underlying tissue is not disrupted. The rest of the pectoralis
muscle flap is raised and transferred into the defect as usual.
As only the outer table of the sternum is harvested, it is
associated with lower risk of pleural damage and pneumo­
thorax than when the rib is included (Figs 34.15, 34.16).
TISSUE EXPANSION
Preliminary expansion of the skin or the muscle may be of
occasional value in enlarging the flap or making primary
closure of the donor site easier.
FREE PECTORALIS MAJOR MUSCLE OR
MYOCUTANEOUS FLAP
Its usefulness as free tissue transfer is limited by the pedicle
length.
PEDICLED PECTORALIS FLAP UNDER THE CLAVICLE
To overcome the potential disadvantage due to the bulk of
the flap and limitation in the arc of rotation of pectoralis
major flap, modifications have been made by either remov­
ing a section of clavicle or passing the muscle pedicle deep
to it. The technique involves harvesting the flap in the usual
way and while transferring the flap to the recipient defect,
dissection is continued down to the inferior border of the
subclavius muscle fascia. A spacious subclavicular tunnel is
created and enlarged by blunt dissection to ensure a safe
passage of the pedicle of the flap. Dissection is kept adjacent
to the clavicle and the subclavius muscle is used as protec­
tion to avoid injury to the underlying subclavian vessels or
lung apex. Although this technique may improve the arc of
rotation and increase the reach of the flap to more cephalad
defects, some authors are concerned about the potential
compromise of the flap while the pedicle passes beneath the
clavicle. Reports have shown that there is no significant dif­
ference in flap survival or development of major complica­
tions between supraclavicular and subclavicular route of
flap transfer.16
MUSCLE-PRESERVING METHOD OF FLAP HARVEST
This can be achieved by identifying the pedicle first and
cutting the muscle close to the pedicle, so that the clavicular
portion and the lateral border of the muscle can be pre­
served. Advantages include minimal functional sequelae of
the arm, and no visible depression in the infraclavicular
region or loss of anatomic configuration of the anterior
axillary line.17
REVERSE FLAP/TURNOVER FLAP
The turnover flap based on the minor segmental pedicles
can be used mainly for coverage of defects of the sternum
and mediastinum. The insertion of the muscle to the
humerus is left intact, thereby preserving the anterior axil­
lary fold.
is repaired with primary closure. For larger perforations
(Fig. 34.14), the insertion of a chest drain, together with the
return of the chest wall skin will result in a good primary
healing.
OSTEOMYOCUTANEOUS FLAP
As described by Green et al.,15 this is useful for reconstruc­
tion of composite defects in the head and neck region. The
skin island is designed along and over the sternum. The
incision is carried down to the periosteum of the sternum
so that the attachment of the pectoralis muscle on the ante­
rior part of the sternum is not detached. A longitudinal
incision through the outer table and the cancellous portion
of the sternum is made with a reciprocating saw and
Figure 34.13  The segment of costal cartilage is isolated but still
remained attached to the pectoralis major muscle (arrow). The under­
lying parietal pleura is intact (P).
Figure 34.14  A large perforation of the parietal pleura showing the
lung (arrow). The defect heals well with the return of the chest wall
flap and the insertion of a chest drain.

406
PART 4 — CONVENTIONAL WORKHORSE FLAPS
situated lower in the chest wall, on the other hand, is sup­
plied by the segmental intercostal nerves, which make it
impossible for coaptation.
MULTIPLE SKIN ISLAND FLAP
This may be required when reconstructing compound
defects involving both mucosa and overlying skin. Weaver
et al.18 described a bilobular “Gemini” flap, which includes
two separate skin paddles side by side. Further modification
by harvesting two separate musculocutaneous units from
the same pectoralis major muscle, one depending on the
lateral thoracic artery, while the other is based on the pec­
toral branch of the thoracoacromial artery, as has been
described by Tobin et al.19
CLAVICULAR HEAD OF THE PECTORALIS
MAJOR MUSCLE AS A FUNCTIONAL
MUSCLE TRANSFER
Pectoralis major flap has a role in shoulder disruption inju­
ries where it can be used to wrap around the repaired
glenohumeral joint, permitting a good range of shoulder
movement and restoring shoulder contour. By keeping the
clavicular origin of the muscle intact and transposing it into
the deltoid insertion, it helped in shoulder abduction when
the major abductors were absent.20
EXTENDED PEDICLE FLAP
As mentioned earlier, to increase the reach of the flap, the
clavicular head is divided along the axis of the vascular
pedicle. The sternocostal portion of the muscle with its
SENSORY FLAP
Sensate musculocutaneous flap of the clavicular head of the
pectoralis major flap is made possible by coaptation of the
supraclavicular nerve of the cervical plexus, which supplies
sensation of skin over the upper chest wall. The skin paddle
Figure 34.15  (A) The outer cortex of the sternum is cut with a sharp burr. The attachment of the pectoralis major muscle to the periosteum
is left intact. (B) the outer cortex of the sternum is lifted with the pectoralis major muscle, leaving the posterior cortex behind.
A
B
Figure 34.16  The outer cortex of the lateral part of the sternum
(arrow) is harvested and attached to the pectoralis major muscle as
an osteomyocutaneous flap.

CHAPTER 34 — Pectoralis Major Flap
407
• During the dissection of the pectoralis major myocutane­
ous flap and its transposition to the head and neck region,
care must be exercised in the handling of the skin island.
Traction and shearing should be avoided as these might
injure the perforators, thus reducing blood supply to the
skin island.
• When the skin island over the pectoralis major myocuta­
neous flap is employed for reconstruction of a circumfer­
ential pharyngeal defect, then the skin island will be
turned into a tube and sutured to the oropharynx proxi­
mally and the esophagus distally. To avoid stenosis at the
myocutaneous junction, the skin island should be incised
at two sites to form three flaps. Each of these flaps can be
sutured into the corresponding gaps created on the
esophageal end. This will create a wavy suture line, thus
reducing the circumferential contraction leading to ste­
nosis (Fig. 34.18).22
• For the reconstruction of two epithelial linings, the pec­
toralis major muscle can be elevated and split-thickness
skin graft be laid on its deep surface. The reconstruction
can be done in one stage (Fig. 34.19).
• When the pectoralis major myocutaneous flap is trans­
posed to the neck passing through a subcutaneous tunnel
over the chest wall, the tunnel should be wide enough to
avoid any compression on the muscle (Fig. 34.20).
• We do not use special techniques to avoid injuring the
pedicle during dissection of a muscle-preserving tech­
nique. Direct visualization of the pedicle during flap har­
vesting and muscle cutting remains the best way to avoid
injury to the pedicle, although some authors have
described placing Kelly clamps or intestinal clamps on
either side of the pedicle before transecting the muscle
around the clamps.
skin island is then transposed upward; the vascular pedicle
will be sitting in a triangular space created by the edges
of the split clavicular head. It is also possible to pass the
pedicle under the clavicle or even remove a segment of
the clavicle where the pedicle is transposed. Moreover,
placing the skin paddle more distally can also increase the
arc of rotation.
CLAVICULAR HEAD
OSTEOMUSCULOCUTANEOUS FLAP
The clavicular portion of the pectoralis major muscle can
be employed as a muscle flap, a musculocutaneous flap,
or an osseous musculocutaneous flap. When the clavicle is
taken, the segment of the bone measures 7–11 cm in
length and 0.5–0.75 cm in thickness and width. During
harvesting of the flap, the origin of the clavicular head of
pectoralis major muscle is left attached to the clavicle.
The clavicle is then cut longitudinally with an oscillating
saw, preserving sufficient bone to avoid fracture. A stain­
less steel plate may be used over the defect for further
support.
EXTENDED SKIN ISLAND
The entire skin overlying the muscle and up to 40% more
can be harvested with the pectoralis flap.
BREAST SHAPE PRESERVING
In women, the classical method of flap harvesting and
donor site closure inevitably results in distortion of breast
shape. The use of muscle-only flap or designing the skin
paddle near the inframammary fold minimizes the unsightly
distortion.
DONOR SITE CLOSURE AND
MANAGEMENT
The skin defect over the chest wall can be closed primarily
with a subcutaneous drain in the majority of the cases.
However, if the donor site is too large to be closed without
tension, it can be repaired using partial-thickness skin graft
or local transposition flaps.21
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
• When twisting of the myocutaneous flap is required
under some conditions, such as when the skin paddle
has to face outwards, then this 180° twisting should take
place gradually over the course of the muscle (Fig. 34.17).
The pedicle of the flap over the clavicle should not be
twisted.
• The design of the shape and size of the skin paddle on
the pectoralis major muscle should follow the size of
the defect. As mentioned, the skin island will shrink by
about 10%, thus appropriate adjustment in the design of
the dimensions of the skin island should be taken into
account.
Figure 34.17  The twisting of the flap should be gradual and take
place along the whole length of the pectoralis major muscle (arrow).
The pedicle should not be twisted.

408
PART 4 — CONVENTIONAL WORKHORSE FLAPS
reconstruction while at the same time primary closure of
the donor defect can be achieved depends on the elasticity
of the skin and the thickness of the subcutaneous tissue.
FLAP USAGE
Typical Indications for the Use of This Flap
1. Reconstruction of partial pharyngeal defects: when pectoralis
major myocutaneous flap is used for reconstruction of a
partial pharyngeal defect, a neck dissection is usually
carried out at the same time to accommodate the bulk
of the flap. The epithelial surface of the skin island when
transposed to the neck will be facing inward, and this is
sutured to the pharyngeal defect with interrupted sutures
(Fig. 34.21).
2. Repair pharyngocutaneous fistula after total laryngectomy or
pharyngogastric anastomosis: the fistula is explored and
resected until healthy tissue is encountered. Pectoralis
FLAP USAGE
The pectoralis major muscle alone can be used to fill defects
in the chest wall or in the mediastinum. More frequently, as
a myocutaneous flap, it is used for reconstruction of various
intraoral and pharyngeal defects. Its transposition to the
neck contributes to replace neck skin or replace the irradi­
ated skin in the head and neck area so that further brachy­
therapy can be applied to the region. When the costal
cartilage or the outer cortex of the sternum is attached to
the undersurface of the muscle, it can be used for recon­
struction of mandibular defects.
For replacement of chest wall or mediastinal defects, it can
reach the upper medial portion of the opposite chest wall.
For the head and neck area, externally, it can reach up
to the zygomatic arch while internally it can reach the soft
palate. The division of the clavicular head, isolating the
vascular pedicle that supplies the sternocostal head and
using this portion of the muscle to carry the skin island will
allow the flap to reach higher.
All the skin overlying the pectoralis major muscle can be
transposed with the muscle for reconstruction, then split-
thickness skin graft have to be used to cover the donor
defect. The amount of skin that can be used for
Figure 34.18  (A) Incision on the skin island (B) interdigitating the skin island flaps with the corresponding incisions on the upper end of the
esophagus.
A
B
Figure 34.19  Split-thickness skin graft laid on the undersurface of
the pectoralis major muscle to provide reconstruction of two epithelial
surfaces.
Figure 34.20  Large subcutaneous tunnel on the anterior chest wall
is essential to avoid compression on the flap.

CHAPTER 34 — Pectoralis Major Flap
409
fashioned into a tube-like conduit to reconstruct circum­
ferential pharyngeal defects. The defect should be accu­
rately measured and the length of the skin island marked.
The width of the skin island should be at least 6 cm in
order to provide a skin tube with a 2 cm diameter. The
flap is raised and transposed to the neck as usual. The
skin paddle is then folded into a tube and anastomosed
to the oropharynx above and cervical esophagus below.
The interdigitating suturing method may be employed
in the lower anastomosis and the resultant suture line is
in a wave-like form rather than circular. On healing, the
scarring stretches the anastomosis wider rather than
causing it to stenose, thereby reducing the risk of anas­
tomotic stricture formation.
3. Reconstruction of mandibular defects: this is possible by
harvesting an osteomyocutaneous flap including a
segment of rib or anterior table of the sternum for bony
reconstruction. The skin island may be used to repair
mucosal defect inside the oral cavity or cutaneous defects
externally.
4. Reconstruction of partial defects in the trachea: in cases where
there is partial defect of the trachea and the remaining
supporting cartilages are intact, the pectoralis major
myocutaneous flap can be used for repair with the skin
island facing inside the tracheal lumen.
5. Reconstruction of any of the above defects using the flap as a free
flap: this method may be particularly useful as a method
of salvage when the pedicle has been injured or the reach
of the flap is unexpectedly found to be inadequate.
6. Pedicled sternocostal portion for intrathoracic defects: the origin
and insertion of the muscle are transection, two or three
ribs are resected creating a space where the flap can pass
through, and the flap is inserted into the defect. This can
be used to repair intrathoracic defects, such as broncho­
pleural fistulas.
7. Functional muscle transfer: as mentioned above, pectoralis
major flap has a role in shoulder disruption injuries
where it can be used to wrap around the repaired gleno­
humeral joint, permitting a good range of shoulder move­
ment and also restoring shoulder contour. By keeping
the clavicular origin of the muscle intact and transposing
it into the deltoid insertion, it helped in shoulder abduc­
tion when the major abductors were absent.
The sternocostal head has been reported to be trans­
ferred for wrist and finger function.
POSTOPERATIVE CARE
GENERAL
Postoperatively the patient is monitored, as are all other
patients who have undergone major surgery. In particular,
maintain normal blood pressure and closely monitor urine
output to ensure adequate tissue perfusion pressure. Ade­
quate analgesia is provided.
RECIPIENT SITE
Because the pedicle of the pectoralis major myocutaneous
lying on the clavicle is directly covered by neck skin, any
pressure in the area should be avoided.
major myocutaneous flap is harvested and transposed to
the neck with the skin island facing inward and sutured
to the pharyngeal wall defect created. When the neck
skin cannot close over the pectoralis major muscle, then
a split-thickness skin graft can be used for coverage.
3. Reconstruction of intraoral defects: pectoralis major myocu­
taneous flap is harvested and transposed to the neck with
the skin island facing inward in the oral cavity, passing
under the mandible for reconstruction of floor of mouth
defects or over the mandible for closing defects of the
cheek.
4. Coverage of cutaneous defects or major vessels in the neck: pec­
toralis major myocutaneous flap is transposed to the neck
with the skin island facing outward to repair cutaneous
defects. This may be too bulky for some patients, and in
these situations muscle-only flap can be used to protect
underlying major vessels in the neck, and the cutaneous
defect is repaired by skin graft on the transposed muscle.
5. Replacement of irradiated tissue in the head and neck region so
that further brachytherapy can be used after tumor extirpation:
pectoralis major myocutaneous is raised and transposed
to the neck with the skin island facing outward to replace
the unhealthy irradiated skin. Brachytherapy afterload­
ing tubes can be inserted and passed underneath the
flap. The healthy flap muscle provides adequate protec­
tion to the underlying major vessels in the neck.
6. Coverage of defects in the chest wall or mediastinum: the flap
can be advanced with or without detachment of the inser­
tion to cover defects across the midline as a turnover flap.
Atypical Indications for the Use of This Flap
1. Turnover flap for midline defects of the chest extending
more inferior to the level of the xiphoid cartilage
2. Reconstruction of circumferential pharyngeal defects: the skin
paddle of the pectoralis major myocutaneous flap can be
Figure 34.21  Pectoralis major myocutaneous flap used for recon­
struction of partial pharyngeal defect.

