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Comparative analysis of single-stage vs. two-stage deltopectoral flap reconstruction in patients with oral cavity squamous cell carcinoma: a case series.Swini Kaushal1, Deepika Garg1, Sanjeev Kumar1, Prakash Nagpure1 Introduction The deltopectoral (DP) flap remains a reliable regional reconstructive option in head and neck surgery, particularly in resource-constrained settings where microvascular reconstruction may not be feasible. First described by Bakamjian in 1965, the DP flap is based on perforators of the internal mammary artery, offering a predictable vascular supply and minimal donor site morbidity [1]. Although traditionally performed as a two-stage procedure to enhance flap reach and vascular integration, refinements in technique have enabled its use as a single-stage reconstruction for moderate-sized mucosal and cutaneous defects [2, 3]. In high-income countries, free tissue transfer has become the standard for head and neck reconstruction due to its versatility in complex composite defects. However, free flaps demand technical expertise, prolonged operative time, and intensive postoperative monitoring, which may not be readily available in many parts of the world. In contrast, regional pedicled flaps—such as the deltopectoral (DP) and pectoralis major myocutaneous (PMMC) flaps—continue to play an essential role globally, particularly in low- and middle-income countries (LMICs). These techniques are also used internationally as salvage options in irradiated fields, vessel-depleted necks, or when free flaps fail, underscoring their enduring clinical relevance. The choice of reconstructive approach is also influenced by the epidemiological burden of disease. In India, oral cavity squamous cell carcinoma (SCC) is among the most common malignancies, accounting for approximately 30-40% of all head and neck cancers, and nearly 20% of all cancers in men. High prevalence is linked to tobacco and betel quid use, poor oral hygiene, and late presentation, particularly in rural areas [10, 11]. Sevagram, the location of this study, lies within a rural region endemic for kharra use—a smokeless tobacco preparation comprising tobacco, lime, and areca nut—which contributes significantly to the local burden of oral squamous cell carcinoma. In such contexts, timely and effective reconstruction is crucial—not only for restoring anatomy and function but also to minimize delays in adjuvant therapy. This case series aims to compare the outcomes of single-stage versus two-stage DP flap reconstructions in patients undergoing surgery for oral cavity SCC. Specific focus is placed on flap design, postoperative recovery, complication rates, and time to adjuvant therapy, with attention to the practical implications in real-world clinical settings. Materials and methods A retrospective chart review was performed at a tertiary health centre between March 2023 and March 2025. Twelve patients with biopsy-proven oral cavity SCC underwent ablative surgery followed by DP flap reconstruction. Patients were grouped based on flap technique: Group A (n=7): single-stage DP flap Group B (n=5): two-stage DP flap Inclusion criteria:
Results Among the 12 patients (mean age: 58.9 years; M:F ratio 5:1), the buccal mucosa was the most common primary site (n=6), followed by the alveolar ridge (n=4), and floor of mouth (n=2). Flap design and reach: all single-stage DP flaps were utilized for anterior and moderate-sized defects. Direct rotation to the defect site without de-epithelialization was feasible in most cases. The two-stage flaps were reserved for anterior and extensive or posterior defects, such as those involving the retromolar trigone. The second stage involved flap division and inset after 2–3 weeks, allowing greater reach and flexibility. Hospital stay and recovery: mean hospital stay: 10 days (single-stage) vs. 25 days (two-stage). Time to oral intake and mobilization was earlier in the single-stage group. Patients reported higher comfort scores and lower wound care requirements in the single-stage group. Complications: Minor flap tip necrosis: 1 patient in each group (resolved with local care). Wound dehiscence (single-stage group): 1 patient, healed conservatively. No total flap loss or donor site morbidity in either group. Adjuvant Therapy: Mean time to initiation: 26 days (single-stage) vs. 41 days (two-stage). The delay in the two-stage group was due to healing from the second procedure and delayed wound closure. Illustrations: Figures 1–6. Discussion Our findings align with recent literature that advocates for selective use of single-stage DP flaps in head and neck reconstruction. This approach streamlines postoperative recovery, reduces cost, and accelerates adjuvant therapy timelines—critical in oncologic outcomes [6, 7]. While the two-stage flap still plays an important role for large, posterior, or complex defects requiring increased reach or inset accuracy, its necessity should be weighed against the burden of an additional surgical procedure and potential delay in treatment [3, 8]. Importantly, this case series reinforces the value of regional flaps in modern practice, especially in salvage cases, irradiated fields, or low-resource environments where free flaps may not be feasible. The low complication rates and favourable healing in both groups highlight the robustness of the DP flap technique [4, 9]. From a cosmetic perspective, single-stage flaps resulted in more favourable outcomes in anterior defects due to fewer scars and shorter healing times. However, two-stage procedures provided superior contouring in extensive or posterior defects where tension-free closure and tailored inset were critical. Limitations This study is limited by its retrospective design and small sample size. Future studies with larger cohorts and prospective analysis are needed to validate these findings.  Figure 1. Single-stage deltopectoral (DP) flap inset into an anterior buccal defect. The flap was rotated without de-epithelialization and secured with a skin graft for donor site closure. [please click on the image to enlarge] |
