Development of the Pectoral Perforator Flap and the Deltopectoral Perforator Flap Pedicled With the Pectoralis Major Muscle Flap

Purpose: Because thinning of the pectoralis major myocutaneous flap is impossible due to blood circulation, it is difficult to produce thin flaps. Although the pectoral flap and the deltopectoral flap are the best flaps that provide a highly desirable color-texture match to facial skin, their reach is restricted and they require resection in 2 stages. The purpose of this paper is to develop a new method of elevating a flap and to resolve these problems. Methods: First, include the third intercostal perforating branch of the internal thoracic artery in the skin paddle and, outward therefrom, design a skin paddle of the pectoral flap in accordance with the shape of the defect. After a skin incision along the design, elevate the pectoral flap pedicled with the third intercostal perforating branch. Then, after cutting the third intercostal perforating branch at the lower surface of the pectoralis major muscle, harvest the approximately 5- to 6-cm-wide pectoralis major muscle in the lateral direction. In doing so, it is important to include in the harvested muscle body of the pectoralis major muscle the muscular branch of the third intercostal perforating branch, the branch of thoracoacromial artery, as well as the true anastomosis of both. Thereafter, elevate the entire flap, with the thoracoacromial artery for vascularization, and move it to the head and neck region via the subclavian route. In this way, the pectoral perforator flap pedicled with the pectoralis major muscle flap (PP flap) is elevated. As for the deltopectoral perforator flap with the pectoralis major muscle flap (DPP flap), after elevating the deltopectoral flap pedicled with both the second and third intercostal perforating branches of the internal thoracic artery, carry out the same flap elevation operations. Results: The PP flap was used in 4 cases and the DPP flap was used in 1 case. In all cases, the flaps were completely grafted and quite satisfactory, functional, as well as demonstrating good cosmetic results. Discussion: Unlike the conventional pectoralis major myocutaneous flap, the PP flap does not contain in its skin paddle the pectoralis major muscle and the mammary gland, making it possible to produce a thin flap. In addition, the development of this method has now substantially extended the reach of the flap, thereby making it possible for the PP flap to reach the oropharyngeal region and for the DPP flap to reach the frontal region at a single time. Originally, the skin over the precordium is relatively thin and flexible and provides a desirable color-texture match to facial and neck skin; therefore, it is believed that this method may serve as an extremely useful means in the future in the functional and cosmetic reconstruction of the head and neck region.