Surgery and Healing in the Developing World - Dartmouth-Hitchcock

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254 Surgery and Healing in the Developing World
Figure 25. One stage release and single deltopectoral
axial pattern flap use
Figure 26. Dectopectoral flap. Note that
the proximal donor site can be closed primarily.
The distal shoulder area is closed
with a split thickness skin graft.
3. After the appropriate measurements are carried out, the flap is elevated.
4. Movement of the head is necessary at this stage in the operative procedure.
5. The bleeding vessels are grasped and ligated or cauterized as the flap is
elevated starting distally over the shoulder and progressing proximally
toward the sternum. The underlying fascia is included.
6. After the junction of the deltoid and pectoral muscles is reached, it is
important to include the pectoralis fascia with the elevated flap as mentioned
previously as the supporting vessels lie superficial to that.
7. Sharp dissection is used to within one inch of the sternum. At this point
the tissues should be carefully and gently spread with a blunt dissecting
scissors to avoid injury to the vascular supply.
8. The donor site can be partially closed primarily with nylon mattress sutures
leaving an area about 4 inches in diameter over the anterior shoulder
for skin grafting.
9. This is sutured in place after circumferentially running a suture to decrease
the exposed area to be grafted.
10.The recipient site is then prepared with turn in cheek, or anterior neck
flaps for the oral surface of the required tissue defect. Usually three turn
in flaps from the area near the defect in the cheek can be carried out. The
three areas for donation of inner cheek lining are superior, lateral and
inferior. The flaps are elevated with skin hooks. Two-thirds of the flap is
elevated. The proximal one-third is left undisturbed and undissected to
preserve adequate blood supply. These flaps are then joined as shown in
the second and third photo and in the diagrams.