Surgical Technique
Reconstruction is performed following laryngectomy and circumferential
pharyngectomy +/- cervical oesophagectomy. A DP flap is raised in the
subfascial plane. The blood supply from the 2nd and
3rd internal mammary perforator arteries allows
harvesting of a broad tissue flap with a width extending from the
clavicle to the 5th intercostal space, and a length
reliably extending towards the shoulder tip. The flap is sutured onto
the posterior oropharyngeal mucosa superiorly, and the proximal
oesophagus inferiorly (Figure 1). In one individual, the superior extent
of the flap repair extended to the level of the soft palate. Total time
required to raise the DP flap and suture it to the inferior edge of the
oropharynx is approximately 30 minutes.
A second flap is then harvested. This can be a free flap or a pedicled
flap. In our series, a pectoralis major myocutaneous flap or a
supraclavicular fasciocutaneous flap on the opposite side was used. This
is to form the anterior and lateral pharyngeal wall. This second flap is
raised and inserted in a similar manner to a partial pharyngeal patch
repair. 3,7
The distal part of the deltopectoral cutaneous tissue is left to form
the posterior pharyngeal wall and skin de-epithelialisation is performed
to a small middle segment of the flap, so that the only cutaneous tissue
buried within the neck is the neopharynx itself (Figure 2). The skin of
the deltopectoral flap near the stump of the oesophagus is sutured,
thereby ensuring the integrity of the neo-posterior pharyngeal wall from
oropharynx to oesophagus.
The second flap can then be sutured to the anterior mucosa of the
proximal oesophagus, the DP flap laterally, and the tongue base
superiorly, creating a conical neopharynx. Flap harvest sites are then
closed primarily. A salivary bypass tube is positioned in the
reconstructed neopharynx to help the healing process splinting it open,
which is subsequently removed 3 weeks later, prior to commencement of
oral diet. Six-month post-operative outcome is displayed in Figure 3.