 Generate PDF/or right-click and save as.../  Figure 2. Combined reconstruction using a single-stage DP flap for skin coverage and pectoralis major myocutaneous (PMMC) flap for bulk and mucosal lining in a complex lateral defect. [please click on the image to enlarge]  Figure 3. Two-stage DP flap for posterior oral cavity defect. The flap was initially raised and reattached to enhance vascularity, then inset after 2–3 weeks. [please click on the image to enlarge]  Figure 4. Two-stage DP flap used for anterior vestibular defect. Full epithelialization before division ensured low tension and optimal inset. Images on right demonstrate preoperative and postoperative outcomes, highlighting effective defect coverage and satisfactory aesthetic restoration. [please click on the image to enlarge]  Figure 5. Two-stage DP flap reconstruction of anterior buccal defect. Image also depicts flap viability following adjuvant therapy. [please click on the image to enlarge]  Figure 6. Visual summary of outcome differences between groups, emphasizing the faster recovery associated with single-stage flaps. [please click on the image to enlarge] Clinical implications The choice between single-stage and two-stage deltopectoral (DP) flap reconstruction should be guided by defect characteristics, patient comorbidities, and the urgency of postoperative adjuvant therapy (Table 2). This study reinforces the following practice points: Single-stage DP flap is preferable for:
Conclusion Single-stage deltopectoral flap reconstruction is a reliable and efficient option for anterior and moderate oral cavity defects, enabling earlier recovery and timely adjuvant treatment. The two-stage approach, while more versatile for complex reconstructions, should be reserved for select cases due to its extended recovery. The choice of reconstruction must be individualized based on defect characteristics, patient fitness, and oncologic timelines.
Table 1. Clinical characteristics and outcomes of patients undergoing deltopectoral flap reconstruction.
[please click on the image to enlarge] 
Table 2. Comparative summary of outcomes between single-stage and two-stage DP flap reconstructions.
[please click on the image to enlarge]  References: [1] Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 1965; 36:173-84. [2] Purkayastha J, Hazarika B. Single stage delto-pectoral flap cover for large defects following extensive neck dissection. Indian J Otolaryngol Head Neck Surg 2007; 59:33-4. [3] Devaraja K et al. Single Stage Deltopectoral Flap for Reconstruction of the Soft Tissue Defects of Neck. Indian J Otolaryngol Head Neck Surg 2024; 76:3183-8. [4] Ducic Y, Smith JE. The cervicodeltopectoral flap for single-stage resurfacing of anterolateral defects of the face and neck. Arch Facial Plast Surg 2003; 5:197-201. [5] Varghese BT, Arora S. Immediate deltopectoral flap salvage of a failing anterolateral thigh free flap. Oral Oncol 2020; 100:104451. [6] Chan RC, Chan JY. Deltopectoral flap in the era of microsurgery. Surg Res Pract 2014; 2014:420892. [7] Pantvaidya GH, et al. Deltopectoral flap: still relevant in the era of microvascular free flaps. Indian J Otolaryngol Head Neck Surg 2013; 65(Suppl 1):114-7. [8] Nayak BB, Nilamani M. Single stage reconstructions using deltopectoral and pectoralis major myocutaneous flaps. Indian J Plast Surg 2012; 45:151-3. [9] Mikami T, et al. Deltopectoral flap revisited for reconstruction in advanced thyroid cancer: a case report. BMC Surg 2017; 17:101. [10] Mathur P, Sathishkumar K, Chaturvedi M, et al. Cancer Statistics, 2020: Report from National Cancer Registry Programme, India. JCO Global Oncology 2020; 6:1063-75. DOI: 10.1200/GO.20.00122 [11] Gupta B, Johnson NW, Kumar N. Global epidemiology of head and neck cancers: a continuing challenge. Oncology. 2016; 91:13-23. DOI: 10.1159/000446117 Conflict of interest: No funding was received for this study. The authors declare no competing interests. Ethical considerations: informed written consent was obtained from all patients included in this study. Patient identities have been protected and no names or identifying information appear in this publication. Authors’ affiliations: 1 Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India. Corresponding author: Dr Swini Kaushal Room no. 31, Married PG Hostel, MGIMS, Sewagram, Wardha, Maharashtra, India Tel.: +91 9996672083 e-mail: swinikaushal75540@gmail.com To cite this article: Kaushal S, Garg D, Kumar S, Nagpure P. Comparative analysis of single-stage vs. two-stage deltopectoral flap reconstruction in patients with oral cavity squamous cell carcinoma: a case series. World J Med Images Videos Cases 2025; 11:e9-18. Submitted for publication: 13 May 2025 Accepted for publication: 30 June 2025 Published on: 10 August 2025 |
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