Reconstruction of circumferential defect of the hypopharynx: Experimental studies and clinical application of a new method

Reconstruction of circumferential defect of the hypopharynx is a challenging problem in head and neck surgery. Reconstruction with a totally tubed pectoralis major myocutaneous flap (PMMCF) has been advocated in recent years, but this procedure has the disadvantage of excessive bulkiness. In order to solve this problem, the author experimented with a partially tubed platysma myocutaneous flap and an inner surface of apron skin flap of the anterior neck in the reconstruction of the circumferential defect of the hypopharynx in ten dogs. Subsequently, the same surgical technique using PMMCF instead of the platysma myocutaneous flap was used for reconstruction following total laryngopharyngectomy in eight patients. The new partially tubed flap was successful in solving the problem of excessive bulkiness of the totally tubed PMMCF.     

Pectoralis major muscle flap in head and neck reconstruction

Pectoralis major muscle flaps have rarely been used on their own for head and neck reconstruction. Some of the problems experienced with myocutaneous flaps can be avoided by the judicious use of muscle flaps. These include suture line separation, excessive bulk, hair growth from the flap, and alteration of breast position. In contrast to the pectoralis major myocutaneous flap, the pectoralis major muscle flap is light and pliable. When it is employed for reconstruction in the oral cavity, oropharynx, or hypopharynx, it can be covered by a "quilted" skin graft or used on its own. We believe that pectoralis major muscle flaps provide a valuable alternative to the more bulky myocutaneous flaps in head and neck reconstruction.     

Neurotization of pectoralis major myocutaneous flap by the hypoglossal nerve in tongue reconstruction: clinical and experimental observations

Recently, neurotization has been proposed for providing mobility to the pectoralis major, or other myocutaneous flap in lingual reconstruction following total glossectomy. The development of an active tongue-like structure may offer the patient higher potential for rehabilitation of speech and deglutition. The purpose of this thesis is to report experimental and clinical observations on neurotization of the pectoralis major myocutaneous flap. The pectoralis major myoflap of 16 rats was reinnervated by either a hypoglossal nerve pedicle of hypoglossal-genioglossus muscle neuromuscular pedicle. Functional flap reinnervation was confirmed in eight of the 16 animals. The author's clinical experience with reconstruction of the tongue utilizing neurotized pectoralis major myocutaneous flap is presented.     

Reconstruction of the hypopharynx with U-shaped pectoralis major myocutaneous flap after total pharyngo-laryngectomy

Resection of the whole circumference of the pharynx and esophagus is usually reconstructed with gastric pull-up, jejunum free graft or free forearm flap. The aim of this study was to assess the use of pectoralis major myocutaneous flap for closure of total pharyngeal defect. In 11 patients with hypopharynx and larynx cancer, total pharyngo-laryngectomy and excision of the cervical part of the esophagus and neck dissections were performed; the defects were closed with pectoralis major myocutaneous flaps. The skin island was sutured to prevertebral muscles, forming a letter U shape. Good healing was obtained in six patients, and five patients developed fistula that closed spontaneously within 3–4 weeks. The use of U-shaped pectoralis major myocutaneous flap, suturing it to prevertebral muscles, gives good functional results, and it is a simple and time-saving second choice method of reconstruction of the pharynx after total pharyngo-laryngectomy.     

颈段食管癌手术喉功能保留问题的探讨

目的:探讨颈段食管癌手术喉功能保留的适应证和咽食管重建方法, 以及胃咽吻合术误吸并发症的原因和防治措施.方法:9例保留喉功能的颈段食管癌手术患者,其中单纯颈段食管癌2例,颈段食管癌侵犯下咽部6例,颈胸段食管重复癌1例.喉功能保留:全部喉功能保留8例,部分喉功能保留1例.下咽-食管重建:胃咽吻合7例,游离前臂皮瓣1例, 胸大肌皮瓣1例.结果:喉功能恢复良好4例,中等2例,差3例.胃咽吻合术7例均发生不同程度的胃液反流、咳嗽反射暂时性消失和误吸,5例发生声带麻痹;吻合口越高,误吸程度越重.游离前臂皮瓣移植术1例死于大出血.胸大肌皮瓣转移术1例虽能恢复良好的喉功能,但6个月后发生吻合口狭窄.结论:单纯颈段食管癌和颈段食管癌向上侵犯下咽部1 cm以内的患者适宜行全部喉功能保留手术;而颈段食管癌向上侵犯下咽部部1 cm以上的高龄患者不宜行全部喉功能保留手术,可行部分喉功能保留手术或不保留喉功能手术.胃咽吻合术误吸并发症的发生与咽-食管吞咽功能障碍和喉防误吸功能障碍密切相关.     

