The Adipofascial Deltopectoral Flap to Cover the Brachial Plexus in Thoracic Outlet Syndrome and Radiation Plexitis.
Dolan RT., Moosa A., Giele HP.
Revascularisation of the brachial plexus is controversial. Traditional techniques use free tissue transfer of omentum, groin fat or muscle, on the principle of supplying rich quantities of vascularised tissue to wrap around the nerves permitting neural gliding and revascularising the scarred nerves. However, the complexity of an additional microsurgical procedure coupled with uncertainty of their effectiveness have curtailed their clinical application. We describe a local pedicled transposition flap that is a novel modification of the deltopectoral (DP) flap using only the subcutaneous adipofascial tissue vascularised by the medial pectoral perforators. This flap is harvested through the supraclavicular brachial plexus access incision. This avoids free tissue transfer and additional donor scarring, yet provides adequate volumes of well-vascularised tissue for mechanical protection and revascularisation of the plexus. We reviewed sixteen consecutive patients who underwent a pedicled adipofascial DP flap to protect the brachial plexus over the 20-year study period. Inclusion criteria were patients with recurrent thoracic outlet compression and patients with radiation plexitis. At latest follow-up (average 3.6 years), 75% of patients reported the improvement or resolution of symptoms. The majority of patients reported improved pain scores (82%) with an average pain visual analogue scale (VAS) score of 5.1. Patients were very satisfied with scar outcomes, reporting low Vancouver Scar Scale Scores and low scar VAS scores. Post-operative MR imaging, available in 31% of the cohort, demonstrates the maintenance of flap position and vascularity at an average of 2.1 years. This novel and simple technique is recommended in aiding revascularisation and cover of the brachial plexus in recurrent and recalcitrant plexopathy.