Major Head and Neck Reconstruction Using the
Deltopectoral Flap
A 20 Year Experience
Tom oilas, MD, KumaoSako, MD, MohamedS. Razack, MD, VahramY. Bakamjlan,MD, DonaktP. She&t, MD,
and Peter M. Calamel, MD, Buffalo, New York
Surgical ablation of almost all primary and regional-
ly advanced head and neck tumors continues to be
the primary modality of treatment when possible.
With this trend towards more radical ablation has
been an increasing emphasis and acceptance of im-
mediate reconstruction of large defects after sur-
gery for head and neck cancer. Since its introduc-
tion in 1964 by Bakamjian [I] for total pharyngeal
reconstruction, the medially based deltopectoral
flap has been the mainstay of flaps at our institution
and others when reconstruction of major defects is
called for. It is a simple, reliable, and relatively
hairless flap with a large amount of versatile tissue
available within the immediate operative field that
leaves a donor site easily concealable by normal
clothing.
Within the past 10 years, several alternative
methods of reconstruction of major defects in the
head and neck area have been introduced, such as
myocutaneous flaps from the pectoralis major, ster-
nomastoid, and trapezius muscles, as well as vascu-
larized free flaps [2-S]. In addition, there are other
established regional flaps, such as the forehead flap
and the Abb&Estlander flap [7,8]. The introduction
of myocutaneous flaps has supplanted the preemi-
nent position of the deltopectoral flap in head and
neck reconstruction and has made the choice of
reconstructive procedures available far greater to-
day than in the past. At our institution, the recent
trend towards more frequent use of myocutaneous
flaps has paralleled the general experience, but their
use remains complementary to that of the deltopec-
toral flap. This study was undertaken to examine
From the Department of Head and Neck Surgery, Roswell Park Memorial
Institute, Buffalo, New York.
Requests for reprints should be addressed to Kumao Sako, MD, Depart-
ment of Head and Neck Surgery, Roswell Park Memorial Instltute, 666 Elm
Street, Buffalo, New York 14263.
Presented at the 32nd Annual Meeting of the Society of Head and Neck
Surgeons, Colorado Springs, Colorado, May 7-10, 1986.
430
the reconstructive experience at our institution
with the use of the medially based deltopectoral flap
and to evaluate the results and complications in an
attempt to formulate more accurate guidelines for
flap construction and use. The influence of radia-
tion and flap delay on the incidence of flap compli-
cations is also discussed.
Material and Methods
The hospital records of all patients who received delto-
pectoral flaps during a 20 year period (January 1,1964 to
December 31,1984) at the Roswell Park Memorial Insti-
tution were reviewed in a retrospective manner. Demo-
graphic data, diagnoses, concurrent medical conditions,
preoperative radiotherapy, type of operation, and extent
of surgical defect and complications were taken from pa-
tient histories, progress notes, and operative reports. In
addition, clinical photographs were frequently used.
During this period, 604 patients with a mean age of 59.8
f 11 years received a total of 678 deltopectoral flaps
(Table I). In the initial experience with the flap, the
preliminary flap operation was delayed for selected pa-
tients based on nutritional status, tissue turgor, circula-
tory complications, metabolic problems such as diabetes,
and the need for unusually long flaps or modified flaps for
complex reconstruction.
The deltopectoral flap is usually constructed with the
upper incision along the upper edge of the clavicle and the
width of the base encompassing four interspaces. The
length of the average flap extended to the middle or
posterior edge of the lateral aspect of the upper arm. The
medial limit of elevation was usually 8 to 10 cm lateral to
the midsternal line. The standard flap for reconstruction
of the pharynx, the tongue, and the floor of mouth usually
had a length to width ratio of 2:l.
Initially, delay of the flap consisted of raising it com-
pletely, replacing it, and suturing the skin back together.
Since 1969, the method of delay has consisted of incising
the skin margin and undermining only that part of the
The American Journal of Surgery
 Head and Neck Reconstruction With Deltopectoral Flaps