410
PART 4 — CONVENTIONAL WORKHORSE FLAPS
DONOR SITE
The donor site should heal uneventfully.
UNTOWARD OUTCOMES
GENERAL
The incidence of complete flap failure is 1–2%. The most
common reason for flap failure is twisting and occlusion
of the pedicle. When there is complete failure of the
flap, it should be taken down and a new flap used for
reconstruction.
RECIPIENT SITE
When there is partial necrosis of the skin paddle, especially
for intraoral reconstruction, then the necrotic skin or
tissue should be debrided and secondary healing will take
place.
When there is leakage of saliva following partial failure of
the flap, conservative management can be instituted when
the leakage is small and the fistula is expected to heal. When
leakage is significant, then the dehisced wound should be
exteriorized and a second-stage closure performed after
inflammation has subsided.
DONOR SITE
Keloid scar may occur in the chest wall donor site, especially
in genetically susceptible individuals. When split-thickness
skin graft has to be used for coverage, some of them may
not take on the costal cartilages. The exposed cartilage may
develop chondritis and then it will take a long period before
secondary healing takes place.
LONG-TERM OUTCOMES
GENERAL
The muscle will undergo atrophy in the long term as the
motor nerve to the muscle is divided.
RECIPIENT SITE
For mucosal reconstruction, the skin epithelium will become
thin and the skin appendages will also atrophy, especially
when it is in contact with saliva for a long time. The skin,
however, will remain intact and serve its function as lining
of a cavity or as part of a conduit of the alimentary tract.23
DONOR SITE
Asymmetry of the chest wall and the anterior axillary fold
is to be expected, although this could be minimized by
muscle-preserving method of flap harvesting.
CONCLUSIONS
The pectoralis major muscle has a constant, reliable, and
good blood supply. As a myocutaneous flap, it has its role
in the reconstruction of certain defects in the head and
neck region. Modified surgical techniques in its harvesting
and insetting increase its safety and application.
All dressings, drainage tubes, monitor devices, tracheos­
tomy strappings, and the oxygen mask tube should not be
placed in the neck to avoid compression or strangulation of
the vascular pedicle. The perfusion of the flap is monitored
clinically and documented regularly.
ESOPHAGEAL RECONSTRUCTION PATIENTS
An imaging study such as a barium swallow is performed in
patients with pharyngeal and esophageal reconstruction to
ensure complete healing of the flap with the surrounding
tissue before allowing oral feeding. Patients are discharged
after they have resumed oral feeding. In general, this takes
7–10 days, but delayed healing can occur in patients who
received previous radiotherapy.
FUNCTIONAL MUSCLE TRANSFER PATIENTS
After functional muscle transfer, the wounds were immobi­
lized until healing. Subsequently, patients received intensive
rehabilitation exercises and relearning programs provided
by a physiotherapist.
MANDIBULAR RECONSTRUCTION WITH PEDICLED
OSTEOMYOCUTANEOUS FLAP
A temporary tracheostomy is usually required in these
patients and is removed when postoperative edema of the
floor of mouth and upper neck is resolving, approximately
by 1 week. Look out for wound infection, which may result
in partial or even complete flap loss. If there is a high degree
of suspicion, the use of broad spectrum antibiotics and early
drainage of infective collection may prevent serious compli­
cations. Instruct patients to avoid chewing hard objects 2–3
months after operation.
DONOR SITE
Dressings of the donor sites are usually kept intact and
changed only if necessary. Nature and volume of drain
output is monitored and charted regularly. If the donor site
is closed by local transposition flap, the perfusion of the flap
should be monitored regularly. When skin graft is utilized,
the wound should be assessed from time to time to make
sure that there is no collection under the graft, which may
cause graft failure.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
The pectoralis major muscle is expected to survive, and the
skin island is expected to survive completely.
RECIPIENT SITE
The flap should survive completely. The inset of the skin
paddle should heal with the surrounding tissue, so that
leakage of saliva is prevented. The presence of healthy bulk
of muscle from the flap improves tolerance of the wound to
infection.

CHAPTER 34 — Pectoralis Major Flap
411
Patient presented with a recurrent papillary thyroid cancer
encasing the left carotid and subclavian vessels, also invading
sternum, mediastinum, and ribs. The thoracoacromial vessels
were intact. The carotid artery and subclavian vein were resected
with the tumor and reconstructed with cryopreserved grafts. The
left pectoralis major muscle was pedicled and turned over to
cover the exposed neck vessels. The right pectoralis major
muscle was dissected free from its attachments and pedicled on
the pectoral branch of the thoracoacromial vessels and advanced
to cover the sternal defect, which had been reconstructed with
Gore-Tex. The patient healed and is to undergo radiation
therapy (Fig. 34.22).
CASE 34.1  Sternal and Neck Defect Reconstructed with Bilateral Pedicled Pectoralis
Major Flaps
(Courtesy of Karim Bakri, MD.)
Figure 34.22  (A) Exposed vessels in the left neck that were reconstructed with cryopreserved graft. Exposed Gore-Tex used to recon­
struct the sternal defect. (B) Left pectoralis major muscle was pedicled based on the pectoral branch of the thoracoacromial vessels. (C)
The left pectoralis major was turned over and used to cover the exposed vessels in the neck. (D) Neck vessels covered with left pectoralis
major muscle. The right pectoralis major muscle medial margin is exposed and dissected away from the chest wall and the subcutaneous
tissue. Dissection from the subcutaneus tissue can be avoided in many circumstances. (E) The pectoralis major muscle is pedicled, based
on the right pectoral branch of the thoracoacromial vessels. (F) The pectoralis major muscle is cut lateral to the pectoral branch of the
thoracoacromial vessels. This is only necessary in some situations where significant advancement is necessary. (G) The neck vessels and
Gore-Tex are covered. Bilateral skin flaps were advanced to cover the pectoralis major muscles. On the right side, detaching the pectoralis
major muscle from the subcutaneous tissue is not necessary, and advancing a pectoralis major myocutaneous flap would be equally as
effective without compromising blood supply to the skin. (H) Early postoperative photograph showing good coverage and a healing
incision.
A
D
B
E
G
H
C
F

412
PART 4 — CONVENTIONAL WORKHORSE FLAPS
The patient underwent pharyngolaryngoesphagectomy for car-
cinoma of the cervical esophagus. The pharyngogastric closure
dehisced and the leakage was converted to a pharyngogastric
cutaneous fistula. A pectoralis major myocutaneous flap was
employed to close this fistula (Fig. 34.23).
CASE 34.2  Pharyngogastric Cutaneous Fistula Closed with a Pedicled Pectoralis Major
Myocutaneous Flap
Figure 34.23  (A) Pharyngogastric cutaneous fistula. (B) Pectoralis major myocutaneous flap (M) used for repair of the pharyngogastric
cutaneous fistula.
A
B
A

CHAPTER 34 — Pectoralis Major Flap
413
Figure 34.24  (A) Floor of the mouth and mandible defect reconstructed with a pedicled pectoralis major myocutaneous flap. Squamous
cell carcinoma over the right lower alveolus extending to floor of mouth (arrow). The extent of resection marked. (B) Following resection,
the defect on the floor of mouth and remaining lower part of the mandible can be seen (arrow). (C) Pectoralis major myocutaneous flap
(PMF) was used to reconstruct the floor of mouth defect and cover the mandible. (D) Right facial defect reconstructed with a pedicled
pectoralis major myocutaneous flap (PMF). Pectoralis major myocutaneous flap covers the facial defect following resection of recurrent
carcinoma of parotid and the tubes placed on the tumor bed for afterloading brachytherapy.
An 86-year-old man with multiple medical diseases had squa-
mous cell carcinoma of the right lower alveolus extending to the
floor of the mouth (Fig. 34.24); the cortex of the underlying
mandible was not affected. Resection of the tumor, floor of the
mouth, and upper partial mandibulectomy was carried out (Fig.
34.24B). A pectoralis major myocutaneous flap was employed to
reconstruct the defect on the floor of mouth and to cover the
exposed mandible (Fig. 34.24C).
CASE 34.3  Floor of the Mouth and Mandible Defect Reconstructed with a Pedicled
Pectoralis Major Myocutaneous Flap
A
B
C
D

414
PART 4 — CONVENTIONAL WORKHORSE FLAPS
The patient suffered from carcinoma of the hypopharynx. He
underwent total laryngectomy and partial pharyngectomy.
The width of the remaining pharyngeal mucosa was too
narrow for primary closure. A pectoralis major myocutaneous
flap was employed for reconstruction (Fig. 34.21).
CASE 34.4  Partial Pharyngeal Defect
Reconstructed with a Pedicled
Pectoralis Major
Myocutaneous Flap
Figure 34.25  The pectoralis major (M) myocutaneous flap was
delivered into the pleural cavity via a window on the thoracic
cage (arrow). (Inset) Endoscopic view showing the skin island
replacing the anterior tracheal wall. The carina can be seen
(arrow).
The patient had segmental resection of trachea for a localized
tumor in the trachea. The primary closure of the trachea
broke down partially. Emergency exploration was done with
an endotracheal tube inserted through the dehisced tracheal
closure. A pectoralis major myocutaneous flap was elevated
and delivered into the pleural cavity through a window created
by removing a segment of the second intercostal cartilage.
The skin island was used to reconstruct the partial tracheal
defect (Fig. 34.25).
CASE 34.5  Partial Trachea Defect
Reconstructed with a Pedicled
Pectoralis Major
Myocutaneous Flap
Expert Commentary
Hung-Chi Chen, MD, PhD, FACS
In the reconstruction after wide excision of head and neck
cancers, when the patient is not a good candidate for micro-
surgical free flap transfer, pectoralis major (PM) flap is always
considered first. During the inset of the pectoralis major flap,
care should be taken for protection of the vascular pedicle
to prevent venous congestion.
If the defects include buccal mucosa and cheek skin, the
deltopectoral (DP) flap can be used at the same time for
reconstruction of buccal mucosa defect, and PM flap is used
for cheek skin defect. This may result in a temporary orocu-
taneous fistula, which can be closed at a later date after
establishment of good neovascularization from the surround-
ing tissue.
The DP-preserving PM flap should be mentioned, because
oral cancer patients may have long survival regardless of
multiple local recurrences. Therefore, all useful regional flaps
should be preserved as far as possible in case they may be
needed in the future. Therefore, if only a PM flap is needed,
a DP flap should be preserved while raising the PM flap. The
DP flap can be partially elevated with two parallel incisions
and the dissection is done below the fascia, so that the raised
PM flap can be passed in the created space under the fascia
to be transposed to the cheek defect. Thus, the DP flap can
be preserved for later use in the future.
The PM flap can be used as a free flap. In our series, five
patients had problems in the inset of PM flap, which was
then changed into a free flap. There is a waste of flap length
when PM is used as a pedicled flap. For example, in some
patients, the PM flap was initially designed for reconstruction
but there was tension in wound closure and it had to be
changed to a free PM flap. The recipient vessels can be
superficial temporal vessels, or vessels in the neck closer to
the defect. In this situation, care should be taken for the
patients’ general conditions, because these patients were
initially evaluated to be not suitable for free flaps.
Another possible condition is that the defects after cancer
ablation are so large that a plastic surgeon may choose a
free flap plus a pedicled PM flap. For example, when there
is a very large defect of oral mucosa, mandible and cheek
skin, a free fibular osteocutaneous flap can be used for
reconstruction of mandible and oral mucosa, but a pedicled
PM flap is used for cheek skin defect. In this situation, the
vascular pedicle of the free osteocutaneous flap should be
protected from being compressed by the PM flap, which
is quite heavy and may interfere with the venous return of
the fibular osteocutaneous flap. Therefore, in this situation,
proper cushioning for the vascular pedicle of the fibular
osteocutaneous flap should be provided using local tissue.
Costochondritis is a possible complication of the PM flap,
and may need extensive ablation of the affected cartilages
later. There are two steps that are important to mention: (1)
In elevation of a PM flap, the cartilage should not be cauter-
ized during hemostasis to avoid costochondritis. (2) When
the donor site cannot be closed primarily, a skin graft will be
needed and a tie-over dressing is often used for compres-
sion. In cases of potential infection, the tie-over dressing
must be removed early to prevent infection from affecting
the cartilage.

CHAPTER 34 — Pectoralis Major Flap
415
13. Moloy PJ, Gonzales FE. Vascular anatomy of the pectoralis major
myocutaneous flap. Arch Otolaryngol Head Neck Surg 1986;112:
66–9.
14. Lam KH, Wei WI, Siu KF. The pectoralis major costomyocutaneous
flap for mandibular reconstruction. Plast Reconstr Surg 1984;73:
904–10.
15. Green MF, Gibson JR, Bryson JR, et al. A one-stage correction of
mandibular defects using a split sternum pectoralis major osteo-
musculocutaneous transfer. Br J Plast Surg 1981;34:11–16.
16. Kerawala CJ1, Sun J, Zhang ZY, et al. The pectoralis major myocu­
taneous flap: is the subclavicular route safe? Head Neck 2001;
23(10):879–84.
17. de Azevedo JF. Modified pectoralis major myocutaneous flap with
partial preservation of the muscle: a study of 55 cases. Head Neck
Surg 1986;8(5):327–31.
18. Weaver A, Vandenberg H, Atkinson D, et al. Modified bilobular
(“Gemini”) pectoralis major myocutaneous flap. Am J Surg 1982;
144:482.
19. Tobin G, Spratt J, Bland K, et al. One stage pharyngoesophageal
and oral mucocutaneous reconstruction using two segments of one
musculocutaneous flap. Am J Surg 1982;144:489–93.
20. Paterson P, Prinsloo DJ. The pectoralis major muscle flap – a first
choice for shoulder disruption injuries. Injury 2004;35(5):536–9.
21. Belt PJ, Emmett J. Local transposition flap repair of the pectoralis
major myocutaneous flap donor site. Plast Reconstr Surg 2004;
114(3):732–7.
22. Lam KH, Wei WI, Lau WF. Avoiding stenosis in the tubed greater
pectoral flap in pharyngeal repair. Arch Otolaryngol Head Neck
Surg 1987;113:428–31.
23. Wei WI, Lam KH, Lau WF. Fate of skin element of pectoralis major
flap in intraoral reconstruction. Arch Otolaryngol Head Neck Surg
1989;115:360–3.
REFERENCES
1. Hueston JT, McConchie IH. A compound pectoral flap. Aust N Z
J Surg 1968;38:61–3.
2. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap
for reconstruction in the head and neck. Plast Reconstr Surg
1979;63:73–81.
3. Biller HF, Baek S, Lawson W, et al. Pectoralis major myocutaneous
island flap in head and neck surgery: analysis of complications in
42 cases. Arch Otolaryngol 1981;107:23–6.
4. Wilson JS, Yiacoumettis AM, O’Neill T. Some observations on
112 pectoralis major myocutaneous flaps. Am J Surg 1984;147:
273–9.
5. Vucak MC, Masic T, Hassouba M, et al. Reconstructive option of
extensive head and neck defects in cancer surgery. Med Arch
2013;67(4):275–7.
6. Schneider DS, Wu V, Wax MK. Indications for pedicled pectoralis
major flap in a free tissue transfer practice. Head Neck 2012;34(8):
1106–10.
7. Reid CD, Taylor GI. The vascular territory of the acromiothoracic
axis. Br J Plast Surg 1984;37:194–212.
8. Palmer JH, Taylor GI. The vascular territories of the anterior chest
wall. Br J Plast Surg 1986;39:287–99.
9. Macchi V, Tiengo C, Porzionato A, et al. Medial and lateral pectoral
nerves: course and branches. Clin Anat 2007;20(2):157–62.
10. Robertson MS, Robinson JM. Pectoralis major muscle flap in head
and neck reconstruction. Arch Otolaryngol Head Neck Surg 1986;
112:297–301.
11. Talmi YP1, Benzaray S, Peleg M, et al. Pulmonary function after
pectoralis major myocutaneous flap harvest. Laryngoscope 2002;
112(3):467–71.
12. Wei WI, Lam KH, Wong J. The true pectoralis major myocutaneous
island flap: an anatomical study. Br J Plast Surg 1984;37:568–73.

