Transferring pectoral muscle flap to depleted neck to create a new recipient source for free flaps in head and neck reconstruction

The thoracoacromial vessels (TA) are one of the options as recipient for free flaps in head and neck reconstruction when the neck is depleted. However, it has limitations such as need of vein graft or kinking and being under pressure on clavicle. The authors describe a new modification of using pectoral branch of TA as recipient vessel.

Between July 2019 and January 2022, 8 patients (1 female, 7 male) underwent head and neck reconstructions with free flaps. Age of patients ranged from 53 to 73 years old. All surgeries were because of SCC. Defects were including 3 total lower lip, 2 pharyngoesophageal defects, 1 cheek, lower and upper lip, 1 mandible, cheek and mount floor and 1 tongue and mount floor. Defects were between 12 × 5 cm and 21 × 9 cm. Pectoral branch of TA was transposed to the depleted neck as pectoral muscle flap to prevent kinking and pressure. Over the clavicle, the proximal root of the pedicle of muscle was found and dissected distally until tensionless anastomoses could be accomplished between the muscle and free flaps. ALT, MSAP, and Radial forearm free flaps were used as free flaps. In one patient the fibula and ALT flaps were used as flow through so the pedicle of ALT flap was anastomosed to pectoral muscle pedicle. Pectoral muscle was rotated 180° on its horizontal axis after finishing anastomoses to guard anastomoses from radiated neck skin. Muscle was fixed to sternocleidomastoid muscle with sutures to maintain its position. All donor sites were closed primarily.

The diameter of recipient artery was between 1 and 1.6 mm. The veins were approximately same as arteries. All anastomosis were performed end-to-end fashion. Three patients needed skin grafts to closure of tight radiated neck skin. Complications as 1 hematoma and 1 wound dehiscence were salvaged successfully. All flaps survived. Patients were followed up between 2 and 6 months. Our first patient died at post-operative 6th month so long follow-up could not be achieved. The final outcomes such as chewing, oral competence and swallowing were successful for remaining patients.

Transposing TA as pectoral muscle flap to the neck can decrease need of vein graft and prevent kinking or pressure of the pedicle on the clavicle.