flap overlying the thoracoacromial component of the TABLE I Pattern ot Deltopectoral (DP) Flap Use: Alone
blood supply and ligating this vessel. This method of and In Comblnation Wlth Other Flaps
delay was introduced to diminish hematomas, seroma,
Number & Types
infection, and induration of the edge of the flap after of Flaps Patients (n)
delay.
Single flap 496
Results Two flaps
Synchronous (n = 21)
Five hundred fifteen of the 678 flaps (76 percent) DP&DP 9
were in men and 163 (24 percent) were used in DP&PM 11
women. There was an equal distribution of left- and DP & SCM 1
Metachronous (n = 81)
right-sided deltopectoral flaps. Five hundred thirty DP, DP (14.3 mo) 61
patients (88 percent) received a single deltopectoral DP, PM (16.3 mo) 9
flap, 496 of whom (82 percent) required no addition- DP, LD (5 mo) 3
al flaps. In 34 instances (6 percent), a single delto- DP, SCM (9.5 mo) 2
PM, DP (4 mo) 1
pectoral flap were used in combination with one or
LD, DP (4.3 mo) 3
more myocutaneous flaps for reconstruction. Sev- SCM, DP (9 mo) 2
enty-four patients (12 percent) received two delto- Three flaps (n = 5)
pectoral flaps; in 63 patients (10 percent), these DP 8. PM, DP (2 mo) 1
flaps were used in separate procedures and in 11 DP, TP & SCM (9 yr) 1
DP & DP, PM (1 wk) 1
patients (2 percent) simultaneous bilateral delto- DP, TP (5 mo), 1
pectoral flaps were needed for reconstruction. Table TP, LD (3 wk)
I illustrates the combinations and time sequences in DP & DP, TP (15 mo) 1
which the deltopectoral flap was used in combina- Four flaps
DP B PM, LD (1 mo) 1
tion with other myocutaneous flaps. Of the 81 pa-
LD, DP (5 mo)
tients who received two flaps on different occasions,
41 (50 percent) were for reconstruction of new de- lData in parentheses indicate the time intervals between flaps.
fects resulting from resection of recurrent or new DP = deltopectoral; LD = latissimus dorsi; PM = pectoralis
myocutaneous; SCM = sternocleidomastoid; TP = trapezius.
primary malignancy with a mean interval between
procedures of 24 months, whereas 14 (17 percent)
were used in planned staged reconstruction with a
mean interval of 4 months. In 26 cases (33 percent), TABLE II Frequency d De&pectoral Flap Use For
the subsequent flaps used to repair defects due to Reconetructtonln Varkw Head and Neck
failed previous flap reconstruction (mean interval Anatomic Sites
between procedures 4.2 months). In our series, five Area Flaps Employed
patients received three flaps and one patient re- Reconstructed n Percentaoe
ceived four flaps, with each patient receiving at least Skin 308 45.4
one deltopectoral flap in combination with other Oropharynx 299 44.1
myocutaneous flaps. Multiple flaps in these pa- Hypopharynx 220 32.4
tients were needed to correct failed previous recon- Floor of mouth 174 25.6
structions (3 patients) or for reconstruction of new Tongue 131 19.3
Cervical esophagus 128 18.8
defects resulting from resection of recurrences (3 Base of tongue 118 17.4
patients). Sofl palate 95 14
The indication for surgery in the majority of the Buccal 86 12.6
patients in this series was for resection of a primary Tonsil 52 7.6
Hard palate 57 a.4
or recurrent malignancy of the upper aerodigestive
Other
tract, salivary or thyroid glands, or skin. However, Maxillectomy defect 45 6.6
in 56 patients, deltopectoral flaps were used for Nasopharynx 22 3.2
other indications, including planned staged recon- Speech fistula 6
structions after resection of benign tumors, forma- Cervical esophagostomy 1
Colon interp&iti& failure 1 1
tion of speech fistulas, and repair of strictures, ra-
dionecrotic ulcers, chemosurgical defects, and
preexisting defects and fistulas. As would be expect-
ed in a series of patients requiring major distant from an examination of the operative notes and
flaps for reconstruction of large defects, the major- clinical photographs. Table II illustrates the per-
ity of primary tumors resected were stage III or IV, centage of the deltopectoral flaps used to recon-
with roughly an equal number of patients having struct the indicated particular anatomic head and
resections for recurrent tumors. neck sites. Skin coverage was the most frequent
An estimate of the extent of the defect recon- indication for deltopectoral flap reconstruction, fol-
structed by the deltopectoral flap was determined lowed by oral and hypopharyngeal sites. The mean