Pharyngo-esophageal reconstruction using pectoralis major cutaneous muscular flap after total laryngopharyngectomy

Using the pectoralis major myocutaneous flap is a good opportunity for one-stage reconstruction of the removed hypopharynx after total laryngopharyngectomy. The authors share their experience with five patients who underwent this kind of operation for T4 cancer of the hypopharynx and discuss their results.     

Pectoralis major myocutaneous pedicled flap in head and neck reconstruction: retrospective review of indications and results in 244 consecutive cases at the Toronto General Hospital.

The pectoralis major myocutaneous pedicled flap (PMMPF) has been considered to be the "workhorse" of pedicled flaps for head and neck reconstruction, and several series of PMMPF procedures have been reported in the literature. Between 1983 and 1997, 244 reconstruction procedures using the PMMPF were carried out on 229 patients by the Otolaryngology-Head and Neck Surgery Department at the Toronto General Hospital. Pectoralis major myocutaneous pedicled flap reconstructions were completed after ablation of cancer in the following sites: oral cavity, 113; oropharynx/hypopharynx, 50; larynx, 59; and other, 21. The locations of reconstruction were oral cavity, 121; pharynx, 74; and neck or face, 50. Of the 244 cases, 202 were carried out as primary reconstructive procedures, whereas 42 flaps were "salvage" procedures (reconstruction after fistula, flap failure, osteoradionecrosis, and internal jugular vein rupture). Eighty-five cases (35%) were affected by complications such as dehiscence, infection, hematoma, seroma, partial flap failure, total flap failure, fistula, and donor site complications. The duration of admission for cases with complications was longer, and higher complication rates were associated with salvage procedures, number of comorbidities, number of pack-years of cigarettes smoked, and oral cavity reconstructions. This series of consecutive PMMPF procedures is the largest reported to date.     

Immediate pharyngoesophageal reconstruction. Use of a quilted skin-grafted pectoralis major muscle flap

Pharyngoesophageal reconstruction continues to be a problem in the management of cancer involving the hypopharynx. In our experience, the use of deltopectoral and pectoralis major myocutaneous flaps for total reconstruction has been disappointing. We report four cases of immediate near-total reconstruction using a quilted , skin-grafted pectoralis major muscle flap. All cases had received full dosage preoperative irradiation. A thin-walled pharynx was created that has allowed early development of a good esophageal voice. There has been no stricture formation. All patients have experienced no difficulty in establishing a good oral intake.     

Oral cavity reconstruction using pectoralis major muscle and amnion

The pectoralis major myocutaneous flap has become the mainstay of major oral cavity reconstruction. The flap provides excellent soft-tissue bulk and cavity or surface lining for major defects. There is a high rate of primary take. However, the flap has some deficiencies. A group of patients were identified that are likely to have less than ideal results with the pectoralis major myocutaneous flap technique. In these cases, the flap has been modified and amnion has been added. Initial results indicate enhancement of reconstruction with the modified technique.     

Pharyngeal fistula after irradiation and laryngectomy. Problem of the reconstruction of the pharynx

A 39-year-old patient with an epiglottic carcinoma stage T4N2M0 was treated initially by radiotherapy, but later underwent laryngectomy for irradiation necrosis. A pharyngeal fistula occurred in the irradiated area. After resection of the damaged skin reconstruction was performed by a double skin paddle myocutaneous pectoralis major flap. A recurrence of the fistula in the same area was closed by invagination of the flap. Three years later a massive scar stenosis developed in the reconstructed hypopharynx, so that the patient was unable to swallow. This required a total resection of the scar tissue which extended from the entrance of the hypopharynx to the upper oesophageal sphincter. The gap was bridged by a free microvascular jejunal graft. To date 6 months have elapsed since this operation and the patient is symptom free.     