e87
INTRODUCTION
The deltopectoral (DP) fasciocutaneous flap, also known as
the Bakamjian flap, is an important reconstructive tool that
has been used for a wide variety of reconstructive problems
in head and neck surgery.1 A variation of this flap that is
based on a single perforator of the internal mammary artery
is called the “internal mammary artery perforator (IMAP)
flap.” The DP flap was initially described for facial recon­
struction and resurfacing, as it was found to have an excel­
lent color and thickness match to the native facial skin. In
addition, the tissue from this region is thin and pliable, with
the potential to provide a large area of well-vascularized
tissue that is easily contoured.
This flap was first described in 1917 by Aymard for nasal
reconstruction.2 In the 1930s, Joseph described this flap for
head and neck reconstruction. However, it was not until the
1960s that this flap came to be used on a routine basis in
head and neck reconstruction. In 1965, Bakamjian described
the use of the medially based DP flap in the reconstruction
of the laryngopharyngectomy defect, and the DP flap
became the “workhorse” flap for resurfacing mucocutane­
ous defects of the head and neck.3
With proper planning, as well as delay techniques in
select circumstances, the DP flap can be used for reconstruc­
tion of any part of the anterior head and neck below the
zygoma. The DP flap has been used in a variety of settings,
including, but not limited to, closure of dehiscent wounds
and fistulas, restoration of compromised regions including
irradiated head and neck defects, and reconstruction of
pharyngeal defects. Furthermore, reconstruction of complex
head and neck surgical defects may require multiple flaps,
and the DP flap may obviate the need for multiple micro­
vascular free flaps. For some time now, the pedicled form
of the DP flap has been largely overshadowed by the devel­
opment of highly reliable regional flaps and the expanded
use of free tissue transfer for head and neck reconstruction.
Despite these trends, the DP flap remains a reliable option
for the head and neck surgeon.
FLAP ANATOMY (see Figs 11.2, 11.3, 11.8
and 11.9)
This flap is based on the parasternal fasciocutaneous perfo­
rating branches of the internal mammary artery, which per­
forate the intercostal muscles and the pectoralis muscle to
reach the skin. The blood supply to the anterior chest wall
comes from perforators from the internal mammary artery
that traverse each intercostal space; branches of the thoraco-
acromial artery; musculocutaneous branches that traverse
the deltoid muscle; the posterior intercostal vessels that give
off perforators to the posterior, lateral, and anterior thoracic
skin; and minor contributions from the lateral thoracic
artery.
ARTERIAL SUPPLY OF THE FLAP (see Figs 11.2
and 11.3)
Dominant:  second or third perforating branches of the
internal mammary artery
Length: 1.5 cm (range 1–2 cm)
Diameter: 1 mm (range 0.8–1.2 mm)
The internal mammary artery (IMA) branches off the
subclavian artery.
• The IMA diameter of 1–2 mm; accompanying vein diam­
eter of 2–3 mm
• Terminates into the musculophrenic and the deep supe­
rior epigastric arteries at the sixth intercostal space
• At each intercostal space, the IMA has three branches:
• Medial branch, which supplies the sternum
• Lateral branch, which communicates with the anterior
intercostal artery
• Anterior branch, which supplies this flap.
• The anterior branch pierces the intercostal muscles
and the pectoralis fascia running toward the skin.
This vessel travels superficial to the fascial covering
Deltopectoral Flap and
Internal Mammary Artery
Perforator Flap
J.R. Castro  |  Charles E. Stewart IV  |  Mark L. Urken
35 
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION B  —  LOCAL AND FREE FLAPS IN THE CHEST

e88
PART 4 — CONVENTIONAL WORKHORSE FLAPS
ADVANTAGES
• The anatomy is reliable, and flap harvest is relatively easy.
• There is no need for additional patient positioning or
preparation when dealing with defects in the head and
neck or anterior part of the body.
• There is very little donor site morbidity and no significant
functional deficits. The donor defect is easily covered by
clothes.
• The fasciocutaneous flap is thin and pliable.
• The lack of a bulky muscular component makes it an
excellent choice for replacing cutaneous defects.
• The skin of the flap matches the color and texture of the
face.
• The flap size can be increased if a “delay” procedure or
tissue expansion is performed.
• Two symmetrical DP flaps can be simultaneously har­
vested, effectively enlarging the available skin.
• The arc of rotation can be extended by removing a
portion of rib and dissecting out the internal mammary
artery.
• The effective pedicle length can be increased through
modification referred to as the deltopectoral island flap
(see below).
• This flap can be used even if a patient has had a pectoralis
major flap if care was taken not to cut into the delto­
pectoral skin, and the internal mammary perforators
were protected during harvest of the pectoralis flap (see
Fig. 34.5).
• The DP flap can be used as a large migrating tube flap
(“waltzing”).
DISADVANTAGES
• Skin grafting of the donor site may be necessary if the
harvest includes more than four interspaces or about
8 cm of skin. However, skin laxity in certain individuals
may allow for more extensive donor defects to be closed
primarily.
• Distal flap necrosis can occur when the skin paddle is
extended over the deltoid region without a delay
procedure.
• For some patients, hirsute skin can be an issue.
• In female patients there is the morbidity of chest skin
scarring as well as the potential for alteration in breast
symmetry and positioning or nipple distortion.
PREOPERATIVE PREPARATION
In general, the DP flap can be used for most head and neck
applications without the need for additional studies.
FLAP DESIGN
ANATOMIC LANDMARKS
• The lateral edge of the sternum (Fig. 35.1) marks the
medial aspect of the flap, the clavicle marks the superior
aspect of the flap, the lower aspect of the 4th rib denotes
the inferior aspect of the flap, and the lateral aspect of
of the pectoralis major and deltoid muscles and ter­
minates approximately 12 cm from the midline at
the anterior axillary line.
• The caliber of this perforator ranges 0.5–1.2 mm.
• The second and third perforators are usually the
largest caliber and run with their associated veins in
the intercostal interspaces approximately 1–1.5 cm
lateral to the border of the sternum.
• The flap is usually based on these large second and
third perforators, but can be based on a single vas­
cular pedicle in situations where a clearly dominant
perforator is present.
Minor:  first and fourth perforating branches of the inter­
nal mammary artery (see Figs 11.2 and 11.3)
Length: 1.5 cm (range 1–2 cm)
Diameter: 0.7 mm (range 0.5–1.2 mm)
Minor:  direct cutaneous artery that arises from the thora­
coacromial system
This artery supplies a small area of skin below the lateral
aspect of the clavicle overlying the deltopectoral groove.
Minor:  intercostal perforators
Some of the intercostal vessels send perforators that
supply the skin of the anterior chest.
VENOUS DRAINAGE OF THE FLAP
(see Fig. 11.8)
Primary:  venae comitantes of the perforators from the
internal mammary artery
Length: 1.5 cm (range 1–2 cm)
Diameter: 2.5 mm (range 2–3 mm)
The venae comitantes drain into the internal mammary
vein, which subsequently drain into the innominate vein.
Secondary:  branch of the thoracoacromial vein
This branch could be used potentially to augment the
venous drainage of a free DP flap.
Secondary:  cephalic vein
The cephalic vein runs in the deltopectoral groove
between the axial pattern and the random pattern of the
DP flap. Drainage through this vessel is presumed to improve
blood flow of the distal DP flap.
FLAP INNERVATION (see Fig. 11.9)
Sensory:  the supraclavicular nerves of C3 and C4, and
the anterolateral intercostal nerves of T2, T3, and T4 (see
Figs 11.2 and 11.9)
Motor:  this flap does not have a muscle component.
FLAP COMPONENTS
This flap is harvested as a cutaneous or a fasciocutaneous
flap. Although not necessary for flap survival, the fascia
overlying the pectoralis major muscle is often included with
the flap harvest, for the purpose of protecting the nutrient
blood supply. There is not a reliable source of bone that can
be harvested with this flap.

CHAPTER 35 — Deltopectoral Flap and Internal Mammary Artery Perforator Flap
e89
discussion, the primary region supplied by the internal
mammary perforators includes the skin extending from the
lateral border of the sternum to the deltopectoral groove.
This area also receives musculocutaneous perforators arising
from the thoracoacromial system and the pectoralis major
muscle.
In the process of raising the skin flap over the deltoid
muscle (beyond the deltopectoral groove), these musculo­
cutaneous and direct cutaneous vessels are disrupted and
the blood supply relies exclusively on the internal mammary
perforating vessels, which transforms this distal region into
a random pattern flap. In the angiosome model described
by Taylor and Palmer, the blood supply to skin in immedi­
ately adjacent angiosomes is usually quite reliable.4 However,
as one moves to the angiosome next in line or “once
removed” from the source vessel, the pressure gradient of
the nutrient flow diminishes. The skin overlying the deltoid
muscle is an “angiosome once removed” from the internal
mammary angiosome and, therefore, this skin is at risk for
partial or total necrosis. Daniel et al.5 felt that if these lateral
and posterior deltoid regions are to be incorporated in the
flap harvest, it should be done following a delay procedure,
to reduce the risk and subsequent morbidity of distal flap
necrosis.
SPECIAL CONSIDERATIONS
The DP flap is a medially based axial flap with limited arc
of rotation. The body habitus of the patient may influence
the reach and therefore the utility of this flap. For example,
a patient with broad shoulders and a short neck is a favor­
able scenario that expands the versatility of this flap.
Several different techniques with respect to flap geometry
have been described. In discussing these variations, it should
be kept in mind that one of the main problems with the DP
the flap, without a delay procedure, is 3–4 cm lateral and
parallel to the deltopectoral groove.
• The superior and inferior limits of the flap may be
adjusted based on the perforator chosen.
• The flap can be centered over one perforator, preferably
the largest (the second or third perforator).
GENERAL THOUGHTS ABOUT FLAP DESIGN
• A handheld Doppler probe can be used preoperatively to
detect the exact location of the perforators and the rela­
tive size of each perforator.
• The zone located 2 cm lateral to the border of the
sternum should not be violated during harvest of this flap
in order to avoid injury to these nutrient vessels.
• The flap can be designed based on any of the internal
mammary perforators and oriented in a lateral, oblique,
or inferior direction. The lateral direction toward the
acromial process allows for the furthest extension of the
flap, whereas the other two designs are limited in length
unless a delay is performed.
• The DP flap can be raised and transferred in the primary
setting with a high degree of reliability, provided that it
does not include an extended territory overlying the
deltoid muscle.
ANGIOSOME CONCEPT
The lateral extent to which the DP flap can be safely
extended is of great importance in determining the utility
of the flap for a particular defect and the safety of perform­
ing a one-stage reconstruction. In reviewing the vascular
territory of the upper chest, it is apparent that vascular
compromise, leading to distal flap ischemia, may occur
when extending this flap to include skin overlying the
deltoid muscle. Applying the angiosome model to this
Figure 35.1  Anatomic landmarks.
The sternal midline marks
the medial aspect of the flap
3–4 cm lateral and parallel
to the deltopectoral groove
marks the lateral aspect
of the flap
The lower aspect of the 4th
rib marks the inferior aspect
of the flap
The superior of the clavicle
marks the superior aspect
of the flap
Deltopectoral groove marks
the lateral aspect of the flap
without the need for delay

e90
PART 4 — CONVENTIONAL WORKHORSE FLAPS
The flap is extended in the direction of the acromion to the
deltopectoral groove and beyond if a delay procedure is
performed. The length can be extended 6–8 cm beyond the
deltopectoral groove with a delay procedure.
PATIENT POSITIONING
The supine position is preferable but the flap can be har­
vested in the contralateral decubitus position.
ANESTHETIC CONSIDERATIONS
Because the DP flap is superficial, it can be harvested using
local anesthesia and sedation. However, most often this flap
is used for the reconstruction of defects that require general
anesthesia to complete.
TECHNIQUE OF FLAP HARVEST
The flap is harvested by extending the incision through the
dermis and subcutaneous layers to the pectoralis fascia.
Typically, the fascia is then incised and thus incorporated
on the undersurface of the flap. This helps to preserve the
perforating blood vessels that travel superficial to this fascial
layer. The initial description of the harvest by Bakamjian
described a subfascial dissection in order to preserve the
flap blood supply.1 The flap should be elevated in this plane
from a lateral to medial direction, with extreme care taken
to stay at least 2 cm from the lateral border of the sternum.
Several different designs have been described for the DP
flap. Traditionally, the flap is raised and transferred in the
primary setting and does not require a two-stage delay pro­
cedure. The skin between the defect and the donor site can
flap is the potential for distal flap necrosis, which is due to
the intrinsic limitations of the blood supply to this flap, as
previously described.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
• The pedicled version of the flap usually includes more
than one perforator from the internal mammary artery.
• During the harvest of the DP flap as a free flap, the branch
of the thoracoacromial vein or the cephalic vein can be
included in order to provide additional venous drainage
if necessary. This would require the performance of
venous anastomosis to a recipient vein in the neck.
• For both pedicled and free flaps, the pedicle length can
be extended by dissecting the internal mammary vessels
more proximally.
FLAP DIMENSIONS
Skin Island Dimensions
Length: 25 cm (range 10–30 cm)
Width: 8 cm (range 6–12 cm)
Maximum to close primarily: 5–9 cm
Primary closure of the donor site can be achieved if the
flap is <5–6 cm, or 8–9 cm in elderly patients with lax skin.
The medial and lateral aspects of the donor site are the most
difficult to close primarily. Even if skin grafting is necessary,
this can usually be limited by wide undermining and the use
of retention sutures if necessary.
FLAP MARKINGS
The flap is generally marked with a line parallel to the
clavicle and centered over the second or third intercostal
space or both (Fig. 35.2), depending on the width necessary.
Figure 35.2  Flap markings. Dotted area: subcutaneous tissue is included with the flap if harvested as an island flap.
Extension of the flap
past the deltopectoral
groove
A back-cut can be
performed to increase
the arc of rotation
Island deltopectoral
flap
Typical design of the
deltopectoral flap