Volume 152, October 1966 431

Gilas el al

TABLE III Compllcatlonr Encountered In the Use of 678 reconstruction (mean f standard error of the
Deltopectoral Flaps In 604 Patients mean). Two hundred fifteen deltopectoral flaps
Undergolng Major Head and Neck (31.7 percent) were used in patients who had re-
Reconstructlon8 ceived radiotherapy before resection with a mean
Flaps dose of 5,663 f 1,347 rads.
Complications n Percentage We analyzed the complications encountered in
reconstructions using the deltopectoral flap with
lntraoperative loss 3 1
Infection 71 10.5 particular attention to occurrence of intraoperative
Fis@la 110 16.2 problems, postoperative infections, fist& forma-
Necrosis tion, flap necrosis, and other less common complica-
Major 115 16.9 tions (Table III). Skin flap necrosis was defined as
Minor 196 14.2
Other
major if there was full-thickness skin loss of more
Separation 42 6.2 than 1 square inch of skin surface, if another proce-
Stricture 11 1.6 dure was required to salvage or repair the recon-
Exposure of bone graft 12 1.7 struction as a result of the necrosis, or if operative
or prosthesis
debridement of the flap was required. All other
Prolonged healing 4 1
Seroma. hematoma, bleeding 7 1 degrees of necrosis were designated as minor. In 8 of
Drainage, ecchymosis 7 1 125 delayed deltopectoral flaps, necrosis occurred
Overall complications 349 51.4 after the delay. There were three instances of major
necrosis; in one, the degree of major necrosis prohib-
ited subsequent use of the deltopectoral flap for
reconstruction. Necrosis was minor in five patienta.
number of anatomic sites reconstructed per flap was In three patients, intraoperative problems with
2.6. Fifty-three percent (362 flaps) were used for blood supply were encountered, and in two in-
lining only, 27 percent (185 flaps) were used for skin stances this occurred in previously delayed flaps.
coverage only, and 130 (19 percent) were used both Trimming of the flap to adequately perfused tissue
as lining and cover. Complete defect closure without resulted in an inability to complete reconstruction
controlled fist&s and the need for subsequent with the flap in two of these patients.
staged procedures was accomplished in 26 percent With increasing experience in the use of the delto-
of reconstructions utilizing the deltopectoral flap. pectoral flap, routine delay was abandoned because
The majority of the incomplete procedures in the of our belief that the incidence of complications was
deltopectoral flap reconstructions were related to unaltered by delay of the flap. When we compared
the need for future division and inset of the delto- the incidence of complications in all of the catego-
pectoral flap pedicle, with subsequent closure of the ries shown in Table III between delayed and nonde-
surgical fistula that had been created as a necessary layed deltopectoral flaps, there was no statistically
part of the reconstruction. significant difference between the two groups in any
Tubulation of the deltopectoral flap pedicle was category. The rate of major necrosis with delayed
often performed either as a necessary part of the flaps was 16.1 percent versus 17.1 percent in unde-
reconstruction or to form a skin-covered surface in layed flaps . We also compared the incidence of
those instances when the pedicle was brought exter- complications in patients who had received radio-
nally into the reconstructed area through the upper therapy versus those who had not (215 flaps versus
double transverse neck incisions. One hundred nine 463 flaps, respectively). No statistically significant
flaps (16 percent) were not tubulated, the majority differences were seen, with the exception of a higher
of these being used for external skin replacement; rate of major necrosis in those who had received
thiee hundred ninety-eight (59 percent) required a radiotherapy (15.1 percent versus 21 percent, p
single tubulation and 170 (25 percent) required a <0.005).
double or reversed tubulation to provide both a raw The overall rate of major necrosis was 16.9 per-
surface for apposition to the tissues while in the cent and that of minor necrosis, 14.2 percent. These
subcutaneous portion and a skin-covered external figures are similar to our previously reported earlier
pedicle. and partial experience with the use of the deltopec-
During the initial experience, deltopectoral flaps toral flap in reconstruction [9].
were delayed for diabetic patients, elderly patients, The overall complication rate for reconstructions
malnourished patients, patients with vascular dis- carried out with deltopectoral flaps was 51 percent,
ease, and those who had received previous irradia- 22 percent of which were major complications (Ta-
tion. Creation of 125 deltopectoral flaps (18.4 per- ble III).
cent) was delayed, with 90 (72 percent) delayed in In order to determine which characteristics of
one step 20.8 f 16 days before definitive reconstruc- flap construction or areas of flap use were responsi-
tion and 35 (28 percent) delayed in two steps, at 26.1 ble for the most morbidity, an analysis of complica-
f 22.3 days and 54.5 f 33.8 days before definitive tion rate for a number of variables describing vari-

