We read with great interest the article ‘Use of the external pectoralis myocutaneous major flap in anterior skull base reconstruction’, by Kadlub et al. In spite of the historical experience of the authors with the pectoralis major myocutaneous flap (PMMF) in head and neck reconstruction, we believe that the sacrifice of the deltopectoralis fasciocutaneous flap (Bakamjian flap, DPFF) in the case presented in Fig. 1 in that article should be discussed.

Ariyan described the PMMF in head and neck reconstruction in 1979. Since then, following the development of microsurgery, the status of this flap has evolved from gold standard to salvage solution. Nevertheless the PMMF remains a good technique and is still performed widely. The PMMF is most often used in oncologic surgery, in patients who are scheduled to undergo external radiation beam therapy or chemotherapy and in whom wound healing complications can occur (exposure of the cervical vessels or of the internal oral bone fixation device). In these cases, the preservation of a ‘third line’ salvation flap is essential. In oncoplastic surgery, local and free flaps must be managed strategically.

Described in 1965 by Bakamjian, the DPFF is a fasciocutaneous flap based on the perforating arteries emerging from the three or four first anterior intercostal arteries. The skin paddle can be harvested up to the acromioclavicular joint and the lateral aspect of the shoulder. This flap is useful in cervical or oral reconstruction, in the case of failure of a previous reconstruction with the PMMF. In our department, the DPFF is systematically preserved, or at best harvested, during PMMF dissection, in order to keep this salvage solution if needed. Moreover it facilitates the harvesting. In our experience, very few specific complications occur (rare haematoma, distal skin paddle necrosis).

In conclusion, we recommend that the deltopectoralis flap be preserved systematically, or harvested, in PMMF dissection, in order to keep it as a potential salvage solution. Once again, we thank the authors for sharing their very interesting experience.