CHAPTER 35 — Deltopectoral Flap and Internal Mammary Artery Perforator Flap
e91
undersurface of the flap. The graft may be buried at the
time of an initial delay procedure.
FENESTRATED FLAP
East et al. described the placement of a fenestration in the
distal portion of the DP flap for reconstruction of a trache­
ostoma.9 In using this technique, the surgeon must be
mindful of the possibility of distal tip necrosis. However, the
authors advised that the short arc of rotation required to
reach the tracheostoma allows the design of a short flap,
and therefore the fenestra can be placed in a proximal,
well-vascularized segment of the flap.
FREE MICROVASCULAR TRANSFER OF
THE DELTOPECTORAL FLAP
The DP flap has also been used as a microvascular free flap,
first described in 1974 by Harii et al.10 The base of the free
DP flap is located over the perforating branches of the
internal mammary vessels parasternally; the upper border
corresponds to the clavicular line and the lower parallels
the upper and extends laterally across the apex of the ante­
rior axillary fold. The base of the free flap is designed with
the second perforating branch located along its midline. As
with other free fasciocutaneous flaps, it has greater versatil­
ity than the conventional pedicle flap, and staged proce­
dures are avoided. The DP flap provides an ample source
of good quality skin suitable for facial reconstruction. Unlike
the pedicled DP flap, which will not reach much beyond the
zygomatic region, the free flap can be used for defects
located throughout the head and neck region.
Fujino et al. described the transfer of a de-epithelialized
dermis–fat flap for augmentation of contour deformities of
the head and neck.11 The flap can be harvested as a free
flap using the internal mammary perforators. However, the
small caliber of these vessels, coupled with the short length
of the vascular pedicle, render the revascularization techni­
cally difficult. It is technically feasible to anastomose vessels
of this caliber, but the tenuous nature of this revasculariza­
tion process has yielded a high incidence of anastomotic
failure. Sasaki et al.12 were able to achieve improved reli­
ability of the DP free flap by incorporating a segment of the
internal mammary vessel in the vascular pedicle. In their
experience, the caliber of the internal mammary perfora­
tors ranged 0.6–1.2 mm, with an average of 0.9 mm.
However, if a segment of the internal mammary artery was
used, the average size was 2.1 mm, with the vein averaging
2.9 mm. In addition, there was another 2–3 cm gained in
pedicle length, which greatly facilitates the revascularization
process and improves flap reliability.
FLAP MODIFICATION/FLAP HANDLING
SENSATE FLAP
In 1977, David was the first to describe the successful resto­
ration of sensation to the reconstructed oral lining. In this
report, excellent sensation was obtained when the nerves
were mobilized and not transected.13
In order to allow for rotation of the DP flap, the lateral
cutaneous branch of the intercostal nerve is typically divided
be excised, allowing for one-stage inset of the entire flap.
Alternatively, the intervening skin bridge can be left in place
with the DP flap tubed and exteriorized over the clavicle
and neck skin. This technique then requires a second pro­
cedure to excise or return the pedicled component.
DELTOPECTORAL ISLAND FLAP
The deltopectoral island flap is designed and harvested by
detachment of the parasternal portion of the DP flap. This
modification allows for a free axis of rotation (up to 180°),
additional flap length, and improved spatial orientation
capabilities. The flap is centered over the second intercostal
perforator and is harvested as a traditional DP flap, with the
additional parasternal elevation and detachment providing
the island modification. The deltopectoral island flap is less
tethered at the parasternal region, and the increased mobil­
ity and freedom of orientation allow for less tension on
both the flap and the pedicle, stabilizing the flap and reduc­
ing the risk of vessel kinking with head movement. In addi­
tion, the proximal segment of the flap can be de-epithelialized
and tunneled underneath the cervical skin between the
defect and the clavicle. This maneuver allows for improved
flap mobility and rotation and therefore greater versatility.
Chen et al. described the use of the Bakamjian island flap
for patch esophagoplasty of the cervical esophagus.6 This
island flap was used on 12 patients who had short segment
esophageal strictures, with successful resumption of oral
nutrition in all patients. An additional advantage described
by Portnoy and Arena is the ability to incorporate the flap
into closure of the donor site, allowing for primary closure
and avoidance of skin grafting the donor site.7
SPLIT DELTOPECTORAL FLAP
Krizek and Robson described the vertically split DP flap that
provides two epithelial surfaces.8 In this design, an incision
is made along the longitudinal axis of the flap through the
distal end of the skin paddle. This design allows for two
separate segments that can be used for inner and outer
lining restoration. This modification is safer, with respect to
distal flap vascularity, than de-epithelializing a distal segment
and folding the flap over on itself. This latter technique of
a transverse fold at the distal segment of the flap creates
more risk for vascular compromise as it requires a longer
flap to be harvested, as well as placing the fold at the distal,
less reliable portion of the DP flap.
L-SHAPED DELTOPECTORAL FLAP
Another technique used to obtain an inner and outer lining
is the two-stage L-shaped DP flap described by Bakamjian.3
In the first stage, the short limb of the “L” extending down
along the upper arm was elevated and folded under the
deltoid component to produce a buried skin flap. The two
epithelial surfaces were then transferred at the time of the
second procedure.
TWO-LAYERED DELTOPECTORAL FLAP PROVIDED
BY SKIN GRAFTING THE UNDERSURFACE
Another alternative solution to the requirement for a
double epithelial surface is the use of a skin graft on the

e92
PART 4 — CONVENTIONAL WORKHORSE FLAPS
increasing the skin surface area. It also thins the flap,
improves its vascularity, reduces the risk of distal necrosis,
and facilitates direct closure of the donor site.
Serra et al.19 used an expander that was modified by sur­
rounding it with a skin graft, and placement of the modi­
fied expander was aided by endoscopy. The surgical
technique begins with outlining the flap and incisions. A
2 cm longitudinal incision is made in the distal margin of
what is to be the DP flap to allow introduction of an endo­
scope and retractor. Another incision is made inferiorly to
introduce the endoscopic dissector. Under endoscopic
vision the subfascial plane is dissected. Next, a rectangular
tissue expander is positioned and coated with a partial-
thickness skin graft such that the epidermis is in contact
with the expander circumferentially and the dermis is in
contact with both the donor site bed and the undersurface
of the deltopectoral skin to be transferred. The expander is
then filled with sequential injections of saline. At 3 weeks
later the expander is removed. This results in both the
internal surface of the expanded DP flap and the donor site
defect over the pectoralis major muscle to be covered with
a skin graft. The deep surface of the DP flap lined by the
graft, is then sutured to the walls of the pharynx. The exter­
nal surface of the flap, which is full-thickness skin of the
upper chest wall, is sutured to the skin surrounding the
pharyngostome.
SIMULTANEOUS IPSILATERAL PECTORALIS
MAJOR MYOCUTANEOUS FLAP AND
DELTOPECTORAL FLAP
Massive defects in the head and neck area can be immedi­
ately reconstructed by the combined use of simultaneous
ipsilateral pectoralis major (PM) and DP flaps as described
by Nishi et al.20 In this design, the upper limb of the skin
paddle of the PM skin paddle should correspond to the
lower border of the DP flap. Thus, skin incisions are made
along the inferior border of the DP flap, then around the
PM skin paddle. Wide undermining is then performed to
expose the pectoralis. Great care must be taken not to injure
the second and third internal mammary perforators when
elevating skin from the underlying pectoralis muscle.
SUPRACLAVICULAR EXTENSION OF THE
DELTOPECTORAL (DP), CERVICODELTOPECTORAL
(CDP), CERVICOPECTORAL FLAPS
Cervicodeltopectoral (CDP) and cervicopectoral flaps are
considered locoregional flaps, and they are modified delto­
pectoral (DP) flaps combined with local cervical or cervico­
facial flaps.
With the CDP flap, the cervical or cervicofacial extension
is added to the standard DP flap. The CDP flap was described
by Ducic and Smith.21 The CDP flap is based on the perfo­
rating branches of the internal mammary artery, as is the
case with the standard DP flap. However, superior and pos­
terior limbs of the CDP flap extend in a subcutaneous tissue
plane to the margins of the neck or facial defect. Thus, the
DP flap and the entire intervening skin bridge from the
defect to the DP flap are transferred in continuity.
With the cervicopectoral flap, described by Becker for
cheek coverage, the cervicofacial extension is added to a
and this flap is not a true sensate flap. There remains the
possibility of preserving this nerve and performing micro­
surgical nerve anastomosis during free tissue transfer.
However, with the availability of other donor sites such as
the sensate radial forearm flap described by Urken et al.,
this application is probably more of academic interest than
practical.14,15
EXTENDED FLAP
The length of a DP flap that can be safely transferred
without a delay is somewhat controversial. Kirkby et al.16
reported that the end of the flap could be safely extended
to the tip of the shoulder. In addition, if more flap length
was needed, they also recommended a back-cut that
extended from the inferior limb of the flap across the
sternum and then in a cephalad direction lateral to the
contralateral internal thoracic (mammary) perforators.
However, the efficacy of this maneuver has been questioned
by authors such as McGregor and Reid, who feel that the
arc of rotation of a DP flap is more limited by the upper
limb of the flap than by the inferior limb, as is most com­
monly believed.17
Feng et al.18 designed the extended DP flap in the shape
of a club based on the second and third internal mammary
perforators confirmed by intraoperative Doppler mapping.
The “head” of the club may be wider than its body beyond
the distal third of the clavicle, and is extended to the lateral
margin of the deltoid. The length of the flap is determined
by the location of the defect such that a tension-free closure
is achieved. The patient is instructed to avoid both flexion
and hyperextension of the neck until the pedicle is divided
about 4 weeks later (range 3–6 weeks).
EXTENDED ARC OF ROTATION
Another modification is applicable to the harvest of the flap
as a free flap. An intervening costal cartilage is excised
between two perforators, and the internal mammary vessels
are dissected proximally and used as the pedicle of the flap.
This has the advantage of lengthening the pedicle, increas­
ing the size of the vessels for anastomosis, and including
more than one perforator to the skin island.
INTERNAL MAMMARY ARTERY PERFORATOR FLAP
This flap may be based on any of the upper four internal
mammary perforators. The skin incisions are made in tra­
ditional DP flap fashion. A supra- or subfascial dissection is
then performed until the perforator is visualized. It is then
dissected through the intercostal musculature. Costal carti­
lage can then be removed on either side, which allows access
to the distal internal mammary vessels. Care must be taken
to avoid injury to the vessels, which are located just under­
neath the perichondrium of the rib. These vessels can then
be safely ligated and divided, which then maximizes the arc
of rotation for the pedicled flap.
EXPANDED DELTOPECTORAL FLAP
Pre-expansion of the distal portion of the deltopectoral skin
accomplishes several important things in addition to simply

CHAPTER 35 — Deltopectoral Flap and Internal Mammary Artery Perforator Flap
e93
Typical Indications for the Use of This Flap
• Closure of salivary fistulas. Guha et al.23 classified pharyn­
gocutaneous fistulae according to size. With fistulae
>0.5 cm but <2 cm, the pharyngeal layer was repaired
with interrupted sutures, then a DP flap was used to close
the skin defect. With fistulae >2 cm, a pectoralis myocu­
taneous flap was used to close the pharyngeal defect with
the skin surface inside, then a DP flap was used to close
the external skin defect.
• Reconstruction of complex tracheoesophageal defects
• Skin or mucosal coverage in patients with extensive
central compartment defects and, in particular, patients
requiring reconstruction, who, as a result of prior therapy,
have a paucity of suitable recipient vessels for free tissue
transfer
• Skin defects from thyroid cancer involvement. In locally
advanced differentiated thyroid cancer with skin involve­
ment, skin margins can be maximized, and the defect of
the neck can be reconstructed with a DP flap.
• Skin breakdown from prior radiation therapy
• Anterior neck scar contractures. One of the best choices
for treatment of post-burn neck contractures
• Skin resurfacing in conjunction with other pedicled flaps
or free flaps.
Atypical Indications for the Use of This Flap
• Skin/soft tissue defects of the face. Reconstruction of
nasal defects, upper and lower eyelid defects after ablative
surgery
• Palate defects. Bakamjian and Poole described using the
DP flap for reconstruction of the palate following ablative
surgery.24
• Through-and-through cheek defects. McGregor and Reid
described the reconstruction of through-and-through
cheek defects with a forehead flap internal lining and DP
flap external lining.17 Morris et al.25 utilized a PM flap
internal lining and DP flap external lining.
• Intraoral reconstruction of floor of mouth, tonsil, or
pharynx.
• Combined with jejunal transfer for tracheostomal and
pharyngoesophageal single-stage reconstruction in large
defects of the central compartment. McCarthy et al.26
described the use of the DP flap combined with jejunal
transfer for tracheostomal and pharyngoesophageal
single-stage reconstruction in large defects of the central
compartment. Free jejunum was used to restore alimen­
tary tract continuity, with the DP tissue providing cutane­
ous and tracheostomal coverage. Due to the thin pliable
nature of the DP flap, these authors were able to avoid
some of the problems of myocutaneous flaps, where
tissue bulk can cause technical difficulties such as soft
tissue prolapse and tracheostomal obstruction.
• Laryngopharyngectomy defect. In 1965, Bakamjian
described a two-stage operation that involved the transfer
of a tubed DP flap as a solution to the problem of a laryn­
gopharyngectomy defect and gullet discontinuity.3 Fol­
lowing the initial procedure in which the DP flap was
tubed on itself, a controlled salivary fistula was created at
the lower end of the tube that was positioned lateral and
inferior to the tracheostoma, permitting a safer and more
manageable salivary egress. The stump of the esophagus
was sutured in an end-to-side fashion to the skin tube.
pectoral flap based on the perforating branches of the
internal mammary artery.22 The incision for the flap begins
at the posterior aspect of the cheek defect. It is then
extended posteriorly around the earlobe to the hairline
behind the ear, then carried inferiorly to the lateral edge
of the pectoralis muscle. The inferior incision is then
carried anteriorly and parallel to the clavicle at about the
third intercostal space. The flap is elevated deep to the
platysma and the anterior pectoral fascia and then rotated
into place.
DONOR SITE CLOSURE AND
MANAGEMENT
The use of a skin graft to cover the donor site is required
in most patients. However, with wide undermining and
tacking the surrounding skin to the underlying muscle and/
or placement of retention sutures, the need for a skin graft
can be reduced. If a skin graft is needed, a bolster dressing
can be applied over the top of the skin graft by using
5 × 9 inch petrolatum gauze with bismuth and several 2-0 silk
stitches to retain the petrolatum gauze. Typically, there is no
need for active drain placement, but passive drainage with
a Penrose can be considered.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES
AND AVOID COMPLICATIONS
Inclusion of the fascia overlying the pectoralis major muscle
improves reliability of the most distal part of the flap and
should be performed whenever possible.
Attention to detail during flap transfer, such as prevent­
ing tension, kinking, and severe angulation of the distal
aspect of the flap, can help avoid some of the more common
complications that can occur with this flap.
Avoid excessive manipulation and tension during the
initial inset of the flap, particularly the distal part of the flap,
which is based on a random blood supply.
Although distal ischemia resulting from extension of the
flap over the deltoid region is the most common cause of
partial necrosis, there are a variety of other etiologic factors
that have been implicated. Placement of the flap over a
mandibular K wire and 3-dimensional reconstruction plate,
kinking, and an inadequate aperture through which to pass
the DP flap for mucosal replacement, have all been associ­
ated with DP flap necrosis and should be avoided or per­
formed with caution.
The standard DP flap has a limited arc of rotation that is
hindered by the parasternal skin and perforators that are
left untouched during the dissection. By dissecting out the
perforators and freeing the parasternal skin, this flap can
achieve a rotation of up to 180°.
FLAP USAGE
Historically, the DP flap was a “workhorse” flap for head and
neck reconstruction. Performing a pedicled DP flap avoids
the need for technical expertise in microsurgery and reduces
operating room time and donor site morbidity.

