Last update: before 2017

GENERAL CONSIDERATIONS

1. Indications
   1. Carotid coverage after pharyngocutaneous fistula formation
   2. Reconstruction of large cutaneous cervical defects
   3. Hypopharyngeal reconstruction
2. Contraindications
   1. For most cases, other flaps are a better choice
   2. Prior chest wall surgery or injury (eg, radical mastectomy, pacemaker)
   3. Prior cardiac surgery with use of internal mammary artery for bypass

PREOPERATIVE PREPARATION

1. Additional Preoperative Evaluations
   1. None
2. Consent Inclusions
   1. Chest wall and neck scar
   2. Possible need for skin grafting to shoulder
   3. Bleeding, infection
   4. Flap failure (distal necrosis possible)

NURSING CONSIDERATIONS

1. Room Setup
   1. See Basic Soft Tissue Room Setup
2. Instrumentation and Equipment
   1. Standard
      1. Major Instrument Tray 1, Otolaryngology
      2. Major Instrument Tray 2, Otolaryngology
      3. Bipolar Forceps Trays
      4. Tracheotomy Tray
   2. Special
      1. Padgett Dermatome Instrument Tray
      2. Varidyne vacuum suction controller
3. Medications (specific to nursing)
   1. Antibiotic ointment
   2. 1% lidocaine with 1:100,000 epinephrine
   3. Mineral oil, heavy sterile topical (liquid petroleum), 10 ml (for skin graft)
4. Prep and Drape
   1. Standard prep, 10% providone iodine (neck, chest, shoulder, and upper thigh)
   2. Drape
      1. Head drape
      2. Towels around the neck (from the chin), chest from beyond the contralateral sternal border, below xiphoid, beyond midline on shoulder, and axillary line
      3. Towels around the skin graft site
      4. Split sheet
5. Drains and Dressings
   1. Penrose or suction drain
6. Special Considerations
   1. Possibility of a skin graft done in conjunction with procedure

ANESTHESIA CONSIDERATION

1. General Anesthesia
   1. Tube position: along contralateral arm or chest
   2. Paralysis is acceptable for this procedure
2. Systemic Medication
   1. Antibiotics (see Antibiotic Prophylaxis in Head and Neck Surgery protocol)
   2. Steroids: Decadron 10 mg IV will decrease flap edema
3. Positioning
   1. Supine
4. Estimated Blood Loss
   1. 200 cc (50-500)

OPERATIVE PROCEDURE

1. Pertinent Anatomy
   1. Skin paddle
      1. Covers the anterior-superior chest wall extending over the anterior shoulder from the clavicle to a line drawn from axilla to fifth thoracic interspace. The lateral extension extends over the anterior deltoid muscle. The blood supply to the extension of this flap beyond thoracoacromial artery and deltopectoral groove is nonaxial and becomes random pattern. The risk of skin necrosis increases the farther onto the shoulder the flap is extended. Flap failure is also increased if the perforating arteries are traumatized during elevation and if the flap is placed under tension during its rotation and inset.
2. Blood Supply
   1. Perforator arteries from the internal mammary artery that reach the skin paddle as they exit the chest between the ribs along the sternum
3. Flap Elevation
   1. The flap is outlined over the anterior chest wall and shoulder as noted above. The plane of elevation is deep to pectoral and deltoid muscle fascia. Muscle fibers will be exposed as the flap is elevated. Elevation should end 2 cm lateral to the sternal border taking care to avoid injury to perforating arteries. Branches from thoracoacromial artery, which perforate through the pectoralis major muscle laterally, are cut during elevation.
   2. Good tissue technique is required. Handle the flap with toothed pickups, skin hooks, or suture. Avoid excessive use of monopolor electrocautery.
   3. Do not overly rotate, kick, or compress the proximal flap.
   4. To improve the survival of the distal portions of the flap, a delay technique may be valuable.
4. Closure
   1. Donor site is covered with a split thickness skin graft; 0.015-inch thick and meshed 2:1. The skin graft is placed with an emphasis on lateral shoulder coverage. If the flap is to undergo secondary transection, the medial portion will return to the chest wall.
   2. Close wound edge with standard deep (3-0 vicryl) and skin sutures (surgical clips, or 4-0 to 5-0 nylons).
5. Drains
   1. A superficially placed (skin out) deltopectoral flap can be completed with a water-tight/air-tight closure and can suction drains are usually placed.
   2. A Penrose drain may be place under the rotated flap when a water-tight/air-tight closure is not obtained.
6. Dressing
   1. Ointment is applied to chest incisions.
   2. The skin graft site requires a light bolster dressing of fine mesh Xeroform gauze and gauze fluffs, followed by Montgomery straps or silk tie down sutures. The dressing is moistened with saline.

POSTOPERATIVE CARE

1. Dressings
   1. The skin graft bolster is removed on postoperative day 5 to 7. Keeping the dressing moist with sterile saline may increase skin graft survival.
2. Flap Monitoring
   1. No straps, ties, or cords should cover or compress the flap. It may be useful to write on the flap itself and place a sign at the patients bed side: "No ties around patient's neck." The flap is monitored by observation of color and needle prick bleeding. Pressure points and excessive torque should be assessed and improved if possible. Distal sutures may need to be removed to decrease the flap tension if flap blood supply appears compromised. Poor flap appearance may potentially be improved with the use of IV dextran, steroids, and/or hyperbaric oxygen.
3. Proximal (Pedicle) Transection
   1. In our current practice, transection of the base of the deltopectoral flap is rarely needed for its most common uses (ie, skin or carotid coverage). When the flap is "walked" up from the chest to close a defect of the upper aerodigestive tract, the proximal portion of the flap is returned to the chest after three to six weeks, at which time the fistula is closed.

DELAY TECHNIQUES

1. This flap may be delayed to increase its survival after rotation. The most common method is to complete the skin incisions and elevate the distal two-thirds of the flap. The skin flap is then returned to its normal anatomic position. After 10 to 14 days, it is reelevated and rotated into the reconstructive position.
2. Additional advantage may be gained by placing a split-thickness skin graft on the shoulder and chest wall under the flap at the time of primary elevation.

REFERENCES

Bakamijam,VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg. 1965;36:173.

Lore JM. General purpose flaps. In: Lore JM, ed. An Atlas of Head and Neck Surgery. 3rd ed. Philadelphia, Pa: WB Saunders Co. 1988:344-357.