432 lhe Amaflcan Journal of SurWY

 Head and Neck Reconstruction With Deltopectoral Flaps

ous flap, patient, or defect characteristics was TABLE IV Risk ot Flap Necrosts When Strattfled par
carried out (Table IV). The highest rate of compli- Patlent, Flap, and Stto Variables
cations for deltopectoral flap reconstructions oc- Risk of Necrosis 1
curred in those used as lining only; those created by Variable Percentage p Value
reverse tubulation; those with a slit to accept a
Overall 17
stoma or esophageal anastomosis; those used in re- Preop radiotherapy 21 <o.o$E
constructions of the tongue, base of the tongue, Diabetes 18 NS
mouth floor, and for total pharyngeal reconstruc- Delay in flap procedure 17 NS
tion; and those used in previously irradiated beds. Single tube 18 NS
The fewest complications occurred when deltopec- Double tube 18 NS
No tube 12 <0.005
toral flaps were nontubulated and used as skin cov- Flap used as lining only 20 <0.005
erage only. Flap used as cover only 12 <0.005
Flap used as both 18 NS
Slit for stoma 35 <0.005
Buccal 20 NS
This report represents the extensive experience 18 NS
Tongue
of a single institution in the use of the deltopectoral Base of tongue 17 NS
flap for reconstruction after major surgery for head Floor of mouth 21 <0.005
and neck cancer. The overall complication rate for Hard palate 14 NS
reconstruction using a deltopectoral flap was 51 Sofl palate 18 NS
Tonsil 19 NS
percent, with roughly an equal division between Oropharynx 19 <O.Ol
major and minor complications. It should be em- Hypopharynx 19 <O.Ol
phasized that this high complication rate should not Cervical esophagus 23 <0.005
be exclusively attributed to the type of flap used, Total pwomy 26 <0.005
but rather to the inherent nature of the patient NS = not significant.
population and the type of operation performed. In
this series, all complications that occurred in any
reconstruction employing a deltopectoral flap were tion, and other less common complications did not
reported whether or not that complication was re- differ from that seen in myocutaneous reconstruc-
lated to the use of a major regional flap. Multiple tions in our series of myocutaneous flaps and in the
factors such as patient age, preoperative malnutri- series of other investigators [13-171.
tion, previous irradiation, concurrent illnesses, and Although Krizek and Robson 1181 have used the
exposure to oropharyngeal bacteria and saliva all deltopectoral flap in previously irradiated fields
contributed to the incidence of complications; thus, with very little loss and have emphasized the s$ety
separation of complications strictly attributable to of flap use in this situation, our observations from
the use of the deltopectoral flap in a retrospective this series lead us to believe that placing a flap into
series such as this is difficult. Our overall rate of an irradiated field predisposes the patient to a sta-
major complications (22 percent) was slightly high- tistically significant increased risk of major flap
er than the 13.6 percent reported in a series of 44 necrosis. Sutures may hold for 1 to 2 weeks, but with
patients by Tiwari et al [IO]. KrizekandRobson [II] delayed healing of the bed and with traction due to
reported a rate of major necrosis of 10.5 percent in the weight of the flap, the flap edge can begin to
86 patients, whereas Mendelson et al [12] had a 23 retract; and because of separation with a secondary
percent rate of major flap loss. These results are in low grade infection, a slowly eroding type of necrosis
keeping with our more definitive experience report- may occur that can progress to major flap loss. This
ed here. experience with the use of deltopectoral flaps in
In the past decade, myocutaneous and free flaps irradiated fielda has been shared by Ramadan and
have supplanted the deltopectoral flap as the major Stell[19], Tiwari et al [JO], and Mendelson et al (221.
flap used in head and neck reconstruction. At our In this series, 182 deltopectoral flaps were used in
institution, myocutaneous flaps have been used as combination with other deltopectoral flaps and with
complements to deltopectoral flaps. In a series of 99 myocutaneous flaps either simultaneously or se-
myocutaneous flaps used concurrently in the past quentially to repair major defects that could not be
10 years at our institution, our rate of major necrosis closed with a single flap, to reconstruct defects after
was 20 percent, with an overall complication rate resection of recurrent tumors where myocutaneous
comparable to that for reconstructions carried out flaps had been used before, and to correct previous-
with deltopectoral flaps [unpublished data]. This ly failed deltopectoral and myocutaneous flap re-
complication rate compares favorably with those of constructions. In the majority of cases, an unsuc-
other published series of myocutaneous flaps, in- cessful flap reconstruction, when carried out with a
cluding that of Mehrhof et al [13], who reported an deltopectoral flap, could be salvaged by use of resid-
overall complication rate of 54 percent. The inci- ual tissue and flaps. In only 27 percent of cases was
dence of wound infection, fistula formation, separa- another flap necessary to salvage the reconstruc-