e94
PART 4 — CONVENTIONAL WORKHORSE FLAPS
noticeable and represent one of the drawbacks to this flap.
This is more of a cosmetic concern, however, as with routine
harvest there will be no weakness of the shoulder, the arm,
or chest. The patient may experience a feeling of tightness
over the chest skin as the incision sites mature. However, the
overall functions of the chest, shoulder, and arm muscles
are not affected by the harvest of this flap. There will also
be associated numbness to the skin that has been incised,
which will improve with time.
DONOR SITE
Initial incision sites will be raised and relatively firm, with
gradual softening and flattening over a period of 6 months.
UNTOWARD/UNFAVORABLE OUTCOMES
GENERAL
• For cervical skin defects that have been reconstructed,
breakdown can lead to exposure of critical vascular struc­
tures and vascular emergencies such as carotid blow-out.
• Failure of DP flaps that have been used for intraoral or
pharyngeal reconstruction can lead to salivary fistulae.
• The most common causes for flap failure are pedicle
constriction, excess traction on the flap, and folding of
the distal flap segment.
• The incidence of flap tip necrosis has been quite variable
in different series. Partial or total flap necrosis rates
have typically been reported in the range of 10–25%.
Minor complication rates, such as partial necrosis, wound
dehiscence, and donor site problems, have ranged
14%–29%.
The issue of previous neck irradiation and the need for
a staged procedure has been controversial. Bakamjian did
not feel that previous irradiation to the recipient site affected
flap viability or the ability to perform single-stage recon­
struction. In a series of 51 DP flaps placed in irradiated beds,
Krizek and Robson reported only five major complications.8
Kirkby et al.16 noted an overall total flap failure rate of 26%,
with an increase to 49% when the recipient site had been
previously irradiated. Kingdom and Singer reported the use
of the DP flap in 24 patients, 21 of whom had received
radiation to the recipient site, and they had zero flap fail­
ures and no flap necrosis.30
Extended procedures, especially in those reconstructive
cases where the more random portion of skin overlying the
shoulder is incorporated, will have a better chance of success
at the distal aspect if there is a 2-week period of time between
flap elevation and inset.
Gilas et al.31 reported their 20-year experience with DP
flaps. The overall rate of major necrosis was 16.9% and
that of minor necrosis, 14.2%. The overall complication
rate for reconstructions carried out with DP flaps was
51%, 22% of which were major complications. The
highest rate of complications for DP flap reconstructions
occurred in those used as lining only; those created by
reverse tubulation; those with a slit to accept a stomal or
esophageal anastomosis; those used in reconstructions of
the tongue, base of the tongue, floor of the mouth, and
for total pharyngeal reconstruction; and those used in pre­
viously irradiated beds. The fewest complications occurred
when DP flaps were non-tubulated and used as skin cover­
age only.
After a 3–5-week interval, the base of the DP flap was
transected and closed to complete the pharyngoesopha­
geal reconstruction. Bakamjian later described the use of
a staged secondary reconstruction of the pharyngoesoph­
agus by tubing the DP flap on the chest wall prior to
transfer.24
• Pharyngoesophageal strictures. Guha et al.27 reported
that the DP flap alone is very useful for correction of small
segment corrosive strictures and secondary anastomotic
strictures.
• Radiation-induced tracheocutaneous defects. Riedel
et al.28 closed the defect by transplantation of auricular
cartilage followed by closure of the skin defect with a DP
flap. Shinohara et al.29 utilized a prefabricated DP flap
with costal cartilage graft and a palatal mucosal graft.
• Free microvascular transfer of the DP flap. The indica­
tions for this technique are limited since other free flaps
provide good results with longer pedicle length, simpler
dissection of the vessels, better donor site aesthetic out­
comes, and more reliable results.
POSTOPERATIVE CARE
GENERAL
The transferred DP flap is monitored on a daily basis for
color and presence of tension on the flap. If signs of conges­
tion or compromise exist, it is advisable to release sutures,
and the patient’s position should be adjusted to decrease
tension on the flap. If congestion persists, early application
of medicinal leech therapy should be implemented. Any
sign of underlying hematoma or salivary collection causing
vascular compromise would necessitate emergency drain­
age. For patients undergoing pedicled DP flaps for recon­
struction of head and neck defects, the patient’s position
postoperatively should avoid hyperextension of the neck.
Excessive movement of the patient’s neck should also be
avoided, and care is taken to avoid any sort of head or body
positioning that could possibly kink or twist the pedicle.
The postoperative management of the patient who has
undergone a pedicled DP flap is similar to that of most
regional axial pattern flaps. There is no need to give anti­
coagulant medications. Early ambulation is allowed with
continued attention to head position while upright. In those
patients who have had previous radiation therapy, all skin
closure materials (sutures or staples) are left in place for a
period of 2 weeks.
DONOR SITE
The donor site requires care that is typical for a skin-grafted
area. The bolster dressing should be placed so as not to
compress the base of the flap, and can safely be removed
7–8 days following the reconstruction.
OUTCOMES
EXPECTED OUTCOMES
GENERAL
With harvest of a DP flap, there will always be associated
scarring to the anterior chest wall. These incisions are

CHAPTER 35 — Deltopectoral Flap and Internal Mammary Artery Perforator Flap
e95
neck surgery. We rarely use it for mucosal defects and prefer
a myocutaneous flap for challenging wounds where impaired
healing is anticipated. On the other hand, the DP flap is
extremely reliable for cutaneous defects of the lower two-
thirds of the neck where primary transfer, without a delay
procedure, can be reliably accomplished.
The selection of tissue for reconstruction is dependent
upon the defect to be reconstructed. The donor tissue
should be of appropriate bulk and pliability to reestablish
contour and function. Other factors to consider are the
regional vascular status, condition of the surgical site
(history of previous surgery or trauma), and the patient’s
body habitus/overall medical condition. The ideal recon­
structive method is an immediate, single-staged procedure
that allows rapid restoration of function with low morbidity.
Despite many alternative methods of reconstruction in head
and neck surgery fitting these criteria, the DP flap still
remains a useful and reliable method of reconstruction. It
is a versatile tool and has been used in a wide variety of
reconstructive scenarios from intraoral reconstruction of
the tongue, floor of mouth, tonsil, and pharynx to resurfac­
ing hemifacial and orbitomaxillary cutaneous defects.
DONOR SITE
Donor site complications may be immediate, such as post­
operative hematoma or seroma. There can also be delayed
complications such as infection, hypertrophic scarring, and
partial or total loss of skin graft.
LONG-TERM OUTCOMES
GENERAL
The volume and texture of the DP flap will be relatively
constant over time. As this is a fasciocutaneous flap, there
is no muscle atrophy or flap shrinkage that may occur with
myocutaneous flaps. In general, the deltopectoral skin will
remain thin, soft, and supple, which are extremely valuable
characteristics in those patients who have undergone mul­
tiple ablative procedures or radiation therapy.
DONOR SITE
The donor site, which is usually skin grafted, continues to
improve in color and texture with time. The skin graft may
be serially excised or tissue expanders may be placed under
the chest skin with eventual removal of the skin graft.
CONCLUSION
With the availability of microvascular free flaps, the pedicled
DP flap has a more limited role in contemporary head and
The patient had a lower neck cutaneous defect that was reconstituted with an island deltopectoral flap (Fig. 35.3).
CASE 35.1  A Lower Neck Cutaneous Defect Reconstructed with a Pedicled Deltopectoral
Flap
Figure 35.3  Island deltopectoral flap. (A) Design. (B) Harvest. (C) Postoperative.
A
C
B

e96
PART 4 — CONVENTIONAL WORKHORSE FLAPS
5. Daniel RK, Cunningham DM, Taylor GI. The deltopectoral flap: an
anatomical and hemodynamic approach. Plast Reconstr Surg
1975;55(3):275–82.
6. Chen YB, Chen HC, Lee YC. Bakamjian island flap for patch esoph­
agoplasty of the cervical esophagus. Plast Reconstr Surg 1999;103:
1176.
7. Portnoy W, Arena S. Deltopectoral island flap. Otolaryngol Head
Neck Surg 1994;111:63–9.
8. Krizek T, Robson M. Split flap in head and neck reconstruction.
Am J Surg 1973;126:488.
9. East C, Flemming A, Brough M. Tracheostomal reconstruction
using a fenestrated deltopectoral skin flap. J Laryngol Otol 1988;
102:282.
10. Harii K, Ohmori K, Ohmori S. Free deltopectoral skin flap. Br J
Plast Surg 1974;27:231.
11. Fujino T, Tanino R, Sugimoto C. Microvascular transfer of
free deltopectoral dermal-fat flap. Plast Reconstr Surg 1975;55:
428.
12. Sasaki K, Nozaki M, Honda T, et al. Deltopectoral skin flap as a free
skin flap revisited: further refinement in flap design, fabrication,
and clinical usage. Plast Reconstr Surg 2001;107:1134.
13. David JD. Use of an innervated deltopectoral flap for intraoral
reconstruction. Plast Reconstr Surg 1977;60:377.
14. Urken ML, Cheney ML, Blackwell KE, et al. Atlas of regional and
free flaps for head and neck reconstruction. 2nd ed. Philadelphia:
Wolters Kluwer/Lippincott, Williams & Wilkins; 2012.
15. Urken ML, Weinberg H, Vickery C, et al. The neurofasciocutane­
ous radial forearm flap in head and neck reconstruction – a pre­
liminary report. Laryngoscope 1990;100:161.
16. Kirkby B, Krag C, Siemssen O. Experience with the deltopectoral
flap. Plast Reconstr Surg 1977;59:360.
17. McGregor JA, Reid WH. The use of the temporal flap in the
primary repair of full-thickness defects of the cheek. Plast Reconstr
Surg 1966;38(1):1–9.
18. Feng GM, Cigna E, Lai HK, et al. Deltopectoral flap revisited: role
of the extended flap in reconstruction of the head and neck. Scand
J Plast Reconstr Surg Hand Surg 2006;40(5):275–80.
19. Serra JM, Benito JR, Monner J, et al. Reconstruction of pharyngo­
stomes with a modified deltopectoral flap combining endoscopy
and tissue expansion. Ann Plast Surg 1998;41(3):283–8.
20. Nishi Y, Rikimaru H, Kiyokawa K, et al. Development of the pecto­
ral perforator flap and the deltopectoral perforator flap pedicled
with the pectoralis major muscle flap. Ann Plast Surg 2013;71(4):
365–71.
21. Ducic Y, Smith JE. The cervicodeltopectoral flap for single-stage
resurfacing of anterolateral defects of the face and neck. Arch
Facial Plast Surg 2003;5(2):197–201.
22. Becker DW Jr. A cervicopectoral rotation flap for cheek coverage.
Plast Reconstr Surg 1978;61(6):868–70.
A deltopectoral flap for reconstruction of a pharyngocutaneous fistula (Fig. 35.4).
CASE 35.2  A Pharyngocutaneous Fistula Reconstructed with a Pedicled Deltopectoral Flap
Figure 35.4  Island deltopectoral flap. For repair of pharyngocutaneous fistula. (A) Harvest. (B) Inset.
A
B
Expert Commentary
Eric M. Genden, MD, MHCA, FACS
The deltopectoral (DP) flap provides an excellent source of thin
tissue for reconstruction of the head and neck region. With the
exception of the radial forearm free flap, there are few sources
of fasciocutaneous tissue for reconstruction. Although this par-
ticular flap is no longer a first-line tool for reconstruction, it can
be a useful flap when microvascular free tissue transfer is not
available or local or regional skin coverage required. The DP
flap represents one of the few options for thin pliable tissue
when microvascular free tissue transfer is not available. Har-
vesting this flap using the standard approach, as described by
Bakamjian in 1965, remains an important tool in the recon-
structive surgeons armamentarium.3 Staging the flap improves
the reliability of the distal skin paddle especially when the skin
paddle is designed lateral to the cephalic vein. Because this is
a regional flap, rotation limits the applicability of this flap to the
lower neck and peristomal region.
When harvesting the pectoralis myocutaneous flap, we
design the incisions on the chest wall in a way that will not
interfere with the design of the DP flap in the event that this
flap may be used later in the patient’s course of care. One
particularly important application of the DP flap, is the “island”
deltopectoral flap. This flap is designed such that the interven-
ing tissue that typically serves as the carrier for the distal skin
paddle, is de-epithelialized. This unique design provides a
source of fasciocutaneous skin that does not require a second-
stage “takedown.”
REFERENCES
1. 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.
2. Aymard JL. Nasal reconstruction with a note on nature’s plastic
surgery. Lancet 1917;2:888–90.
3. Bakamjian VY. A two-stage method for pharyngoesophageal recon­
struction with a primary pectoral skin flap. Plast Reconstr Surg
1965;36:173.
4. Taylor GI, Palmer J. The vascular territories (angiosomes) of the
body: experimental study and clinical applications. Br J Plast Surg
1987;40:113.