Prevention of hair growth in myocutaneous flap reconstruction

Myocutaneous flaps play a prominent role in the immediate reconstruction of surgical defects following ablative oncologic procedures in the head and neck. Transfer of hair-bearing skin into the reconstructed upper digestive tract can be a major disadvantage associated with the pectoralis major flap. De-epithelialization of skin to the dermal level, removing the majority of skin appendages, can convert a myocutaneous flap to a "myodermal" flap. Platysma myocutaneous and myodermal flaps were grafted into the oral cavity of 13 dogs. Gross and histologic evaluation confirmed decreased hair growth in the experimental myodermal flap. Wound complications and graft survival were similar for both techniques. Diminished hair growth further supports the utility of myodermal flaps in hairy male patients undergoing upper digestive tract reconstruction.     

带蒂胸大肌皮瓣在头颈部肿瘤术后缺损修复中的应用

目的:探讨运用带蒂胸大肌皮瓣修复头颈部肿瘤切除术后缺损的效果及优点。方法:13例晚期头颈部肿瘤患者,行肿瘤切除术后以带蒂胸大肌皮瓣修复术后缺损。结果:术后11例愈合良好;1例出现腮腺瘘,加压包扎后愈合;1例自动出院后失访。结论:胸大肌皮瓣修复头颈部肿瘤切除术后缺损,具有血供丰富、可修复较大面积缺损、术后愈合较好等优点。对延长患者生命,减轻病痛有重要作用。     

胸大肌肌皮瓣在头颈肿瘤术后组织缺损修复中的应用

目的总结胸大肌肌皮瓣在头颈肿瘤术后组织缺损修复中的应用。方法回顾性总结2 0 0 7年1月～2 0 1 0年1 2月收治的3 6例患者因头颈部肿瘤手术后巨大组织缺损应用胸大肌肌皮瓣进行修复的临床资料。结果 32例(88.9%)胸大肌肌皮瓣完全存活,4例(11.1%)胸大肌肌皮瓣远端部分坏死。经换药、口腔护理等对症支持治疗后愈合。结论胸大肌肌皮瓣是一种临床应用广泛的修复材料。它具有丰富的组织量和确切的血液供应,修复操作简单,易存活,适用于头颈部肿瘤扩大切除术后组织缺损的即刻修复。     

Problem of the surgical treatment of malignant tumors of the hypopharynx and cervical esophagus

One of the drawbacks in one-stage reconstruction of the cervical oesophagus and the hypopharynx is the mortality and morbidity of intestinal transposition or free mucosal grafts. The follow up in 19 patients over the last four years showed that the pectoralis major flap is a good alternative for partial reconstructions of the upper gullet, provided that a mucosal strip of 2 cm can be preserved and that secondary shrinkage of the muscle pedicle is allowed for. This means of reconstruction is not ideal for circumferential lesions because of stricture formation and the high risk of fistula formation. Pectoralis major flaps tolerate postoperative radiotherapy well. Functional rehabilitation of the patients can usually be achieved within four weeks.     

Preliminary results in using the myocutaneous pectoralis major flap

The modified pectoralis major myocutaneous paddle flap has been used in 75 cases since 1982 for the closure of major defects of the oral cavity, oro- and hypopharynx and neck. Although almost all of the patients had a stage IV tumour, we had good aesthetic and functional results. There was no total flap necrosis. Three cases of partial necrosis underwent spontaneous healing. The details of the operative techniques are compared with other reconstructive methods, and the advantage of the pectoralis major flap is discussed.     

扁桃体癌手术及修复方法的选择

目的 探讨扁桃体癌手术切除入路与组织缺损的几种修复方法及疗效.方法 采用颈前舌骨入路及下颔骨正中裂开外旋入路切除19例扁桃体癌,分别应用舌瓣、颞肌筋膜瓣及胸大肌肌皮瓣修复缺损.结果 1例胸大肌肌皮瓣术后出现皮肤部分坏死,3例颞肌筋膜瓣修复者术后张口轻度受限,其余患者术后呼吸、吞咽、咀嚼和语音功能恢复良好.结论 在选择合适的手术入路彻底切除肿瘤的前题下,熟练地掌握多种修复方法,择优采用,是恢复良好口咽功能,提高患者术后生活质量的重要保证.     