Volume 152,Octobof1*86 433

Gilas et al
tion. We find the deltopectoral flap to be a reliable
and versatile flap that can be used alone or in combi-
nation with other flaps for major head and neck
reconstruction.
Although several investigators have advocated
frequent and liberal delay of creation of deltopec-
toral flaps, we no longer recommend routine delay
since the incidence of complications in our experi-
ence has not been diminished by delay. In fact, the
delay itself may cause flap necrosis and loss, as
occurred in 8 of our 125 delayed flaps.
In reconstruction of the intraoral area, we bring
the deltopectoral flap outside the cervical flap and
insert it through the upper double transverse neck
incision, and also bring it under the cervical flap
through the lower transverse surgical incision, cre-
ating a long surgical fistula. Bringing the deltopec-
toral flap under the cervical flap through the lower
cervical incision requires less time for reconstruc-
tion but involves more dissection for subsequent
closure of the fistula and return of the unused por-
tion of the flap to the chest wall, but requires only a
single tubulation of the flap. In our series, this ma-
neuver did not seem to increase complications or
necrosis. Bringing the fistula out through the upper
transverse incision takes more time for reconstruc-
tion because of the tubulation of the long portion of
the unused flap and the care with which the reverse
tubulation of the flap must be carried out. The first
tubulation of the flap is made to create a skin-lined
fistula in its subcutaneous course and then a reverse
tubulation to create a skin-covered pedicle in its
external course. This double tubulation may impair
circulation to the distal portion of the flap and be
the cause of complications and necrosis. There was a
higher incidence of flap complications and necrosis
when a double tubulation was carried out in our
series, but was not statistically significant. How-
ever, when no tubulation was carried out and a
deltopectoral flap was used only for skin coverage,
the rate of necrosis was significantly decreased. The
highest rate of flap necrosis occurred when the flap
was tubulated, used in an irradiated bed, had a slit
to receive a stoma or an esophageal anastomosis, or
was used for major reconstructions of the oral and
hypopharyngeal areas or for total pharyngeal recon-
struction.
Summary
Six hundred seventy-eight deltopectoral flaps
were raised in 604 patients, 125 of which were de-
layed and 215 of which were used in previously
irradiated beds. The rate of major flap necrosis was
16.9 percent and the overall rate of complications,
51.4 percent. Delay in creating the deltopectoral
flap had no influence on the risk of complications
and necrosis, whereas the use of the flap in a previ-
ously irradiated bed was associated with a signifi-
434
cantly increased risk of major flap necrosis. The
least flap loss occurred when the deltopectoral flap
was used without tubulation for skin coverage only.
Complications and flap necrosis occurred most fre-
quently when flaps were tubulated in a reversed
manner or used for lining of major portions of or for
total oropharyngeal and hypopharyngeal recon-
struction.
The deltopectoral flap remains a useful, reliable,
and versatile regional flap that can be used alone or
in combination with other flaps in selected circum-
stances for major head and neck reconstruction.
References
1. Bakamjian VY. A two-stage method for pharyngoesophageal
reconstruction with a primary pectoral skin flap. Plast Re-
constr Surg 196536: 173-84.
2. Back S, Biller HF, Krespi YP, Lawson W. The pectoralis major
myocutaneous island flap for reconstruction of the head
and neck. Head Neck Surg 1979;1:293-300.
3. Ariyan S. The sternocleidomastoid myocutaneous flap. Laryn-
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4. Demergasso F, Piazza MV. Trapezlus myocutaneous flap In
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6. Lichtveld PLM, Snow GB. Reconstruction by means of pedi-
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19. Ramadan MF, Stetl PM. Reconstruction after pharyngotaryn-
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The American Journal of Ourgory