CHAPTER 35 — Deltopectoral Flap and Internal Mammary Artery Perforator Flap
e97
cartilage graft and palatal mucosal graft. Ann Plast Surg 2004;
53(3):278–81.
30. Kingdom T, Singer M. Enhanced reliability and renewed applica­
tions of the deltopectoral flap in head and neck reconstruction.
Laryngoscope 1996;106:1230.
31. Gilas T, Sako K, Razack MS, et al. Major head and neck reconstruc­
tion using the deltopectoral flap: a 20 year experience. Am J Surg
1986;152:430.
FURTHER READING
Gingrass RP, Culf NK, Garrett WS, et al. Complications with the delto­
pectoral flap. Plast Reconstr Surg 1972;49(5):501–7.
Kawai K, Kakibuchi M, Hatta C, et al. Microsurgical modification of the
deltopectoral flap. Ann Plast Surg 2001;47:578.
Moore K. Clinically oriented anatomy. 3rd ed. Baltimore: Williams &
Wilkins; 1992.
Park JS, Sako K, Marchetta FC. Reconstructive experience with the
medially based deltopectoral flap. Am J Surg 1974;128:548.
23. Guha G, Saha S, Kundu I. Surgical repair of postlaryngectomy
pharyngocutaneous fistulas. Indian J Otolaryngol Head Neck Surg
2007;59(2):103–7.
24. Bakamjian VY, Poole M. Maxillofacial and palatal reconstructions
with the deltopectoral flap. Br J Plast Surg 1977;30:17.
25. Morris DM, Reed W, Cunningham M. Primary head and neck
reconstruction with a simultaneous ipsilateral pectoralis major
myocutaneous flap and a deltopectoral flap. J Surg Oncol 1984;
25(1):50–3.
26. McCarthy C, Kraus D, Cordeiro P. Tracheostomal and cervical
esophageal reconstruction with combined deltopectoral flap and
microvascular free jejunal transfer after central neck exenteration.
Plast Reconstr Surg 2005;115:1304.
27. Guha G, Gupta S, Chakraborty S. Pharyngo oesophageal strictures
and its reconstruction by delto pectoral flaps. Indian J Otolaryngol
Head Neck Surg 2005;57(3):229–34.
28. Riedel F, Reinhart Goessler U, et al. Management of radiation-
induced tracheocutaneous tissue defects by transplantation of an
ear cartilage graft and deltopectoral flap. Auris Nasus Larynx
2006;33(1):79–84.
29. Shinohara H, Yuzuriha S, Matsuo K, et al. Tracheal reconstruction
with a prefabricated deltopectoral flap combined with costal

e98
INTRODUCTION
The omentum flap was one of the first free flaps reported
in the literature1 but long before that, its use as pedicled
flap for intra- and extra-abdominal reconstructions was well
described. The popularity of the omentum flap has been
variable over the past decades but new harvesting tech­
niques have been developed that aim to reduce donor site
morbidity.2–4
In recent years, the superior epigastric flap has become
a versatile perforator flap for coverage of locoregional
defects. The concepts of angiosomes and perforasomes led
to a better understanding of vascular territories, to a safer
flap harvest,5,6 and therefore to an increased use of this
fasciocutaneous flap.
The external oblique and the internal oblique muscle
flap share not only similar characteristics but also the same
dominant source vessel.7,8 They can be used as both free and
pedicled flaps.
OMENTUM FLAP
FLAP ANATOMY (Fig. 36.1, see also Ch. 38)
ARTERIAL AND VENOUS SUPPLY OF THE FLAP
The blood supply to the omentum flap is equally provided
by the right and the left gastroepiploic vessels. As the diam­
eter of the right gastroepiploic artery is usually bigger than
the one of the left side, the flap is preferably based on the
right gastroepiploic vessels. Additionally, extensive dissec­
tion of the left gastroepiploic vessels may carry the risk of
inadvertent injury to the spleen. The intra-abdominal
arcade has four major branches: the accessory omental
artery, the right omental artery, the middle omental artery,
and the left omental artery. The middle omental artery
anastomoses with the left and right omental arteries. This is
an important consideration when the flap design requires
lengthening of the omentum or splitting of the flap into
several parts.9
Dominant:  right gastroepiploic artery
Length: 20 cm (range 10–30 cm)
Diameter: 2.2 mm (range 1.5–3 mm)
The right gastroepiploic artery originates from the gas­
troduodenal artery. It travels along the greater curvature of
the stomach and gives off the four major branches to the
omentum, as well as multiple short branches to the stomach
– the gastric arteries. It eventually anastomoses with the left
gastroepiploic artery.9
Minor:  left gastroepiploic artery
Length: 20 cm (range 10–30 cm)
Diameter: 2 mm (range 1.2–2.9 mm)
The left gastroepiploic artery arises from the splenic
trunk. It courses along the greater curvature of the stomach
and anastomoses with the right gastroepiploic artery.
Figure 36.1  Anatomy of the omentum.
Right, middle, and
left hepatic arteries
Cystic artery
Internal thoracic arteries
Falciform and round
ligaments with arteries
Inferior
phrenic
artery
2
1
3
4
5
6
Left
gastric
artery
Celiac
trunk
Accessory or replaced arteries
1. Right or common hepatic
2. Left hepatic
3. Right hepatic
4. Cystic
Anastomoses of corresponding arteries
5. Inferior phrenic/left gastric left hepatic
6. Right left hepatic
A. Zone of relative safety
B. Zone of questionable effects
C. Zone of inevitable infarction
Effects of hepatic
artery obstruction
C C C
B
A
Cystic
Right gastric
Gastroduodenal
Capsular
Omentum, Superior
Epigastric, and External/
Internal Oblique Flaps
Marina Barandun  |  Anne O’Neill  |  Stefan O.P. Hofer
36 
PART 4  —  CONVENTIONAL WORKHORSE FLAPS
SECTION C  —  LOCAL AND FREE FLAPS IN THE ABDOMEN

CHAPTER 36 — Omentum, Superior Epigastric, a nd External/Internal Oblique Flaps
e99
VENOUS DRAINAGE OF THE FLAP
Primary:  right gastroepiploic vein
Length: 20 cm (range 10–30 cm)
Diameter: 2.7 mm (range 2–3.4 mm)
The right gastroepiploic vein drains into the superior
mesenteric vein. It runs from left to right along the greater
curvature of the stomach and parallel to the right gastroepi­
ploic artery. Its caliber is comparable with the size of the
artery; however. it is often quite thin and care should be
taken while handling it.4
Secondary:  left gastroepiploic vein
Length: 20 cm (range 10–30 cm)
Diameter: 2.7 mm (range 2–3.4 mm)
The left gastroepiploic vein runs from the right to the left
along the greater curvature of the stomach and parallel to
the left gastroepiploic artery. It drains into the splenic vein.
FLAP INNERVATION
Sensory:  none
Motor:  none
FLAP COMPONENTS
The omentum flap can be harvested as a gastro-omental
flap by including a patch of the greater curvature of the
stomach.
ADVANTAGES
• Free flap or pedicled flap
• Thin and pliable
• Large surface area
• Long pedicle
• Angiogenic and immunogenic properties2,10
• Relatively fast and easy harvest
• Robust blood supply
DISADVANTAGES
• Donor site morbidity may be considerable as it requires
laparotomy for access
• Size and availability cannot be assessed preoperatively
PREOPERATIVE PREPARATION
FLAP DESIGN
ANATOMIC LANDMARKS (Fig. 36.2)
Subcostal margin, midline.
GENERAL THOUGHTS ABOUT FLAP DESIGN
Flap design varies according to defect size. The whole
omentum or part thereof can be harvested based on the
gastroepiploic vessels and one or more branches of the
intra-abdominal arcade. As the flap cannot be combined
with a skin paddle, it must be covered with a split-thickness
skin graft (STSG) or regional skin flaps.
Figure 36.2  Anatomic landmarks: (1) spleen; (2) liver; (3) gallbladder;
(4) duodenum; (5) appendix; (6) root of small bowel mesentery. Sub­
costal margins bilaterally and midline incision. In this illustration, one
can see the approximate location of the root of the mesentery (6),
and the end of the duodenum (4), which marks the beginning of the
jejunum at the ligament of Treitz. (With permission from Lumley JSP.
Surface anatomy, 3rd ed. Churchill Livingstone; 2002.)
2
3
4
5
6
1
SPECIAL CONSIDERATIONS
• Free gastro-omental flap for oral or oropharyngeal recon­
structions4,11
• Free omentum flap for reconstruction of extensive scalp,
lower extremity (consider flow through flap) or head and
neck defects
• Pedicled omentum flap for chest wall, abdominal wall
and breast reconstruction – pedicle can be tunneled sub­
cutaneously or through small diaphragmatic opening
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
No general differences are in the design of flap when using
it as pedicled or free. However, the harvesting technique
(open vs laparoscopic) and closure of donor site may vary.
FLAP DIMENSIONS
Omentum Dimensions
Length: Average 35 cm
Width: Average 25 cm
Thickness: Average 1 cm
The size of the omentum varies significantly with the size
of the patient and previous intra-abdominal surgeries or
infections. Folding the flap onto itself can increase its
thickness.
FLAP MARKINGS
Once the omentum is visualized, the area to be harvested is
marked. Usually, the entire omentum is harvested.
PATIENT POSITIONING
Supine positioning of patient for harvest. Repositioning after
flap harvest may be necessary according to site of defect.

e100
PART 4 — CONVENTIONAL WORKHORSE FLAPS
intra-abdominal infections (peritonitis). If the decision
is made to proceed, extra care should be taken to avoid
injury.
The flap can be lengthened considerably by dividing the
gastroepiploic artery between the right and the left omental
artery. Vascularization of the entire flap is provided by the
anastomoses between the left, right, and middle omental
artery within the intra-abdominal arcades.
FLAP USAGE
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Pedicled (see Cases 36.1, 36.2)
Reconstruction of extensive chest wall or sternal defects: the
omentum can be transposed into the chest wall or sternal
defect through a hole in the diaphragm or a fascial defect
in the abdominal wall. The flap is covered with a STSG or
local skin flaps.14 The arc of rotation of the flap reaches
most defects on the chest and abdominal wall.
Free Flap
• Reconstruction of extensive scalp or lower extremity
defects, chronic avascular or irradiated wounds
• For lower extremity reconstructions flow through flap
designs can be considered to ensure perfusion of distal
part of the limb
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
Pedicled
Reconstruction of the breast in Poland syndrome or
implant coverage after mastectomy. Use laparoscopic tech­
nique whenever possible (see above). After ligation of left
gastroepiploic artery, a small incision is made in the infra­
mammary fold and a small subcutaneous tunnel is created
up to the subcostal margin. The fascia and peritoneum
are incised in the midline. The flap is pulled through the
fascial gap, tunneled subcutaneously, and placed in the
defect.3
Free Flap
Head and neck reconstruction with gastro-omental compos­
ite free flap. The short gastric arteries are left intact while
the left gastroepiploic vessels are ligated. The gastric patch
is excised using a gastrointestinal stapling device taking care
to avoid pyloric outlet.
POSTOPERATIVE CARE
GENERAL
Avoid heavy weight-lifting for 6–8 weeks.
RECIPIENT SITE
General wound and flap care. If STSG had been used for
flap coverage, first dressing change is done on POD 5.
DONOR SITE
An abdominal binder may be recommended for 4 weeks, no
heavy weightbearing for 4 weeks. After pedicled omentum
flaps a considerable abdominal wall hernia can develop.
Although it may be cosmetically unsightly, it can be neglected
as long as it is not symptomatic.
ANESTHETIC CONSIDERATIONS
General anesthesia.
TECHNIQUE OF FLAP HARVEST (Figs 36.6, 36.7)
An upper median laparotomy is performed. The abdominal
cavity is explored and the omentum is inspected for surface
area, volume, and pedicle length. It is elevated off the trans­
verse colon and is mobilized on the gastroepiploic arcade.
This dissection is performed in a thin areolar and avascular
plane using blunt dissection and needle-tip cautery to
ensure bloodless dissection. The lateral splenic attachments
are divided as well as the short gastric vessels to free the
omentum from the greater curvature of the stomach. The
flap is based on the right or left gastroepiploic artery;
the contralateral vessels are ligated. Care is taken to prevent
kinking or twisting of the pedicle when transposing the flap
into the chest wall defect.12
LAPAROSCOPIC HARVEST
Standard laparoscopic surgery techniques are used with
four ports placed in the umbilical region, suprapubic region,
and both lateral iliac fossa. CO2 pneumoperitoneum of
10–12 mmHg is maintained during the procedure. The
gastric wall is elevated and the right gastroepiploic artery
is isolated. The short gastric arteries along the greater
curvature are ligated until the left gastroepiploic artery
is reached. The omentum is carefully released from the
transverse colon preserving the mesocolon vascularity.
The left gastroepiploic artery is ligated adjacent to the left
colic flexure and the flap is evacuated through one of the
ports.3
FLAP MODIFICATION/FLAP HANDLING
As the gastroepiploic arteries give off several short branches
to the greater curvature of the stomach, a patch of gastric
mucosa can be included in the flap for oral or oropharyn­
geal reconstructions.4,11
SPECIAL INSTRUMENTS
Laparoscopic harvest can considerably reduce the donor
site morbidity.3,13
DONOR SITE CLOSURE AND
MANAGEMENT
After harvesting the omentum as a free flap, standard lapa­
rotomy or laparoscopy closure techniques are used.
When the omentum is harvested as a pedicled flap, a
small defect must remain in the abdominal fascia to permit
passage of the pedicle. This, by definition, creates an
abdominal hernia. However, as long as it is not symptomatic
it will not require intervention. Sutures are placed between
the greater curvature of the stomach and the transverse
mesocolon to minimize the chance of volvulus.
A drain is not usually necessary at the donor site.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
Relative contraindications for the use of the omental flap
are previous multiple intra-abdominal surgeries or previous

CHAPTER 36 — Omentum, Superior Epigastric, a nd External/Internal Oblique Flaps
e101
However, the flap is usually planned as an islanded flap and
therefore not innervated.
FLAP COMPONENTS
The superior epigastric flap is a fasciocutaneous perforator
flap. Anterior rectus fascia can be harvested with the flap
although this would weaken the abdominal wall.
ADVANTAGES
• Less invasive, no use of muscle
• Primary closure of donor site
• Relatively fast and easy harvest
DISADVANTAGES
• Limited mobility
• Perforator anatomy may be variable
PREOPERATIVE PREPARATION
FLAP DESIGN
ANATOMIC LANDMARKS
• Caudal: midpoint between xiphoid and umbilicus
• Cranial: xiphoid
• Lateral: anterior axillary line
• Medial: midline
GENERAL THOUGHTS ABOUT FLAP DESIGN
The vascular territory of the superior epigastric artery
and the corresponding perforasomes have been studied
extensively.5,17,18 Flap design in a horizontal direction yields
better outcome than in a vertical direction and can be har­
vested as far as the anterior axillary line. The donor site
can be closed primarily with a reversed abdominoplasty
procedure.
SPECIAL CONSIDERATIONS
The superior epigastric flap is most useful as a propeller-
style perforator flap for chest wall, sternal or breast recon­
structions. The flap can be raised and transferred as an
island flap or with a small cutaneous bridge left intact and
rotated up to 90° into the defect. Unlike other perforator
flaps, it is not necessary to completely skeletonize the
perforator.
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
The superior epigastric flap is mostly used as pedicled per­
forator flap.
FLAP DIMENSIONS
Skin Island Dimensions6,19
Length: average 25 cm (range 16–38 cm)
Width: average 9 cm (range 6–15 cm). Maximum to close
primarily depends on skin laxity
FLAP MARKINGS (Fig. 36.3)
The flap is marked on the skin overlying the perforators of
the superior epigastric artery. The flap is marked in the
OUTCOMES
EXPECTED OUTCOMES
The omentum flap provides versatile, thin, pliable coverage
for various defects and recipient sites. It has a robust blood
supply as well as high angiogenic and immunogenic poten­
tial. It is most beneficial in defects with a large surface area,
chronic avascular or irradiated wounds, or wounds with a
high bacterial load.2,15,16
If the flap can be harvested laparoscopically, the donor
site is quite appealing and complications as abdominal wall
hernias can be avoided. Pedicled flaps create an abdominal
wall hernia by definition, as the pedicle has to be guided
through a fascial gap but as long as they are asymptomatic
no treatment is needed.
UNTOWARD OUTCOMES
Large abdominal wall hernias can develop after pedicled
omentum flaps. Additionally, all intra-abdominal proce­
dures may result in adhesions of varying extent. Gravita­
tional forces may cause sagging of the flap, especially in
head and neck reconstructions. When using a gastro-
omental flap for reconstruction of the oral cavity, extensive
mucus and acid production may be troublesome.4 Sponta­
neous flap growth has been described after transposition.3
SUPERIOR EPIGASTRIC FLAP
FLAP ANATOMY (see Figs 11.2, 11.3, 11.8 and 11.9)
ARTERIAL AND VENOUS SUPPLY OF THE FLAP
(see Figs 11.2 and 11.3)
The blood supply to the superior epigastric flap is provided
by perforators of the superior epigastric artery (SEA) The
SEA originates together with the musculophrenic artery
from the internal mammary artery at the sixth intercostal
cartilage. It passes behind the seventh costal cartilage, perfo­
rates the posterior rectus fascia, and enters the rectus abdom­
inis muscle at a variable distance.17 After giving rise to the
superficial SEA, a large musculocutaneous perforator that
travels subcutaneously along the costal margin, the SEA gives
off several perforators to the overlying skin.5 On average, 4–5
perforators can be found on the upper hemi-abdomen, most
of them encountered in an area 2–6 cm from the midline
and 0–10 cm below the xiphoid process. The diameter of the
perforators is on average 0.82 mm and they are accompanied
by a minimum of one vein.18 Location and number of perfo­
rators may vary significantly between individuals.
Dominant:  superior epigastric artery perforators
Length: 3.4 cm (range 1.5–7 cm)
Diameter: 0.8 mm (range 0.5–2 mm)
VENOUS DRAINAGE OF THE FLAP (Fig. 11.8)
Primary:  superior epigastric perforating veins
Length: 3.4 cm (range 1.5–7 cm)
Diameter: 0.8 mm (range 0.5–2 mm)
FLAP INNERVATION (Fig. 11.9)
Innervation to the skin of this flap is through anterior and
lateral cutaneous branches of intercostal nerves 5–9.