Pulmonary atelectasis after reconstruction with pectoralis major flaps

Forty-four patients were reviewed to determine the incidence of atelectasis following pectoralis major myocutaneous flap reconstruction of head and neck defects. Patients underwent tumor resection with subsequent pectoralis major myocutaneous flap reconstruction (flap group, n = 24) or another major head and neck procedure (control group, n = 20). Chest roentgenograms taken on the first postoperative day were scored for atelectasis by preestablished criteria. Sixty-five percent of control and 70% of flap patients demonstrated postoperative atelectasis roentgenographically. The flap patients with skin paddles larger than 40 cm2 had a 60% incidence of major atelectasis compared with 5% in control patients. The skin island area was strongly correlated with the atelectasis score in the flap group. These results suggest that atelectasis is common following pectoralis major myocutaneous flap reconstruction of head and neck defects. As well, decreased chest wall compliance after primary closure of large donor defects may contribute to the atelectasis observed.     

Skin grafts and flaps in oral cavity reconstruction

Split-thickness skin grafts and regional flaps have been used to reconstruct deficits produced by oral cavity and oropharyngeal cancer resection in 191 patients. The rate of complication, delay in oral alimentation, and the postoperative length of hospitalization was greater for pectoralis myocutaneous and deltopectoral flap reconstructions than for skin grafts, even when comparably sized defects are considered. The adverse effect of weight loss is greater on flap reconstructions than skin grafts and is influenced little by preoperative nutritional therapy. Skin graft reconstruction is recommended for moderate and large defects. The pectoralis myocutaneous flap may be reserved for massive defects or when the anterior part of the mandible has been resected.     

The pectoralis major myofascial flap for intraoral and pharyngeal reconstruction.

The pectoralis myocutaneous flap has been widely used for reconstruction of oral cavity and pharyngeal defects. However, it has several disadvantages, such as chest distortion, hair growth at the reconstructed site, and excessive bulk, all of which can be avoided by the use of the pectoralis myofascial flap. Oral cavities and pharyngeal defects, ranging in size from 4 to 9 cm in largest' dimension, in 26 patients were reconstructed with the pectoralis myofascial flap. All but three defects were successfully reconstructed. The surface of the flap was covered by squamous epithelium in 1 month. The flap remained healthy during and after radiotherapy. The pectoralis myofascial flap is ideal for soft-tissue coverage of small- to medium-size oral cavity and pharyngeal defects. Its major advantages over the pectoralis myocutaneous flap are decreased bulk and improved cosmesis.     

Safe reconstruction of a large cervico-mediastinal tracheal defect with a pectoralis major myocutaneous flap and free costal cartilage grafts

A large cervico-mediastinal tracheal defect in a 72-year-old man as a result of surgery for thyroid carcinoma with tracheal invasion and mediastinal lymph node metastasis was reconstructed using a pectoralis major myocutaneous flap and free costal cartilage grafts. The tracheal defect (55 mm x 30 mm) was located at the thoracic inlet adjacent to the major mediastinal vessels. Our reconstructive procedure was a two-staged surgery. In the first stage, a pectoralis major myocutaneous flap was transferred to the neck to provide a well-vascularized recipient bed for free costal cartilage grafts and to cover large vessels. Two pieces of free costal cartilage were grafted on the pectoralis major myocutaneous flap, one for the lateral wall reconstruction and the other prefabricated for the anterior wall of the trachea. In the second stage, the re-vascularized cartilage graft for the anterior wall of the trachea with overlying skin was rotated onto the trough of the remaining trachea and the closure of the tracheal defect was completed. We conclude that free cartilage grafts for the reconstruction of a large cervico-mediastinal tracheal defect can be safely used when they are combined with well-vascularized pectoralis major myocutaneous flaps.