THE CLAVIPECTORAL OSTEOMYOCUTANEOUS FREE-FLAP

Microvascular free tissue transfer has revolutionized head and neck re construction and currently is considered the most successful and relia ble method of primary oromandibular reconstruction. This study was des igned to assess the feasibility of full thickness free vascularized tr ansfer of the clavicle based on the clavicular branch of the thoracoac romial artery and the soft tissue component associated with the thorac oacromial axis; Forty dissections of the pectoral region were performe d on 26 cadavers. The anatomic relations of the region and the thoraco acromial arterial and venous systems were documented in detail. Select ive ink injections of the thoracoacromial arterial branches were also performed on fresh cadavers. The clavicle was supplied mainly by the c lavicular artery (medial three quarters), with minor contribution from the deltoid artery (lateral quarter). An average of 16.1 cm (range of 12 to 20 cm) was obtained with total clavicular harvest and the clavi cle had sufficient width and height to support dental implants. Two so ft tissue donor sites were associated with the thoracoacromial artery: the sternocostal head of the pectoralis major muscle, with the overly ing skin supplied by the pectoral artery, and the clavicular head of t he pectoralis major muscle, with the overlying skin supplied by the de ltoid and clavicular arteries. Sensory innervation of the upper chest was supplied through the supraclavicular nerves, whereas the lateral p ectoral nerve supplied motor innervation to both heads of the pectoral is major muscle, The anatomy of the clavipectoral donor site and the f irst case of full thickness free clavicular transfer for mandibular re construction in the English literature are presented. The donor site i s an excellent source of well vascularized, thin, pliable, hairless, p otentially innervated (motor and sensory) soft tissue, along with up t o 20 cm of clavicular bone. The surgical anatomy is familiar to the he ad and neck surgeon. The harvesting does not require repositioning of the patient and is amenable to a two-team, simultaneous approach. The functional and cosmetic donor site morbidity is minimal even with clav icular harvest. The major disadvantage of this flap is the relatively short pedicle. The authors conclude that the thoracoacromial system pr ovides a free flap with osseous and soft tissue components that are we ll suited for oromandibular reconstruction.