e102
PART 4 — CONVENTIONAL WORKHORSE FLAPS
horizontal or vertical direction, with the horizontal design
being preferable.
PATIENT POSITIONING
Supine positioning of the patient.
ANESTHETIC CONSIDERATIONS
General anesthesia.
TECHNIQUE OF FLAP HARVEST
The superior epigastric artery perforators are identified
using a handheld Doppler. The flap is designed horizon­
tally, with the most suitable perforator as the pivot point.
The fasciocutaneous flap is elevated in a lateral to medial
direction in the suprafascial plane until the perforator has
been identified. The perforator is dissected sufficiently to
guarantee unrestricted transposition of the flap into the
defect.
FLAP MODIFICATION/FLAP HANDLING
Vascular territories of the superior epigastric artery lie
between the midline and the anterior axillary line and the
xiphoid and the midpoint between the xiphoid and the
umbilicus. To avoid necrosis of the distal tip flap designs
should not reach beyond those borders unless the flap is
delayed. As the vascular anatomy may be quite variable,
perforators should be marked preoperatively using a hand-
held Doppler. The flap is raised in a lateral to medial direc­
tion or, if a vertical flap design is preferred, in a caudal to
cranial direction in the suprafascial plane.
SPECIAL INSTRUMENTS
Handheld Doppler
DONOR SITE CLOSURE AND
MANAGEMENT
The donor site can usually be closed primarily using a
reversed abdominoplasty technique. Frequently the scar can
be concealed in the inframammary fold. At least one drain
should be placed subcutaneously at the donor site and
under the flap.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
Further pedicle length can be achieved by dissecting the
perforator to the SEA and transecting the SEA distal to the
perforator takeoff. This would require an intramuscular dis­
section of the perforator. The pedicle length is increased
and the arc of rotation can be much wider.
FLAP USAGE
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Pedicled
Reconstruction of chest wall, sternal, or breast defects.
POSTOPERATIVE CARE
GENERAL
• Care is taken to avoid compression anywhere around the
flap and the pedicle of the flap.
• Flap monitoring is performed on a regular basis.
• The patient is positioned in a way to avoid tension of the
flap, head of bed slightly elevated.
• Avoid heavy weight-lifting for 6–8 weeks
RECIPIENT SITE
To avoid tension on wound edges patients with larger breasts
should wear a bra 24 h/day until complete wound healing
has been achieved.
DONOR SITE
General wound care, avoid heavy weight-lifting for 6–8
weeks. Abdominal binder may be recommended in the first
4–6 weeks postoperatively if extensive undermining for
reversed abdominoplasty was necessary.
OUTCOMES
EXPECTED OUTCOMES
The superior epigastric flap provides adequate coverage for
chest wall, sternal, and certain types of breast reconstruc­
tion.6,20–22 The donor site is very inconspicuous if the scar
can be concealed in the inframammary fold.
UNTOWARD OUTCOMES
In sternal reconstructions meticulous debridement of
the infected bone has to be performed prior to recon­
struction to avoid persistent osteomyelitis with consequent
osteocutaneous fistula or flap failure. Distal tip necrosis may
Figure 36.3  Superior epigastric perforator flap. Anatomic landmarks
and markings. Black small-dash line, midline; black large dash line,
anterior axillary line; black bold line, skin markings of a horizontal flap
design; red bold line, skin markings of a vertical flap design.

CHAPTER 36 — Omentum, Superior Epigastric, a nd External/Internal Oblique Flaps
e103
Length: 12 cm (range 9–15 cm)
Diameter: 3 mm
The arterial branches of the DCIA are always accompa­
nied by venae comitantes that drain into the paired deep
circumflex iliac veins. These travel parallel to the DCIA and
come together to form a single vein that drains into the
external iliac vein.7
Primary:  posterior intercostal veins
Length: 6 cm (range 3–10 cm)
FLAP INNERVATION (Fig. 11.9)
Sensory:  sensory part of anterior branch of the lateral
cutaneous branches of the fifth to twelfth intercostal nerves
(Fig. 11.8)
Motor:  motor branches of anterior branch of the lateral
cutaneous branches of the fifth to twelfth intercostal nerves
(Fig. 11.8)
FLAP COMPONENTS
Based on the DCIA, the lower half of the external oblique
muscle can be harvested as a free muscle flap; it can include
the overlying skin as well as vascularized bone from the iliac
crest.
When the external oblique muscle is based on its segmen­
tal blood supply from the fourth to eleventh posterior inter­
costal vessels, it is harvested as a pedicled flap and may
include the overlying skin.
ADVANTAGES
• Free flap or pedicled
• Musculo-(osteo-)cutaneous
• Thin and pliable
• Segmental innervation
DISADVANTAGES
• Possible donor site morbidity
• No bulk
PREOPERATIVE PREPARATION
FLAP DESIGN (Fig. 36.4)
ANATOMIC LANDMARKS
• Caudal: inguinal ligament, anterior superior iliac spine,
iliac crest
• Cranial: subcostal margin (free flap), inframammary fold
(pedicled flap)
• Lateral: anterior axillary line
• Medial: midline/rectus abdominis muscle
GENERAL THOUGHTS ABOUT FLAP DESIGN
For a free external oblique muscle flap, only the lower half
of the muscle can be used (up to subcostal margin). When
a skin paddle is included, primary closure depends on the
width of the paddle and the laxity of the skin. Generally,
primary closure is more feasible in elderly patients with suf­
ficient amount of redundant abdominal skin. In a pedicled
occur if the flap was designed beyond the borders of the
vascular territories.
EXTERNAL OBLIQUE FLAP
FLAP ANATOMY (see Figs 11.2, 11.3, 11.8 and 11.9)
ARTERIAL AND VENOUS SUPPLY OF THE FLAP
(Figs 11.2 and 11.3)
In 94% of patients, the main blood supply of the caudal half
of the external oblique muscle is provided by the deep cir­
cumflex iliac artery (DCIA) and vein. In 6% of the cases,
however, a branch of the iliolumbar vessels provides the
dominant blood supply to this part of the muscle and the
DCIA does not contribute any branches.7 The other sources
of blood supply are the segmental vessels originating from
the fourth to eleventh posterior intercostal arteries, which
provide the main blood supply to the cranial half of the
external oblique muscle and the minor pedicles to the
caudal half.23
Dominant:  deep circumflex iliac artery
Length: 12 cm (range 9–15 cm)
Diameter: 2 mm (range 1.5–3 mm)
The DCIA arises from the lateral aspect of the external
iliac artery 1–2 cm above the inguinal ligament and runs
parallel to the ligament toward the anterior superior iliac
spine in the line of junction of the transversalis and iliac
fasciae. It perforates the transversalis fascia lateral to the
anterior superior iliac spine and travels along the inner
margin of the iliac crest where it provides one or two
ascending branches to the external oblique muscle. A larger
lateral branch is given off 1–10 cm (average 5 cm) lateral to
the anterior superior iliac spine, piercing the transversus
abdominis and internal oblique muscles 0.5–4 cm above
the iliac crest and running for 1–5 cm on the deep surface
of the external oblique muscle before entering it. In 45%
of the cases a second, more lateral and smaller branch is
given off 6–10.5 cm (average 8 cm) lateral to the anterior
superior iliac spine and has a course similar to the first
branch.7
Dominant:  posterior intercostal arteries
Length: 6 cm (range 3–10 cm)
Diameter: 1 mm
The posterior intercostal arteries pass obliquely anteriorly
and inferiorly between the transversus abdominis and inter­
nal oblique muscles. Branches perforate the internal oblique
muscle, enter the external oblique muscle near the midlat­
eral line, and travel within the muscle parallel to the muscle
fibers and the supplying nerves until they radiate within the
muscle and give off perforating branches to the skin. The
arteries from the seventh and eighth intercostal spaces are
longer (8–10 cm) than the others (3–6 cm).23,24
VENOUS DRAINAGE OF THE FLAP (Fig. 11.8)
Primary:  deep circumflex iliac vein

e104
PART 4 — CONVENTIONAL WORKHORSE FLAPS
flap based on the segmental posterior intercostal arteries a
V-Y design in the caudal part of the flap is more likely to
achieve primary closure of the donor site.25
SPECIAL CONSIDERATIONS
• Free external oblique muscle flap with vascularized iliac
crest bone flap based on DCIA for reconstructions of, for
example, combined mandibular and floor of mouth
defects; consider chimeric flap design
• Functional free external oblique muscle flap based on
DCIA for facial reanimation with single vascular pedicle
and 2–3 separate segmental nerves
• Pedicled external oblique muscle/musculocutaneous
flap based on DCIA for reconstruction of groin, hemipel­
vectomy, trochanteric or anterior perineal defects
• Pedicled external oblique musculocutaneous flap based
on segmental posterior intercostal arteries for recon­
struction of anterior chest wall defects; consider V-Y flap
design
• Pedicled external oblique muscle turnover flap based on
segmental posterior intercostal arteries for reconstruc­
tion of posterior lower trunk defects26
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
As a free or pedicled flap based on the DCIA, only the lower
half of the external oblique muscle can be harvested. If
the external oblique muscle is raised as a pedicled flap based
on the posterior intercostal arteries the entire muscle or
parts thereof can be harvested according to the defect size.
The territory of the lower abdomen can be supplied
by the superficial inferior epigastric artery (when present)
and vein. These vessels can be included with the flap to
augment venous outflow or arterial inflow in select cases
(Fig. 36.8).
FLAP DIMENSIONS
Skin Island Dimensions
Skin island dimensions corresponding to muscle dimen­
sions or smaller. Primary closure depending on skin laxity.
MUSCLE DIMENSIONS
Length: average 11.5 cm (range 9–15 cm)
Width: average 6.8 cm (range 4–9 cm)
Dimensions for free external oblique muscle flap.7
BONE DIMENSIONS
Length: range 1–16 cm27
According to the defect size the length of the vascularized
iliac crest graft can be harvested up to a length of 16 cm.
FLAP MARKINGS
For flap markings, see Figure 36.4.
PATIENT POSITIONING
Supine positioning of patient, ipsilateral hip slightly ele­
vated. Repositioning after harvesting may be necessary
according to site of defect.
ANESTHETIC CONSIDERATIONS
General anesthesia.
TECHNIQUE OF FLAP HARVEST
Musculocutaneous Flap Design for Coverage of
Chest Wall Defects (Based on Segmental Posterior
Intercostal Arteries)
Flap elevation starts at the medial border of the external
oblique (may include anterior sheath of rectus abdominis);
the upper margin of the flap is the lower border of chest
wall defect and the caudal margin is at the inguinal
ligament/iliac crest. The caudal border of flap is designed
as a “V” to facilitate primary closure in V-Y fashion. Blunt
dissection is performed between external and internal
oblique muscle laterally up to anterior axillary line. The
lower flap margin is incised and transposed into the defect.
The donor site is closed primarily or with STSG.
Musculo-osteo(-cutaneous) Flap Design for
Reconstruction of Combined Mandibular and
Intraoral Soft Tissue Defects, Possibly as
Chimeric Flap
The skin is incised over the inguinal ligament and along
iliac crest. The DCIA is dissected along iliac crest. The
branch to the internal oblique muscle is preserved at this
point. Branches to iliac crest are preserved if vascularized
bone graft is needed. Pedicle is dissected until branch enters
external oblique muscle. Branch to internal oblique muscle
is ligated. May consider detaching external oblique muscle
from iliac crest bone flap to create chimeric flap depending
on configuration of defect.
Figure 36.4  External oblique flap. Anatomic landmarks and mark­
ings. Black dashed lines, midline, anterior axillary line, inframammary
fold, subcostal margin, inguinal ligament/iliac crest; black bold line,
flap design for free or pedicled external oblique flap; red bold line,
flap design for pedicled external oblique flap; blue bold area, iliac
crest bone graft (optional).

