Caterpillar advancement for partially necrosed deltopectoral flap.
CASE HISTORY: A 12 year old boy presented with the defect over right angle of mandible [Figure 1]. He had history of accidental high voltage electric burn injury, while he was marching for 26th January 2014 (Republic day). He was holding the iron pole hoisting our national flag in his hand, and suddenly the upper end of the pole touched high tension electrical line which lead to burn injury over right side of face, neck, bilateral upper limb, lower limb and exit wound over right sole. Subsequently he was treated at primary health care Centre, near his village, later on he developed defect over right angle of mandible, for which he came to our hospital.
On examination a 3x3 cm defect with exposed angle of mandible is seen. So we planned the coverage of defect with deltopectoral flap along with remaining post burn raw area over right upper and lower limb with split thickness grafting.
Deltopectoral flap was done on 21st February. Till 7th post-operative day the flap was healthy but from 8th post-operative day the blackening of the upper part of the flap was started and almost 50 % of upper half of flap was necrosed.
We continued the conservative management and slightly delayed the flap division. The flap division was done at around 32nd post-operative day with slight modification known as CATTERPILLAR ADVANCEMENT was done [Figure 2], In which the free divided part of the flap is transposed to the necrosed part of the flap after the debridement of necrosed part of the flap. Method was worked and flap was healthy at the time of discharge and during the follow-up period [Figure 3].
DISCUSSION: This type of patient presents a significant challenge to the reconstructive surgeon, but also highlights one of the rewards of the field--the ability to choose among many available reconstructive options. As evidence of the wide range of possibilities- the latest edition of Grabb's Encyclopedia of Flaps lists 50 different options for neck and cheek reconstruction.
Among those is the deltopectoral flap, a versatile flap with many potential benefits and few drawbacks when used appropriately. The deltopectoral flap originated in the beginning of the 20th century. Although the modern implementation is attributed to Bakamjian,  the first description was reported by Aymard in 1917, a contemporary of and sometimes rival to Gillies. The deltopectoral flap is a parasternal, axial fasciocutaneous flap based on the perforators of the internal mammary artery. At its fullest extent, it can reach practically all of the lower two-thirds of the face. This flap has been used for nasal reconstruction pharyngoesophageal reconstruction, fistula closure, tracheal reconstruction, full-thickness vascularized skin repair, as cover for critical head and neck structures, and as cover for other flaps. Use of the deltopectoral flap as a free fasciocutaneous flap has been reported. 
The deltopectoral flap is particularly useful in patients requiring coverage of the anterior or lateral neck, and provides an excellent match for colour, texture, thickness and hair-bearing to facial skin. When compared with the pectoralis major myocutaneous flap, the deltopectoral flap has little or no effect on shoulder function. Finally, the deltopectoral flap can be elevated and transposed without repositioning the patient, allowing the donor and recipient sites to be prepared simultaneously.  The deltopectoral flap often requires multiple surgeries to achieve optimum results. Many authors have reported flap success rates in the range of 75% to 90%, with failures typically including distal flap necrosis. 
With meticulous flap handling and careful attention to the fascial plane during dissection, the deltopectoral flap has the potential for rates of success of 90% to 95%.
Feng et al  reported 34 cases using the extended deltopectoral flap with no flap loss, and in which only two cases required local advancement of skin or skin grafting to complete the closure, yielding a success rate of >94%. The present case demonstrated the utility and versatility of the deltopectoral flap in reconstructing the angle of mandible beyond salvage.
[1.] Bakamjian VY. A two-stage method for pharyngeoesophageal reconstruction with primary pectoral skin flap. Plast Reconstr Surg. 1965; 36: 173-84. [PubMed].
[2.] Chen CH, Lin GT, Fu YC, et al. Comparison of delopectoralis flap and free radial forearm flap in reconstruction after oral cancer ablation. Oral Oncol. 2005; 41: 602-6. [PubMed].
[3.] Blackwell KE, Buchbinder D, Biller HF, Urken ML. Reconstruction of massive defects in the head and neck: The role of simultaneous distant and regional flaps. Head and Neck. 1997: 620-8. [PubMed].
[4.] Gilas T, Sako K, Razack MS, Bakamjian VY, Shedd DP, Calamel PM. Major Head and neck reconstruction using the deltopectoral flap--a 20 year experience. Am J Surg. 1986; 152: 4304. [PubMed].
[5.] Feng GM, Cigna E, Lai HK, et al. Deltopectoral flap revisited: Role of the extended flap in reconstruction of the head and neck. Scand J Plast Reconstr Surg Hand Surg. 2006; 40: 275-80. [PubMed].
Anand Narayan Gautam (1), Vicky Khobragade (2), Sanjeev Kumar (3)
(1.) Anand Narayan Gautam
(2.) Vicky Khobragade
(3.) Sanjeev Kumar
PARTICULARS OF CONTRIBUTORS:
(1.) Assistant Professor, Department of Plastic Surgery, Gandhi Medical College, Associated Hamidia Hospital, Bhopal.
(2.) Resident, Department of General Surgery, Gandhi Medical College, Associated Hamidia Hospital, Bhopal.
FINANCIAL OR OTHER COMPETING INTERESTS: None
(3.) Resident, Department of General Surgery, Gandhi Medical College, Associated Hamidia Hospital, Bhopal.
NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:
Dr. Anand Narayan Gautam, Sr. MIG 61, Sahyadri Enclave, Opposite Wireless Office, Bhadbhada Road, Bhopal-462003, Madhya Pradesh.
Date of Submission: 10/03/2015.
Date of Peer Review: 11/03/2015.
Date of Acceptance: 23/03/2015.
Date of Publishing: 07/04/2015.
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|Title Annotation:||ORIGINAL ARTICLE|
|Author:||Gautam, Anand Narayan; Khobragade, Vicky; Kumar, Sanjeev|
|Publication:||Journal of Evolution of Medical and Dental Sciences|
|Article Type:||Clinical report|
|Date:||Apr 9, 2015|
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