CHAPTER 36 — Omentum, Superior Epigastric, a nd External/Internal Oblique Flaps
e105
Free Flap
Musculo-osteo(-cutaneous) flap design for reconstruction
of combined mandibular and intraoral soft tissue defects,
possibly as chimeric flap.
ATYPICAL INDICATIONS FOR THE USE OF
THIS FLAP
Pedicled
• Based on DCIA: musculo(-cutaneous) flap design using
the lower half for coverage of groin, trochanteric, ante­
rior perineal, and hemipelvectomy defects
• Muscle turnover flap for coverage of posterior lower
trunk defects
• Free functional muscle flap for facial reanimation based
on DCIA
• Lower extremity reconstruction: Use as musculo- or
musculo-osteous flap depending on defect configuration,
may include overlying skin depending on thickness of
subcutaneous tissue
POSTOPERATIVE CARE
GENERAL
Avoid heavy weight-lifting for 6–8 weeks.
RECIPIENT SITE
General wound and flap care.
DONOR SITE
General wound care, avoid heavy weight-lifting for 6–8
weeks. Abdominal binder may be recommended in the first
4–6 weeks postoperatively.
OUTCOMES
EXPECTED OUTCOMES
The external oblique muscle flap provides versatile, thin,
pliable coverage for various defects and recipient sites as
well as robust blood supply through DCIA or segmental
posterior intercostal arteries. Inconspicuous donor site if
wound can be closed primarily, especially when using flap
based on DCIA.
UNTOWARD OUTCOMES
Meticulous closer of all layers and use of an inlay/bridging
mesh should be performed to prevent long-term develop­
ment of abdominal hernias.
INTERNAL OBLIQUE FLAP
FLAP ANATOMY (see Figs 11.2, 11.3, 11.6, 11.8,
11.9, 11.10 and see Ch. 42)
ARTERIAL AND VENOUS SUPPLY OF THE FLAP
(see Figs 11.2, 11.3 and 11.6)
The main blood supply of the internal oblique muscle is the
ascending branch of the deep circumflex iliac artery (DCIA)
Additional blood supply is provided by the lateral branches
of the deep inferior epigastric artery (DIEA) and branches
of the lower thoracic and lumbar arteries. However,
FLAP MODIFICATION/FLAP HANDLING
• Based on DCIA: musculo(-cutaneous) flap design using
the lower half for coverage of groin, trochanteric, ante­
rior perineal, and hemipelvectomy defects. Raise flap as
when using it as a free flap until desired arc of rotation
is achieved. Maximal length of pedicle up to 12 cm.
• Muscle turnover flap for coverage of posterior lower
trunk defects: skin is incised on medial or upper border
of external oblique muscle and skin flap is elevated.
Fascia of external oblique muscle is incised medially as
well as on the upper and lower border. External oblique
is lifted off internal oblique muscle up to the supplying
perforators at the midaxillary line. Muscle flap is turned
over, patient is repositioned to prone position, and flap
tunneled into defect.
• Free functional muscle flap for facial reanimation based
on DCIA as vascular pedicle and 2–3 segmental nerve
branches: flap is raised as for typical head and neck recon­
struction with dissection of segmental innervation to at
least 2–3 muscle segments.
When harvesting an external oblique muscle flap based
on the DCIA, the branch for the internal oblique muscle
should be left intact until the entire pedicle has been dis­
sected out. In rare cases of perfusion of the external
oblique muscle through the iliolumbar vessels (6%), the
internal oblique muscle can be used as a salvage
procedure.7
In combined external oblique muscle and vascularized
iliac crest flaps the muscle may be left attached to the iliac
crest, or the two components can be separated transforming
the flap into a chimeric flap depending on the configura­
tion of the defect.
SPECIAL INSTRUMENTS
The pedicled external oblique muscle flap can be harvested
endoscopically.28
DONOR SITE CLOSURE AND MANAGEMENT
After harvesting the external oblique muscle as a free
flap, care should be taken to close the donor site carefully
in layers to avoid abdominal hernias. The transversalis
fascia, the transversus abdominis, and the internal oblique
muscles must be repaired.7 At least one drain should be
placed in the subcutaneous plane and a second drain
without suction near the iliac crest if a bone graft has been
harvested. The skin defect can be closed primarily whenever
possible or by using a split-thickness skin graft (STSG). As
described for the internal oblique muscle flap, reconstruc­
tion with a prosthetic or bioprosthetic mesh is generally
advocated.29
For large pedicled musculocutaneous flaps in chest wall
reconstructions a V-Y design seems to be most beneficial for
primary closure of the defect. Placement of two drains is
recommended.
FLAP USAGE
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Pedicled (see Cases 36.3)
Chest wall reconstruction, defects in the flank.

e106
PART 4 — CONVENTIONAL WORKHORSE FLAPS
The arterial branches of the DIEA are always accompa­
nied by venae comitantes that drain into the paired deep
inferior epigastric veins. These travel parallel to the DIEA
and come together to form a single vein that drains into the
external iliac vein.30
FLAP INNERVATION (see Figs 11.9 and 11.10)
Sensory:  none
Motor:  motor branches of the eighth to twelfth thoracic,
iliohypogastric and ilioinguinal nerves
FLAP COMPONENTS
Based on the DCIA the internal oblique muscle can be
harvested as a free or pedicled muscle flap; it can include
vascularized bone from the iliac crest and a skin paddle
overlying the iliac crest. However, it cannot be harvested as
a purely musculocutaneous flap as the ascending branch of
the DCIA supplying the internal oblique muscle does not
give off any perforators to the overlying skin.
ADVANTAGES
• Free flap or pedicled
• Muscle flap or musculo-osteocutaneous
• Thin and pliable
• Inconspicuous donor site
• Reliable blood supply through DCIA
DISADVANTAGES
• Possible donor site morbidity
• Tedious and often bloody dissection
• Risk of injury of nerves supplying the remaining abdomi­
nal wall muscles
• Musculocutaneous flap design not possible
• No bulk
PREOPERATIVE PREPARATION
FLAP DESIGN (Fig. 36.5)
ANATOMIC LANDMARKS
• Caudal: inguinal ligament, anterior superior iliac spine,
iliac crest
• Cranial: subcostal margin
• Lateral: anterior axillary line
• Medial: midline/rectus abdominis muscle
GENERAL THOUGHTS ABOUT FLAP DESIGN
Generally, the internal oblique muscle flap cannot include
a skin paddle. Therefore, primary closure is always possible
and the remaining scar can be inconspicuously placed along
the inguinal ligament and the iliac crest. If a vascularized
bone graft from the iliac crest is included a skin paddle can
be designed on the skin overlying the iliac crest. Primary
closure can be achieved.
SPECIAL CONSIDERATIONS
Free internal oblique muscle flap with vascularized iliac
crest bone flap based on DCIA for reconstructions of, for
example, combined mandibular and floor of mouth defects
or lower extremity defects, consider chimeric flap design.30
perfusion of the internal oblique muscle based on the DIEA
is reliable in only 40% of cases.30
Dominant:  deep circumflex iliac artery
Length: 5.5 cm (range 5–6 cm)
Diameter: 2 mm (range 1.5–3 mm)
The DCIA originates from the lateral aspect of the
external iliac artery just above the inguinal ligament and
runs parallel to the ligament toward the anterior superior
iliac spine for a distance of 5–7  cm. Lateral to the ante­
rior superior iliac spine it perforates the transversalis
fascia and travels along the inner margin of the iliac
crest. The DCIA perforates the transversalis fascia medial
to the anterior iliac spine in about 12% and care should
be taken in this situation not to mistaken it for the
ascending branch. In its course along the iliac crest the
artery always lies external to the groove of attachment
of the iliacus muscle and the transversalis fascia. In about
80–88%, the ascending branch originates as a single
vessel – in 65% within 1  cm of the anterior superior
iliac spine, in 15% 2–4  cm medial to it. In 12–20%,
several smaller branches of the DCIA enter the muscle
lateral to the anterior superior iliac spine. The ascending
branch(es) run along the deep surface of the muscle
and eventually anastomose with the lateral branches of
the DIEA.8,30
Minor:  deep inferior epigastric artery
Length: 12 cm (range 10–15 cm)
Diameter: 3 mm (range 2–4 mm)
The DIEA originates from the medial aspect of the exter­
nal iliac artery just above the inguinal ligament. It travels
superiorly and medially lying underneath the rectus abdom­
inis muscle. Between the pubis and the umbilicus it gives
off 2–3 lateral branches that supply the internal oblique
muscle. They can measure up to 0.8 mm in diameter.
However, in anatomic studies reliable perfusion of the inter­
nal oblique muscle has been shown in only 40% through
these branches.8,30
VENOUS DRAINAGE OF THE FLAP
(see Figs 11.6 and 11.8)
Primary:  deep circumflex iliac vein
Length: 5.5 cm (range 5–6 cm)
Diameter: 3 mm (range 2–4 mm)
The arterial branches of the DCIA are always accompa­
nied by venae comitantes that drain into the paired deep
circumflex iliac veins. These travel parallel to the DCIA and
come together to form a single vein that drains into the
external iliac vein.7
Secondary:  deep inferior epigastric vein
Length: 12 cm (range 10–15 cm)
Diameter: 3 mm (range 2–4 mm)

CHAPTER 36 — Omentum, Superior Epigastric, a nd External/Internal Oblique Flaps
e107
ANESTHETIC CONSIDERATIONS
General anesthesia.
TECHNIQUE OF FLAP HARVEST
Musculo-osteo(-cutaneous) Flap Design for
Reconstruction of Combined Mandibular and
Enoral Soft Tissue Defects29 or Lower Extremity
Defects,28 Possibly as Chimeric Flap
Skin is incised above and parallel to inguinal ligament and
along iliac crest. External oblique aponeurosis and muscle
is incised. Internal oblique muscle is exposed and incised
transversely just below costal margin. Sharp dissection
is performed between internal oblique and transversus
abdominis muscles. The ascending branch of DCIA is
identified on deep surface of internal oblique muscle. It is
detached from rectus abdominis sheath and iliac crest.
The transversalis fascia is incised close to anterior superior
iliac spine and the ascending branch is traced to its origin
from the DCIA. All ascending branches should be
included if several are found. The DCIA is followed
leaving branches to iliac crest intact if vascularized bone
graft ± skin paddle is to be included. Muscle is divided
inferiorly leaving the inferior-most portion intact to
protect ilioinguinal and iliohypogastric nerves. The DCIA
is ligated close to its origins from external iliac artery. May
consider detaching internal oblique muscle from iliac
crest bone flap to create chimeric flap depending on con­
figuration of defect.
Pedicled Internal Oblique Flap Based on DCIA
Muscle flap for coverage of groin, trochanteric, anterior
perineal and midline lower abdomen defects: the flap is
raised as when using it as free flap until desired arc of rota­
tion is achieved. Maximal length of pedicle up to 6 cm.
FLAP MODIFICATION/FLAP HANDLING
In combined internal oblique muscle and vascularized iliac
crest flaps the muscle may be left attached to the iliac crest
or the two components can be separated transforming the
flap into a chimeric flap depending on the configuration of
the defect.
DONOR SITE CLOSURE AND MANAGEMENT
Care should be taken to meticulously close the transversalis
fascia, the external oblique muscle, and the skin in layers to
avoid defects in the abdominal wall. To avoid postoperative
hernia or bulge of the lateral abdominal wall, reconstruc­
tion with a prosthetic or bioprosthetic mesh is generally
advocated. Whenever possible, inlay mesh repair and myo­
fascial reapproximation to create a dual-layer closure should
be performed. If myofascial reapproximation cannot be
achieved, the mesh repair should be placed as a single-layer
interposition bridging repair. Care must be taken to anchor
the mesh to stable points of fixation.29 When an iliac crest
bone graft is included in the flap, the transversus abdominis
muscle and the external oblique fascia should be anchored
to the remaining ilium bone. If the flap design includes a
skin island over the iliac crest, the skin defect is usually
closed primarily.
Pedicled internal oblique muscle flap based on DCIA for
reconstruction of ipsilateral groin, trochanteric or anterior
perineal defects, midline lower abdomen defects.8
DIFFERENCE IN DESIGN, IF ANY, WHEN
PERFORMING THE FLAP AS PEDICLED OR FREE
In free flap design, consider deep inferior epigastric vein
and artery as supplemental blood supply/drainage for
supercharging the flap.
FLAP DIMENSIONS
Skin Island Dimensions
No musculocutaneous flap design possible, as no direct per­
forators to skin from ascending branch of DCIA.
MUSCLE DIMENSIONS30
Length: average 6 cm (range 4–10 cm)
Width: average 11 cm (range 8–15 cm)
BONE DIMENSIONS
Length: range 1–16 cm27
According to the defect size the length of the vascularized
iliac crest graft can be harvested up to a length of 16 cm.
FLAP MARKINGS
For flap markings, see Fig. 36.5.
PATIENT POSITIONING
Supine positioning of patient, ipsilateral hip slightly ele­
vated. Repositioning after harvesting may be necessary
according to site of defect.
Figure 36.5  Internal oblique flap. Anatomic landmarks and mark­
ings. Black dashed lines, lateral border of rectus abdominis muscle,
anterior axillary line, subcostal margin; black bold line, ingui­nal liga­
ment/iliac crest; blue area, iliac crest bone graft (optional).

e108
PART 4 — CONVENTIONAL WORKHORSE FLAPS
DONOR SITE
General wound care, avoid heavy weight-lifting for 6–8
weeks. Abdominal binder may be recommended in the first
4–6 weeks postoperatively.
OUTCOMES
EXPECTED OUTCOMES
Internal oblique muscle flap provides versatile, thin, pliable
coverage for various defects and recipient sites as well as
robust blood supply through DCIA. Inconspicuous donor
site as wound can usually be closed primarily.
UNTOWARD OUTCOMES
Meticulous closer of all layers and use of an inlay mesh
should be performed to prevent long-term development of
abdominal hernias. Preservation of inferior-most portion of
internal oblique muscle and conjoined tendon to avoid
injury to ilioinguinal and iliohypogastric nerves.
CONCLUSIONS
The above described flaps from the abdomen/abdominal
wall are not routinely used. However, they are valuable
alternatives when the use of the usual workhorse flaps is
precluded. Further understanding of their blood supply
and development of less invasive harvesting techniques
may increase their popularity and use in reconstructive
surgery.
TECHNICAL TIPS TO OPTIMIZE OUTCOMES AND
AVOID COMPLICATIONS
If no single, large ascending branch to the internal oblique
muscle can be identified, care should be taken to include
all the smaller branches to the internal oblique muscle
before dividing the pedicle.
Avoid injury to ilioinguinal and iliohypogastric nerves by
leaving the inferior-most portion of the internal oblique and
the conjoint tendon intact.
FLAP USAGE
TYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Free Flap
Musculo-osteo(-cutaneous) flap design for reconstruction
of combined mandibular and enoral soft tissue defects31 or
lower extremity defects,30 possibly as chimeric flap.
ATYPICAL INDICATIONS FOR THE USE OF THIS FLAP
Pedicled
Based on DCIA: muscle flap for coverage of groin, trochan­
teric, anterior perineal, and midline lower abdomen defects.
POSTOPERATIVE CARE
GENERAL
Avoid heavy weight-lifting for 6–8 weeks.
RECIPIENT SITE
General wound and flap care.
The patient underwent a complex cardiac procedure, which
ultimately resulted in an infected prosthesis and graft exposure.
After multiple debridement and washout procedure, he was
taken to the operating room for coverage with a pedicled
omentum flap based on the right gastroepiploic vessels. Due to
a history of sternal dehiscence, the sternum was reconstructed
with rigid fixation.
CASE 36.1  Exposed Aortic Graft and Infected Mediastinum Reconstructed with a Pedicled
Omentum Flap
Figure 36.6  (A) Exposure of an aortic graft. (B) An upper midline incision is made and the omentum is exposed. (C) The omentum is
brought out of the abdomen. The left gastroepiploic vessels are ligated and the omentum is separated from the stomach and transverse
colon. All vessels connecting these structures are carefully ligated. (D) The omentum is pedicled to the chest based on the right gastro­
epiploic vessels. (E) The omentum is inset over the aortic graft. (F) In this particular patient, it was necessary to fix the sternum with plates
and screws to provide rigid fixation. (G) The patient is seen postoperatively with a well-healed incision.
A
B
C
D
E
F
G
(Case courtesy of Samir Mardini)